Abstract

This article presents data from a research that aimed to identify and understand the practices and concepts of occupational therapy in the Vocational Rehabilitation Program of the National Social Security Institute (INSS), in the state of São Paulo. Vocational rehabilitation aspires to provide means for workers to reenter the job market, being associated with health, education, and labor and employment. Data were collected through a questionnaire sent to occupational therapists, as well as through interviews with some of them. We discussed themes that were categorized to analyze their practices and concepts and highlighted topics that allowed us to reflect on the limits, possibilities and challenges faced by these workers, examining the structure of the program as well. A number of factors imply that their performance at the INSS is more negative than positive, which could be related to structural issues of the program. However, the therapists believe in improving its structure and point out the need to increase the possibilities offered, allowing for a greater participation and responsibility of companies, for more combined efforts with other government sectors and the civil society and for the expansion and reformulation of the Brazilian legislation on vocational rehabilitation.

Keywords:
Vocational Rehabilitation; Social Security; Occupational Therapy; Work

Introduction

According to Law 8,213/91 (Brasil, 1991BRASIL. Lei nº 8.213, de 24 de julho de 1991. Dispõe sobre os Planos de Benefícios da Previdência Social e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 25 jul. 1991. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l8213cons.htm >. Acesso em: 9 jun. 2015.
http://www.planalto.gov.br/ccivil_03/lei... ), employees covered by the National Social Security Institute (INSS) are those considered partially or completely incapacitated for work, those that receive disability benefits or special benefits, dependents of the insured and people with disabilities. They are entitled to Vocational Rehabilitation¹¹11The authors chose to use the expression Vocational Rehabilitation with capital letters when referring to the field and to the Program of the INSS, using lowercase for the practice within the field., which aims at providing "means that enable professional and social (re)education and (re)adaptation indicated for inclusion in the labor market and in the context in which they [the insured] live" (Brasil, 1991BRASIL. Lei nº 8.213, de 24 de julho de 1991. Dispõe sobre os Planos de Benefícios da Previdência Social e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 25 jul. 1991. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l8213cons.htm >. Acesso em: 9 jun. 2015.
http://www.planalto.gov.br/ccivil_03/lei... , p. 33). Vocational Rehabilitation is also a duty according to Normative Instruction 45 from 2010, article 286:

In 2012, 31,401 Brazilians were sent to the Vocational Rehabilitation of the INSS, from which 17,387 were considered rehabilitated. Moreover, 851 of them were given prostheses and orthoses¹²12FORÇA SINDICAL. INSS apresenta nova proposta de reabilitação profissional aos segurados. Disponível em: <http://fsindical.org.br/forca/inss-apresenta-nova-proposta-de-reabilitacao-profissional-dos-segurados>. Acesso em: 12 dez. 2015..

Occupational therapists started working for the National Institute of Social Welfare (INPS), which would later become the INSS, in the 1970s, and a total of 80 therapists had been hired by the next decade. However, that did not last and it was only in 2008 that occupational therapists started working in the INSS once again, and by 2010 a total of 183 therapists had been hired throughout the country 2010 as part of the "Revitalization of Vocational Rehabilitation"¹³13CANNALONGA, L. S. Projeto de Revitalização da Reabilitação Profissional. s/d. Disponível em: <www.proreabilitacao.com.br>. Acesso em: 16 de julho de 2012. and its Vocational Rehabilitation Program.

For (Quarentei, 2001QUARENTEI, M. S. Terapia ocupacional e produção de vida. In: CONGRESSO BRASILEIRO DE TERAPIA OCUPACIONAL, 7., 2001, Porto Alegre: Associação dos Terapeutas Ocupacionais do Rio Grande do Sul e Associação Brasileira de Terapeutas Ocupacionais, 2001.), the human life is a continuum of activities, and occupational therapy has "great inventiveness for strategies that handle different issues of the human existence" (Quarentei, 2001QUARENTEI, M. S. Terapia ocupacional e produção de vida. In: CONGRESSO BRASILEIRO DE TERAPIA OCUPACIONAL, 7., 2001, Porto Alegre: Associação dos Terapeutas Ocupacionais do Rio Grande do Sul e Associação Brasileira de Terapeutas Ocupacionais, 2001., p.2), as human actions are at the center of its concerns. In addition, (Barros, Lopes and Galheigo, 2007BARROS, D. D.; LOPES, R. E.; GALHEIGO, S. M. Terapia ocupacional social: concepções e perspectivas. In: CAVALCANTI, A.; GALVÃO, C. Terapia ocupacional: fundamentação e prática. Rio de Janeiro: Guanabara Koogan, 2007. p. 347-363.) state that these actions have multiple overlapping meanings and are part of the identity formation process, being a relational and political process.

As such, this article discusses the possible contributions of occupational therapy, with its technical and political aspects, for dealing with the demands related to the processes of decreasing the work capacity of the subjects and actions that may lead them back to work activities. Based on these reflections and on the work of Vocational Rehabilitation, we aimed at understanding how occupational therapy contributes to the return of individuals to work, within the Program of Vocational Rehabilitation of the INSS.

Vocational Rehabilitation is the field of knowledge production and development of propositions and actions linked to the processes of returning to work needed by individuals that for many reasons require interventions to restart their professional lives, whether in common work activities - for those, adaptations and adjustments may be made - or through preparation for starting a new job.

The field works as an interface between the Social Welfare system, Health, Education and policies and actions of Labor and Employment. Their coordination is necessary to prepare the insured for their return to the labor market, which usually involves following their condition through the health network, investing in improving or restructuring their education and their preparation in institutions of vocational education.

