Abstract

This article presents a critical overview of theories and practices that aim to enhance black women's health focusing on the concept of resilience. Beyond the academic literature, mostly from Pyschology, this text mobilizes different sources about racial relations, including the social movement production. Black women are exposed to human rights deprivation, to the inefficency of governmental programs that should guarantee the right to education and to comprehensive health care, among others. They are also frequently exposed to racism and sexism that affect their health. The concept of "resilience as a process" adopted in this article, a result of both the critical reflection on the literature and of research data, supports the adoption of a psychosocial approach resulting from vulnerabilities analysis integrated to a human rights based framework. The conclusion calls for initiatives that include the practical knowledge of black women and for valuing their collective and transgenerational experiences that has supported the overcome of their exposure to extreme vulnerable contexts, experiences that enhanced their processes of resilience. In this perspective, there is a need to consider not only black women's assistance and individual care but also their different experiences of belongingness, their trajectories, their networks, communities and territories.

Keywords:
Psychosocial; Race Relations; Ethnicity and Health; Women; Health Vulnerability; Psychological Resilience

Introduction

In Brazil, as several studies included in this journal show, the black population is often exposed to contexts of higher vulnerability to illnesses. This situation expresses historical human rights deprivations (Santos, 2012SANTOS, A. O. Superar o racismo e promover a saúde da população negra: desafios para o trabalho de prevenção ao HIV/Aids no Brasil. In: PAIVA, V.; AYRES, J. R.; BUCHALLA, C. M. (Org.). Vulnerabilidade e Direitos Humanos - Prevenção e promoção da saúde: da doença à cidadania. Curitiba: Juruá, 2012. p. 145-164. (Coletânea Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro 1). ) and, in the case of black women's health, an specific inefficiency of government programs to ensure prevention and integral health care, that adds to the systematic impact of sexism and institutional racism (DFID/Instituto AMMA Psique e Negritude, 2007; Lopes, 2005LOPES, F. Experiências desiguais ao nascer, viver, adoecer e morrer: tópicos em saúde da população negra no Brasil. In: BRASIL. Fundação Nacional de Saúde. Saúde da população negra no Brasil: contribuições para a promoção da equidade. Brasília, DF: Funasa, 2005. p. 9-48.).

Black women should benefit from the critical reflection and of many studies that have described their higher vulnerability to illnesses; it is urgent to go beyond its denunciation and description. Regarding a better professional-patient and service-user interaction, the academic debate recognizes that continuous education and training is important in various sectors (companies, civil society organizations, government bodies) that integrate the effort to understand and to mitigate historical processes of stigmatization and institutional discrimination based on skin color. On the other hand, it is still a challenge to understand those trajectories and experiences that have sustained black women adherence to health services, and ensure a productive interaction in daily life with quality, despite the social and programmatic context.

The objective of this text is to present a critical overview of theories and practices that might enhance the health of black women, focusing on the concept of resilience, using a psychosocial approach within the vulnerability and human rights framework.

From the sociopsychological conception of risk to psychosocial approach of vulnerabilities and rights

The notions of "risk factors" and "risk behavior", even when interpreted in a biopsychosocial or sociopsychological perspective of the health-illness process, found their limits to think health practices throughout the 1990s. In Brazil, the expansion of these notions through the language of human rights had already been shaped since the struggle for the psychiatric reform and throughout the innovative policy implementation of of the Integral Care to Women's Health Program (PAISM) in the 1980s. In the context of the struggle against the AIDS epidemic, this same movement produced a more elaborate alternative.

Over those years, different phenomena made the AIDS epidemic explode. It was soon clear that the notions of "factors" and "risk behavior", from the classic epidemiological description, did not hold the same productivity in the design of actions in the field of prevention and care. On the contrary, the colonization of care and prevention by the epidemiological discourse of risk proved to be counterproductive. The understanding of prevention restricted to risk factors and behaviors resulted, for instance, in the blaming of those affected that were reduced to sociological an epidemiological types, stigmatized and accused of "behaving badly"(maintaining risk behaviors) or, worse, stereotyped as incarnation of risk groups (homosexuals, sex workers, young people). A more dynamic and contextualized description of the epidemic proved to be more productive when integrated into the analysis of programmatic-social response and context, articulated with the language of human rights. The epidemic scenario dependents strongly on the presence or absence of policies and programs.