On the topic of Health, more specifically Worker's Health, we agree with (Hoefel, Dias and Silva, 2005HOEFEL, M. G.; DIAS, E. C.; SILVA, J. M. A atenção à saúde do trabalhador no SUS: a proposta de constituição da RENAST. In: CONFERÊNCIA NACIONAL DE SAÚDE DO TRABALHADOR, 3., 2005, Brasília. Anais... Brasília, DF: Ministério da Saúde, 2005. Disponível em < Disponível em http://conselho.saude.gov.br/wst/documentosdeapoio.pdf >. Acesso em: 9 jun. 2015.
http://conselho.saude.gov.br/wst/documen... ), which state that the Brazilian Unified Health System (SUS) has not effectively incorporated the dimension that work occupies in the life of individuals and their relationships with the social-environmental space into its concepts, paradigms, and actions. We agree with (Maeno and Vilela, 2010MAENO, M.; VILELA, R. A. G. Reabilitação profissional do Brasil: elementos para a construção de uma política pública. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 121, p. 87-99, jan. /jun., 2010., p. 93) as well, for "the health of the worker, including vocational rehabilitation, is a constitutional right that still needs to be implemented".

For (Hoefel, Dias and Silva, 2005HOEFEL, M. G.; DIAS, E. C.; SILVA, J. M. A atenção à saúde do trabalhador no SUS: a proposta de constituição da RENAST. In: CONFERÊNCIA NACIONAL DE SAÚDE DO TRABALHADOR, 3., 2005, Brasília. Anais... Brasília, DF: Ministério da Saúde, 2005. Disponível em < Disponível em http://conselho.saude.gov.br/wst/documentosdeapoio.pdf >. Acesso em: 9 jun. 2015.
http://conselho.saude.gov.br/wst/documen... ), Worker's Health in the context of SUS established actions for promoting health; diagnosis and treatment; health surveillance; guidance for workers; notification of information systems; access to Social Welfare and the Work Injury Benefit (SAT); permanent training and education; knowledge production and social control.

The proposition and creation of the Worker's Health Reference Centers (CEREST) do not ensure its effectiveness and its potential for health promotion due to bureaucracy and slowness of the health sector. Their services are often restricted to death counting and "posthumous" surveillance of the worker's health, and it is difficult to implement health promotion and surveillance as defined by the National Worker's Health Policy (Carvalho et al., 2012CARVALHO, A. P. C. et al. Estrutura, evolução e perspectivas nacionais do Programa de Saúde do Trabalhador. Revista Uniandrade, Curitiba, v. 13, n. 2, p. 116-132, 2012.).

As a result, the field of Worker's Health was constituted posteriorly to Vocational Rehabilitation and assumed a critical position due to the concepts and attention given to Brazilian workers at the time (end of the 1970s), especially in the health sector. The health sector was then expanded to include vocational rehabilitation measures, with the purpose of developing interventions that did not consider workers as their only object and that took into account, as stated by (Lacaz, 2007LACAZ, F. A. C. O campo saúde do trabalhador: resgatando conhecimentos e práticas sobre as relações trabalho-saúde. Caderno de Saúde Pública, Rio de Janeiro, v. 23, n. 4, p. 757-766, 2007.), the interference of relationships, of work organization and of health and disease processes, within an individual and collective perspective.

According to (Vasconcellos, 2007VASCONCELLOS, L. C. F. Saúde, Trabalho e Desenvolvimento Sustentável: apontamentos para uma Política de Estado. 2007. Tese (Doutorado em Saúde Pública) - Escola Nacional de Saúde Pública, Rio de Janeiro, 2007.), Worker's Health is part of the Collective Health field and encompasses epidemiology, health management and planning, and social sciences in the context of health, joining other branches such as demography, statistics, anthropology, ecology, toxicology, geography, ergonomics, production engineeringm and others. In this sense, Collective Health is considered a nucleus (demarcation of the identity of an area of knowledge and professional practice) of the field of Health, which has as some of its main attributions: supporting health systems, the elaboration of policies and construction of models, providing explanations for the processes of health/illness/intervention, and actions aimed at health promotion and disease prevention, focusing on health issues with collective consequences (Campos, 2000CAMPOS, G. W. S. Saúde pública e saúde coletiva: campo e núcleo de saberes e práticas. Ciência e Saúde Coletiva, Rio de Janeiro, v. 5, n. 2, p. 219-230, 2000.). Hence, we believe that Vocational Rehabilitation, in its interface with Workers' Health, should be analyzed and organized based on these principles and attributions instead of focusing solely on repairing actions, which certainly can also be applied to Occupational Therapy.

According to (Lancman et al., 2004LANCMAN, S.; GHIRARDI, M. I G. Introdução. In: LANCMAN, S. Saúde, trabalho e terapia ocupacional. São Paulo: Roca, 2004. p. 9-13.), the correlation between work and rehabilitation incorporates discourses and practices that founded occupational therapy. However, social-economic processes (Ghirardi, 2012GHIRARDI, M. I. G. Terapia ocupacional em processos econômico-sociais. Cadernos de Terapia Ocupacional da UFSCar, São Carlos, v. 20, n. 1, p. 17-20, 2012.) and the processes of going back to work and to the production of social goods within them have suffered many interventions of the field, ever since the first practices occurred at nursing homes and in post-war rehabilitation in Europe and North America.

In Brazil, the vocational rehabilitation of individuals incapacitated for work was one of the main reasons for the formation of occupation therapists, together with practices at homes aimed at institutionalized people, either with mental disorders or disabled. In 1951, the United Nations chose the Hospital das Clínicas of the Medical School of the University of São Paulo (FMUSP) as reference for the implementation of a Rehabilitation Center in Latin America aimed at repositioning into the workforce the large number of disabled people in the region, mostly victims of work injuries that required rehabilitation professionals, such as occupational therapists (Lopes, 1991LOPES, R. E. A formação do terapeuta ocupacional - o currículo: histórico e propostas alternativas. 1991. Dissertação (Mestrado em Educação) - Faculdade de Educação da Universidade Federal de São Carlos, São Carlos, 1991.).

In spite of the origin of occupational therapy being related to the field of Vocational Rehabilitation, there is a lack of studies that link both of them. In 2012, a literature review carried out by the two main Brazilian journals in the area - Cadernos de Terapia Ocupacional from UFSCar and the Revista de Terapia Ocupacional from USP - showed that only two publications mentioned the theme, with just one of them discussing the contributions of occupational therapy for the field. A new manual analysis (2015) of both journals indicates that this reality remains unaltered.

As a result, considering that Vocational Rehabilitation is intrinsically related to the origin of occupational therapy in Brazil, and also the need to improve the theoretical framework related to the field, a research was carried out between 2010 and 2012 aimed at identifying and understanding, through the eyes of occupational therapists, the practices and concepts they use in Vocational Rehabilitation in the INSS of the state of São Paulo¹⁴14As it was impossible to study the entire country in the scope of this research, we chose the state of São Paulo because 22.95% of the occupational therapists of the INSS hired between 2008 and 2010 are located in it. Moreover, it allowed us to observe important characteristics of the work processes in large urban centers such as the large population, partially due to the search for work and employment relationships, the considerable amount of psychosocial care units for workers and the phenomena of illness and work accidents..

Methodological Procedures

This is an exploratory research, since studies and publications on the topic are lacking, and it had the purpose of getting closer to the studied reality to explain it, leading to reflections about it. Moreover, its nature was descriptive and comprehensive as it aimed at explaining the characteristics of a specific phenomenon beyond the study of the relationships among the variables, including other ways to understand it (Gil, 2002GIL, A. C. Como elaborar projetos de pesquisa. São Paulo: Atlas, 2002., ²⁰⁰⁸GIL, A. C. Métodos e técnicas de pesquisa social. São Paulo: Atlas, 2008.).

After an initial bibliographical and document review on Vocational Rehabilitation and of the issue in the context of the INSS, the empirical limits for data collection led us to the elaboration and application of a questionnaire for the occupational therapists¹⁵15The expression "occupational therapists" will refer only to women, as in the state of São Paulo there are only women in the position in the Vocational Rehabilitation of the INSS. of the Rehabilitation Program of the INSS in the state of São Paulo, which, at the time, represented an universe of 45 people. After these answers were tabulated, we conducted in-depth interviews with six of these therapists to enhance the reflections on the themes of the questionnaire. Lastly, an occupational therapist that had been working at the Institute since 1980 also gave us an interview, providing a historic survey of Vocational Rehabilitation and of the work of occupational therapists within the INSS and defending the incorporation of occupational therapy into the INSS.

The questionnaire encompassed 76 questions, and most of them were closed-ended and multiple choice, with the possibilities of choice varying between one or more alternatives. In addition, some of them had space for commentary and additional observations. The last two questions were open-ended and allowed participants to discuss more freely the Vocational Rehabilitation of the INSS and occupational therapy in the area. The main topics discussed were: social-academic and professional profile of the participants; considerations and conceptions regarding their own professional practice and vocational rehabilitation; Vocational Rehabilitation within the INSS; occupational therapy; work. Moreover, an interview script was elaborated to provide more details on these topics¹⁶16The script was constituted of the following topics: presentation of the goals of the research and the purposes of the interview; identification; occupational therapy concepts (individual background; experiences; central instruments and elements; possibilities, limits and challenges; theoretical and practical references); occupational therapy, work and vocational rehabilitation (work and daily life for individuals and groups and for occupational therapists; approaching the themes in the INSS and in occupational therapy during, their practice and professional background); actions/practices developed in vocational rehabilitation (implementation of practices using occupational therapy instruments; situations of professional satisfaction; working on the basic functions of the Program and in other established activities; available resources; contribution of occupational therapy to the Program; occupational therapy actions they would like to develop); considerations about the insureds (profile; demands and possibilities of the Program and of occupational therapy; factors that make going back to work easier or harder); considerations on vocational rehabilitation - in the INSS and in general (definition, field, possibilities, limits, phases and activities of the Program, legislation, staff, professional training of the insureds, propositions for a vocational rehabilitation program); in addition to other comments, reflections and observations..

The participants of the research had the option of answering the questionnaire on paper (which was then mailed), in electronic file (sent through work or personal e-mail accounts) or through a link that provided direct access to the questionnaire in the website of a specialized company ¹⁷17Disponível em: <www.surveymonkey.com>. Acesso em: 25 maio 2016. The collected data were treated collectively with descriptive statistics (Magalhães; Lima, 2000MAGALHÃES, M. N.; LIMA, C. P. Noções de probabilidade e estatística. 2. ed. São Paulo: IME-USP, 2000.).¹⁸18Studies on social welfare, social security and work, and for this last topic we focused on the centrality of work, transformations on the workforce and on the situation and social protection of workers. Studies on vocational rehabilitation, occupational therapy and work, and occupational therapy and vocational rehabilitation were also part of these references.

The interviewed occupational therapists were selected based on convenience sampling carried out through an analysis of the answers to the questionnaires - especially of the parts in which they could write about the topics. In addition, the availability to discuss the themes of the research with more details was also considered, as well as showing a comprehensive view of vocational rehabilitation that went beyond the activities established and/or developed by the INSS, discussing the issues involved in the process of going back to work and the context of their actions as occupational therapists, considering both the reality of the Institute and the social, economic and political panorama of Brazil. The purpose was to conduct a more in-depth conversation with the therapists that had shown interest.

Seven in-person interviews were conducted and the reports were registered through a digital voice recorder and completely transcribed. Initially, we chose one of the interviews as reference and after reading it many times we were able to define the themes that were used as data categories, which increased as the other interviews were read. As the selected interview was very comprehensive, new categories were identified only in the reading of the second interview.

The contents that resulted from this categorization and systematization were studied and discussed using the theoretical references that guided the research, and they were also linked to the findings obtained from the application of the questionnaire.

This article presents part of these results and discussions with the purpose of analyzing the challenges and possibilities of Vocational Rehabilitation in the INSS, focusing on the practices and concepts of occupational therapists that work in the area. We will present data referring to the questionnaires, providing a general overview of the topics studied by the research and especially those that resulted from the in-depth interviews, owing to relevant markers found on the reports of the interviews therapists. To contextualize these reflections, we initially make some observations on the situation of Brazilian workers and on the transformations seen in the labor market and in Vocational Rehabilitation in the country.

The situation and social protection of work and workers

For (Antunes, 2008ANTUNES, R. Adeus ao trabalho? Ensaio sobre as metamorfoses e a centralidade do mundo do trabalho. São Paulo: Cortez, 2008.), the many transformations of the labor market became stronger in the 1990s, reaching mostly developed and capitalist countries, but also affecting developing countries, especially those that are intermediate and have large industrial parks, such as Brazil.

When discussing the lacking structure of work on a global scale, the author affirms that the Brazilian circumstances are dire, and that during the 1990s the industrial and service sectors went through a significant productive restructuring owing to the new international work division, which required changes in production organization and in its processes of territorial redistribution. Automation, robotics and microelectronics were developed during a recession period and caused many workers to leave the workforce, and the proposals of more flexibility, deregulation, and privatization gained strength with the federal neoliberalism of the late 1980s and early 1990s (Antunes, 2008ANTUNES, R. Adeus ao trabalho? Ensaio sobre as metamorfoses e a centralidade do mundo do trabalho. São Paulo: Cortez, 2008.).

The informal labor market increased, violating labor law and causing many employees to stop earning wages and start working without any employment registration. Similarly, starting from the 1990s, the number of outsourcing companies that provide temporary workforce increased significantly in the country, aiming to meet the large demand of the private market for temporary workers, with no employment registration or relationship (Antunes, 2008ANTUNES, R. Adeus ao trabalho? Ensaio sobre as metamorfoses e a centralidade do mundo do trabalho. São Paulo: Cortez, 2008.).

According to (Castel, 2009CASTEL, R. As metamorfoses da questão social: uma crônica do salário. Petrópolis: Vozes, 2009.), the situation of both those who work and do not work is worrisome, and great part of the population is constantly threatened by the possibility of not having minimal autonomy, with unstable, seasonal and intermittent occupations, lower salaries and less social rights, being on the limits of the wage-earning society.

It is necessary to discuss those who do not work, not because they are not capable, but because there is no work for them - there is no place for these individuals who are stuck between the obligation of working and the impossibility of doing so according to regulations. The categorical imperative of work is set but many people do not have access to it (Castel, 2009CASTEL, R. As metamorfoses da questão social: uma crônica do salário. Petrópolis: Vozes, 2009.).

Vocational Rehabilitation in Brazil

After 1945, social movements to defend labor rights and the publication of the comprehensive concept of social security of the International Labour Organization (ILO), that went beyond traditional benefits, led to the creation of Law 3,087/1960, the Organic Law of Social Welfare (LOPS), which unified the social welfare system for all workers under the Labor Code (CLT) regarding the legislation of the Institutes of Retirement and Pensions (IAP) (Brasil, 1960BRASIL. Lei nº 3.087, de 26 de agosto de 1960. Dispõe sobre a Lei Orgânica de Previdência Social. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 5 set. 1960. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/leis/1950-1969/L3807.htm >. Acesso em: 01 mar. 2016.
http://www.planalto.gov.br/ccivil_03/lei... ).

The new attributions incorporated by LOPS included educational care and assistance for the vocational adaptation of the insureds receiving sickness benefits, retired workers and invalid pensioners (Soares, 1991SOARES, L. B. T. Terapia ocupacional: lógica do capital ou do trabalho? São Paulo: Ed. Hucitec, 1991.). The unification of the social welfare system came into force through Decree-Law 72, from 1966, when the IAP started constituting the National Institute of Social Welfare (INPS) (Brasil, 1966BRASIL. Decreto nº 72, de 21 de novembro de 1966. Unifica os Institutos de Aposentadoria e Pensões e cria o Instituto Nacional de Previdência Social. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 22 nov. 1966. Disponível em: <Disponível em: https://www.planalto.gov.br/ccivil_03/decreto-lei/1965-1988/Del0072.htm >. Acesso em: 9 jun. 2015.
https://www.planalto.gov.br/ccivil_03/de... ).

(Soares, 1991SOARES, L. B. T. Terapia ocupacional: lógica do capital ou do trabalho? São Paulo: Ed. Hucitec, 1991.) points out that in the end of the 1970s there were Centers of Vocational Rehabilitation (CRP) in large urban areas, which aimed to handle cases of victims of work accidents before the final phase of their clinical treatment. According to (Maeno, Takahashi and Lima, 2009MAENO, M.; TAKAHASHI, M. A. B. C.; LIMA, M. A. G. Reabilitação profissional como política de inclusão social. Acta Fisiátrica, São Paulo, v. 16, p. 53-58, 2009.), the Centers and Nuclei of Vocational Rehabilitation, larger and smaller units, respectively, had therapeutic sectors, teaching and vocational training workshops, market researches, material and human resources.

(Struffaldi, 2011STRUFFALDI, M. C. B. Comunicação pessoal. 16 set. 2011, 19p.) makes important observations for the understanding of the practice in old CRPs in the city of São Paulo, providing information about the work of occupational therapy in these large centers:

In 1977, the National Institute of Medical Assistance and Social Welfare (INAMPS) was created, centralizing the medical care activities and rehabilitation activities, which were comprised of medical-surgical treatment, physical rehabilitation and vocational rehabilitation (Brasil, 1977BRASIL. Lei nº 6.439, de 1º de setembro de 1977. Institui o Sistema Nacional de Previdência e Assistência Social, e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 2 set. 1977. Disponível em: <Disponível em: https://www.planalto.gov.br/ccivil_03/leis/l6439.htm >. Acesso em: 1 mar. 2016.
https://www.planalto.gov.br/ccivil_03/le... ). In June 1990, a change was made through Decree 99,350, which created the National Institute of Social Security (INSS) by merging the Institute of Financial Administration for Social Security (IAPAS) with the INPS (Brasil, 1990BRASIL. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 20 set. 1990. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l8080.htm >. Acesso em: 9 jun. 2015.
http://www.planalto.gov.br/ccivil_03/lei... ). The Institute was responsible for managing the social contributions destined to the financing of social security, in addition to guaranteeing the right the worker had to to receive the benefits managed by it, no longer defining the healthcare which so far had been carried out by INAMPS (Soares, 1991SOARES, L. B. T. Terapia ocupacional: lógica do capital ou do trabalho? São Paulo: Ed. Hucitec, 1991.).

As for rehabilitation aimed at work reinsertion, the Organic Health Law of 1990 determined that the Unified Health System (SUS) was in charge of physical rehabilitation, with the INSS being responsible for vocational rehabilitation and paying the benefits while the worker was on leave of absence (Brasil, 1990BRASIL. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 20 set. 1990. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l8080.htm >. Acesso em: 9 jun. 2015.
http://www.planalto.gov.br/ccivil_03/lei... ).

In the 1990s, the Vocational Rehabilitation of the INSS was set aside, and its human resource staff decreased. The Vocational Rehabilitation Modernization Plan determined through Decree 2,172/1997 the end of all therapeutic activities of the staff, among other measures (Brasil, 1997BRASIL. Decreto nº 2.172, de 5 de março de 1997. Aprova o Regulamento dos Benefícios da Previdência Social. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 6 mar. 1997. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/decreto/D2172.htm >. Acesso em: 1 mar. 2016.
http://www.planalto.gov.br/ccivil_03/dec... ; Maeno; Takahashi; Lima, 2009MAENO, M.; TAKAHASHI, M. A. B. C.; LIMA, M. A. G. Reabilitação profissional como política de inclusão social. Acta Fisiátrica, São Paulo, v. 16, p. 53-58, 2009.).

Decree 3,048/1999, which regulates social welfare in Brazil, defines that the main attributions of Vocational Rehabilitation are (Brasil, 1999BRASIL. Decreto nº 3.048, de 6 de maio de 1999. Aprova o Regulamento da Previdência Social, e dá outras providências. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 7 mai. 1999. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/decreto/d3048.htm >. Acesso em: 9 jun. 2015.
http://www.planalto.gov.br/ccivil_03/dec... ): evaluation of the work potential; guiding and following the vocational program (leading the worker undergoing rehabilitation to consciously choose a new activity to perform in the labor market); working together with the community in partnerships and collaborations aimed at the new insertion of the insured on the labor market, without the INSS being obliged to ensure their effective insertion; lastly, following and researching their stabilization in the labor market (a set of actions to verify how the person who underwent rehabilitation is adapting to work and the effectiveness of the rehabilitation process, as well as to provide data for the management system).

The Carta do São Paulo, a document elaborated in 2003 by staffs of the Vocational Rehabilitation of the INSS of the entire country, entities, and non-governmental organizations provided a diagnosis for the situation of Vocational Rehabilitation inside the INSS and was one of the main instruments that led to the creation of the Revitalization of Vocational Rehabilitation proposed by the Ministry of Social Security in 2008. Its goals encompassed readopting a more comprehensive perspective of the process of Vocational Rehabilitation and of policies on the health of workers, together with the Ministries of Health, Labor and Employment and Education, proposing a new creation and training of multidisciplinary staffs. Thus, in 2008 a total of 101 civil servants were admitted to work as Social Security Analysts with a degree in Occupational Therapy, starting the process of recreating these staffs¹⁹19See: CANNALONGA, L. S. Projeto de Revitalização da Reabilitação Profissional. s/d. Disponível em: <www.proreabilitacao.com.br>. Acesso em: 16 de julho de 2012..

Practices and concepts of occupational therapists of Vocational Rehabilitation of the INSS

Considerations about the work²⁰20A summary of what we will discuss over the next three subitems was presented by the authors in the text "A atuação dos terapeutas ocupacionais no Instituto Nacional do Seguro Social" (Bregalda; Lopes, 2013).

During the interviews, work was mentioned as a central element in the chain of signified and signifiers of human making, which is in accordance with the centrality of work mentioned by (Castel, 2009CASTEL, R. As metamorfoses da questão social: uma crônica do salário. Petrópolis: Vozes, 2009.), who considers it the main element of citizenship and an axis of social relationships. The following topics were discussed: aspects that bring meaning to many areas of life through work; its role in integrating other events and spaces of daily life; the feeling of social belonging and contributing to society when working with something considered useful; the impacts of being on work leave; the transformations in the workforce, from its organization to the values attributed to it.

Part of the interviewees said their work is important to transform the work view of the insureds. The issue is very delicate, since a concept of work constructed throughout an entire career cannot be deconstructed - nor should it be - due to risky conditions of the labor market and to the fact that many of these workers did not have the possibility of assigning different meanings to their work regarding the choice of what to do or exercising their potential.

We believe a combined effort is required to help workers go through a path that leads to a new professional activity, based on their vocational abilities and beliefs regarding work, considering the complexity inherent to the process.

Observations on the insureds participating on the Program

With their answers to the questionnaire, occupational therapists mentioned that the following aspects of the insureds compromise the process or make it harder: the fear of being dismissed right after returning to the company or after the job security period ends, if it exists (97.5%); insufficient education (95%); long leaves of absences (95%); self-indulgence due to the benefits received (90%); lack of motivation for vocational training in a different area (87.5%).

More specifically, the interviewees expressed other fundamental issues for the difficulties faced by the insureds regarding their perspectives of returning to work, such as a work history based on heavy activities and the fear of unemployment. Their largest concern is not related to working, but to not finding any work.

For (Castel, 2009CASTEL, R. As metamorfoses da questão social: uma crônica do salário. Petrópolis: Vozes, 2009.), the current issue is the existence of populations which cannot be integrated because they are incapable of following the dynamics of a wage-earning society, whether due to some disadvantage or to having few resources to adapt to the rhythms of the "progress". These individuals have "lost the train to modernization and stay on the platform with very few luggage" (Castel, 2009CASTEL, R. As metamorfoses da questão social: uma crônica do salário. Petrópolis: Vozes, 2009., p. 530).

The relationships that individuals create with and in their work are fundamental elements for the constitution of their character, since they enable the experience of belonging and setting long-term goals for their lives (Sennett, 2010SENNETT, R. A corrosão do caráter: consequências pessoais do trabalho no novo capitalismo. Rio de Janeiro: Record, 2010.). In the current workforce, where conditions are becoming increasingly precarious, and in the case of Vocational Rehabilitation with its restrict possibilities, these elements are permanently menaced since there are no guarantees that the individuals will stay on their workplaces, and many insureds do not feel sufficiently confident to perform activities they were not rehabilitated to perform.

Observations on companies with employment relationship

As for the receptiveness of companies with employment relationship regarding the insureds returning to work through the Vocational Rehabilitation Program, 75% of the occupational therapists that participated in the research considered it regular; 12.5% considered it poor; and 12.5% considered it good. None of them classified it as excellent. The interviewees pointed out that companies collaborate very little to the rehabilitation of their employees, partially due to the lack of legal obligation to reinsert them in compatible functions and to the lack of knowledge, preparation and/or interest regarding the situation of the employees on leave and their perspectives of returning to work. Moreover, the therapists expected having more significant interventions inside the companies, which would go from increasing the analyses of work posts to bringing awareness regarding the principles, goals and actions of Vocational Rehabilitation.

Even though 67.5% of participants believe the Program partially prepares the insureds for their return to the labor market, both for cases when the worker returns to companies with an employment relationship and cases in which vocational training is provided through courses in areas that interest them, the interviews showed that being assigned to a compatible function in companies is still considered the best way to return to work in the opinion of occupational therapists. Hence, more contact with companies, informing their managers and other employers about the legislation and the situations experienced by workers on, as well as their potentials, and creating opportunities for trainings of vocational rehabilitation for positions compatible with these potentials are essential for the insureds to return to work performing activities that leave both employee and company satisfied.

As established by the Technical Manual that guides the actions of the Program (Brasil, 2011BRASIL. Instituto Nacional do Seguro Social. Resolução nº 160/PRES/INSS, de 17 de outubro de 2011. Aprova o Manual Técnico de Procedimentos da Área de Reabilitação Profissional. Diário Oficial [da] República Federativa do Brasil, Brasília, DF, 18 out. 2011. Disponível em: <Disponível em: http://www010.dataprev.gov.br/sislex/paginas/72/INSS-PRES/2011/160.htm >. Acesso em: 9 jun. 2015.
http://www010.dataprev.gov.br/sislex/pag... ), the INSS and the Ministry of Labor and Employment should work closer in cases that require the notification of situations experienced by the insureds, in order that appropriate measures are taken when their labor rights are disrespected, and that require guiding them to a Regional Superintendence of Labor and Employment to inform them about these rights.

The occupational therapists of the INSS were aware of the difficulties of preparing workers to return to work, for there are no guarantees, and the mechanisms that should ease their return and ensure their stay in the labor market are lacking. Moreover, they know that the lack of confidence and the resistance of some insureds regarding their participation in the Program is related to issues that do not pertain to the universe and possibilities of the INSS, as they have little to offer in comparison with their real demands. However, although the process of returning to work is often interpreted based on its inherent complexity, with at least a partial understanding of its many factors, the therapists see that the only possibility is a job appropriate for the individual, depending on how they are able or capable to adapt to a new work situation in the company with which they have an employment relationship.

For (Antunes, 2008ANTUNES, R. Adeus ao trabalho? Ensaio sobre as metamorfoses e a centralidade do mundo do trabalho. São Paulo: Cortez, 2008.), the right to work should be defended in spite of its conditions in contemporary society, for being out of a job for working classes, especially in developing countries, means facing conditions that are even worse than those experienced at work on a daily basis, as they do not rely on effective instruments of social security. Nonetheless, we propose the challenge of defending the right to work with dignity, within the context of Vocational Rehabilitation in the INSS, in which returning to companies with employment relationships is the priority since it is the most effective way to exercise this right.

Legislation and regulation of actions

The Quota Law (Law 8,213/1991) determines companies should hire people with disabilities and/or people that were rehabilitated by the INSS if they have more than 100 employees. Hence, it is a possibility for insureds to return to the labor market without any employment relationship, or to stay at the companies in which they have this relationship. Some of the interviewees were satisfied with this possibility, others were not completely accepting of such a law, for companies should be socially responsible for the lower work capacity of their employees, which is mostly due to the work activities they performed. Moreover, they mentioned the fact that Brazil does not have any mechanisms that promote an effective return of these people to the labor market through a combined effort of the Ministries of Social Security and Labor and Employment.

As for the Technical Manual of Treatment in the Area of Vocational Rehabilitation, a document that guides the actions of the Programs, the interviewees refer both to the need to standardize the procedures after the decentralization of the Vocational Rehabilitation for Executive Managements and Agencies of the Institute and to the structural inflexibility of the instrument, which limits part of the actions the therapists deem the most appropriate in certain situations.

It is necessary to reformulate the laws on Vocational Rehabilitation and the social protection of workers to go beyond ensuring a few rights which are limited to a year of job security in cases of work accidents or vocational diseases and mechanisms that compensate the insertion such as the Quota Law. The Institute is obliged to train the insureds for the labor market, and the insureds are obliged to participate in the Vocational Rehabilitation. Other measures are required to guarantee better conditions for workers in their return to work and stay at work, not only for rehabilitated individuals, but for the entire Brazilian working class.

Observations on the vocational rehabilitation process

The interviewed participants brought up the importance of considering that each insured needs a different amount of time to accept their new life condition - being on work leave - as well as for understanding and accepting the Program. The relevance attributed to the relationship created with the insureds during the entire process is observed from the initial evaluation to the moment they are disconnected from the program, which allows the therapists to take into account the issues they consider most relevant, in spite of the inflexibility of the procedures.

In addition, some statements considered that Vocational Rehabilitation, despite of its limitations and the life conditions of the insureds, which are usually hard, may represent an opportunity to choose a new work path and to even create new relationships with work. Moreover, they singled out the difficulty in providing rehabilitation for a position that usually generates an income that is lower than the income they had before the leave, and the need to inform the insureds about the real possibilities offered by the Program and the challenges they will face when returning to the labor market.

The occupational therapists knew that many events were related to the process of preparing the insureds to start a different work from what they were used to, and they were capable of identifying most of them. In a certain measure, they have been able to insert other elements in the combined evaluations and decisions regarding the projects elaborated together with the insureds, but most of the times this work is limited and carried out by struggling with the required procedures. Nevertheless, the identification of the events and the fact that in some moments they are considered during the elaboration of the projects for bringing the insureds back to work is an important advancement, as it goes beyond the work incapacity that focuses on the limitations caused by their clinical state.

We highlight that the occupational therapists listed some characteristics the insureds should have, or the need to prepare them for acquiring them, in order that their return to work is effective. Moreover, they should know the labor market so that they become more capable to meet the existing demands. However, they did not mention that this type of action is not very effective in an unstable and excluding labor market, and when the legislation for the social protection of workers is lacking. The statements of the interviewees discuss the meaning of the insertion, which presupposes the individuals developing characteristics that allow them to adapt to a specific space and/or situation, as well as the meaning of inclusion, which should encompass a process of transforming the person who wants to belong to a certain social place as well as the place itself, to receive individuals in their many forms of existence. It is necessary to expand the concept of training aimed at the labor market, which should not be limited to the characteristics and abilities of the insured, although the possibilities for considering issues beyond those in the daily life of the Program are insufficient.

The belief in Vocational Rehabilitation: general observations about the Program and ways to improve it

At the end of the answers to the questionnaire, the participants had the possibility to express their opinion regarding their belief or lack thereof in the Vocational Rehabilitation Program. From the 37 therapists which decided to do so, five said they did not believe in the program and 32, i.e., 86.5% of them stated that they believed in it, mentioning that many changes needed to be made.

During the in-depth interviews, a few aspects of Vocational Rehabilitation were brought up, such as: the fact that those responsible for the formulation of public policies and for the Institute itself do not acknowledge the importance of the program for the Brazilian society; the need to expand the work of Vocational Rehabilitation, going beyond vocational qualification and considering other problems of the insureds; the issue of the decentralization of Vocational Rehabilitation, which presupposed the need to standardize procedures through the Technical Manual that guides its actions; the limited structure of the Program considering its objective - the return to work of the insureds. These aspects were discussed through a critical perspective that acknowledges the importance and the structural limitations of the program and the desire to transform its structure and the belief in it, aiming at its enhancement and at a larger coordination with different social and governmental sectors related to the social protection of Brazilian workers.

We question the feasibility of a process that values and enhances the actions of Vocational Rehabilitation in the context of the current work organization and mechanisms of producing services and goods, which become increasingly substandard, seemingly dismissing individuals that have lower work capacity and/or restrictions that should be respected in their work activities. Obviously, the importance of the Vocational Rehabilitation program does not decrease in these circumstances, for it opens opportunities - even if in a limited way - for individuals to work in different activities, considering their needs after the transformations they went through.

Still regarding the many aspects of the social protection of workers and their permanence and/or reinsertion in the workforce, (Lopes, 1999LOPES, R. E. Cidadania, políticas públicas e terapia ocupacional no contexto das ações de saúde mental e saúde da pessoa portadora de deficiência, no Município de São Paulo. 1999. Tese (Doutorado em Educação) - Faculdade de Educação da Universidade Estadual de Campinas, Campinas, 1999.) highlights that for those who have labor power to be included in social exchanges, an educational process is also necessary, as well as a work background and the solution of many problems such as living conditions, mental and physical healthcare for the worker and their family, and transportation between their home and the workplace.

For (Takahashi and Iguti, 2008TAKAHASHI, M. A. B. C.; IGUTI, A. M. As mudanças nas práticas de reabilitação profissional da Previdência Social no Brasil: modernização ou enfraquecimento da proteção social? Cadernos de Saúde Pública, Rio de Janeiro, v. 24, n. 11, p. 2661-2670, nov. 2008.):

As for the principles, goals and ideologies of the program, 50% of the participants believe that they should be entirely reviewed and reformulated, 47.5% of them say they should be maintained but with structural changes, and 2.5% say they should be maintained. Regarding the future of the program, 84.2% of occupational therapists believe it will improve, 10.5% think it will stay the same, and 5.3% think it will become worse.

82.5% of the occupational therapists do not agree with the fact that the INSS is the only institution in charge of the vocational rehabilitation of the insureds. During the interviews, we realized that this opinion is related to the fact that the processes of returning and staying at the job require not only improving the structure of the program, but an urgent coordination with other governmental sectors that should share this responsibility, such as the Ministries of Labor and Employment, Education and Health, to build a set of actions that revolve around attention and care with the worker's health, better educational conditions, encompassing vocational education as well, and more and better opportunities for a (new) insertion in the labor market.

According to (Maeno and Vilela, 2010MAENO, M.; VILELA, R. A. G. Reabilitação profissional do Brasil: elementos para a construção de uma política pública. Revista Brasileira de Saúde Ocupacional, São Paulo, v. 35, n. 121, p. 87-99, jan. /jun., 2010.),

Final remarks

The analysis of the data obtained with the application of the questionnaire and with the contents of the interviews, in the light of the theoretical references that guided this research, allowed for the identification of opinions, perspectives, expectations and beliefs about the themes of the research. By following its goals, we provided a foundation for the study of the performance and knowledge production of occupational therapy on topics related to work, workers on leaves of absence and their return to work, and the formulation of public policies regarding these issues.

The occupational therapists working in the Vocational Rehabilitation of the INSS, in the state of São Paulo, joined the institution mostly because the work motivated them and they had part of the required knowledge for working in the area. However, the fact that the therapists affirmed that the knowledge produced is insufficient to support their work and concepts regarding vocational rehabilitation, owing to the lack of works that link occupational therapy and the process of an individual returning to work after a leave of absence, emphasize the need for more researches such as this one.

Their will to collaborate was noticed since the first contact and confirmed with the participation of virtually all of them, which indicates their availability and the need for discussing the actions and concepts that have been built in the field of vocational rehabilitation, internally and externally to the job.

As a result, it is difficult to harmonize the belief in occupational therapy with the daily tasks of the work and the impotence experienced through them. It is somewhat similar to the situation of the insureds, which do not have sufficient conditions to manifest their work potential.

Although they state being partially satisfied with their work within the program, in many aspects the tendency toward not being satisfied is larger, which can be observed by the fact that a significant percentage of the therapists (43.2% of those who provided the answer in the questionnaire) consider that they do not have suitable conditions for exercising any of the actions defined by the program. Many factors mentioned by them imply that their evaluation of their work within the INSS is more negative than positive, and these factors do not depend on them or their job, being more linked to structural issues of the program. Nevertheless, they believe in enhancing this structure and single out the need to increase the possibilities it offers for a larger participation and responsibility of companies, creating a combined effort with other governmental sectors and the civil society, in addition to expanding and reformulating the legislation on vocational rehabilitation in Brazil.

The belief in their professional potential is related to helping individuals see, give meaning and value to their leave of absence, their professional and personal background; to helping them build strategies for facing these conditions and new actions in the world; to welcoming the insureds; to investigating and identifying the meanings they attribute to their new conditions and the changes that occurred in their lives after the decrease in their work capacity. These aspects stimulate and feed this belief, and at the same time it makes the therapists more critical of the limits inherent to the contradictions of the field, which requires them to reconstruct themselves professionally, to reinvent themselves as workers owing to a new demand and a new practice, recognizing their own identity in the process.

Acknowledgements

We would like to thank the occupational therapists that made this study possible by sharing their experiences, opinions and reflections with us.

References

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