The construction of the response to AIDS consolidated, theoretically and methodologically, the framework of vulnerability and human rights (V&HR) (Paiva; Ayres; Buchalla, 2012PAIVA, V.; AYRES, J. R.; BUCHALLA, C. M. Direitos humanos e vulnerabilidade na prevenção e promoção da saúde: uma introdução. In: ______. (Coord.).Vulnerabilidade e Direitos Humanos - Prevenção e promoção da saúde: da doença à cidadania. Curitiba: Juruá, 2012. p. 9-22. (Coletânea Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro 1).)²2This process is described in the introduction and in several chapters of the collection Vulnerabilidade e Direitos Humanos - prevenção e promoção da saúde. Curitiba: Juruá, 2012. In English, see Ayres, J. R. C., Paiva, V., França-Jr., I. From Natural History of Disease to Vulnerability: changing concepts and practices in contemporary public health. In: R. Parker, M. Sommers (editors). (Org.). Routledge Handbook of Global Public Health. London/New York: Routledge/Taylor and Francis, p. 98-107, 2010..

Vulnerability is understood, according to Lopes (2005LOPES, F. Experiências desiguais ao nascer, viver, adoecer e morrer: tópicos em saúde da população negra no Brasil. In: BRASIL. Fundação Nacional de Saúde. Saúde da população negra no Brasil: contribuições para a promoção da equidade. Brasília, DF: Funasa, 2005. p. 9-48.), as the configuration of individual and collective aspects that, in different contexts, graduate the intensity and the mode of exposure to diseases and harm. Lower or higher vulnerability also modulates the access to better or worse conditions for personal reaction and collective protection against potentially harmful effects of each situation.

One of the principles of the comprehension of the health-illness process in the vulnerability framework is to identify the lines of greater human rights discrimination: in population segments and territories in which there are more diseases and deaths, the probability of finding more violation and discrimination of rights is bigger (Ayres; Paiva; França Junior, 2012PAIVA, V.; AYRES, J. R.; BUCHALLA, C. M. Direitos humanos e vulnerabilidade na prevenção e promoção da saúde: uma introdução. In: ______. (Coord.).Vulnerabilidade e Direitos Humanos - Prevenção e promoção da saúde: da doença à cidadania. Curitiba: Juruá, 2012. p. 9-22. (Coletânea Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro 1).; 2010). Therefore, the AIDS field was pioneer and the first to include the "skin-color cathegory" (quesito-cor) as a key factor for a competent analysis of the epidemic; race/etnicity became required for the design of national policies and programs (Santos, 2012SANTOS, A. O. Superar o racismo e promover a saúde da população negra: desafios para o trabalho de prevenção ao HIV/Aids no Brasil. In: PAIVA, V.; AYRES, J. R.; BUCHALLA, C. M. (Org.). Vulnerabilidade e Direitos Humanos - Prevenção e promoção da saúde: da doença à cidadania. Curitiba: Juruá, 2012. p. 145-164. (Coletânea Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro 1). ). The AIDS program was pioneer in Brazil when published a discussion about most vulnerable groups to AIDS morbity and mortality comparing black with non-blacks.

The analysis in the vulnerability and human rights framework should address the inextricable interactions between the individual ( the person as subject of rights), and the social and programmatic domains. Health programs and the programmatic domain in Brazil should ensure equity, universality and integrality of the constitutional right to health, as well as non-discrimination based on sex and "skin collor". This human rights based approach to health will always depend on the integration of several disciplines - for example, epidemiology and social analyses based on the gender category, different clinical knowledges and complex understanding of cultures and religions of people and communities. A systemic analysis, as the in vulnerability pespective, will consider that the individual dimensions are inextricably linked to the social and programmatic dimensions.

Individuality, or the individual level of analysis, is understood as intersubjectivity in this framework. This V&HR perspective contrasts with the usual approach to the individual dimension as the dimension of the biological-behavioral individual - in other words, an abstract categorization of sociopsychological-behavioral factors derived from population surveys. From the vulnerability and human rights perspective (V&HR), successful approaches will consider each person singularity at each meeting for care or prevention; should understand the person's different intersubjective scenes and life situations.

In the V& HR framework, the individual dimension is the one of the person that will be addressed as sujeito (an agent) of his/her everyday life and of rights (a rights holder), in the living dimension of intersubjectivity (Paiva, 2013PAIVA, V. S. F. Psicologia na saúde: sociopsicológica ou psicossocial? Inovações do campo no contexto da resposta brasileira à aids. Temas em Psicologia, Ribeirão Preto, v. 21, n. 3, p. 531-549, 2013.; Ayres; Paiva; França Junior,2012AYRES, J. R.; PAIVA, V.; FRANÇA JUNIOR, I. Conceitos e práticas de prevenção: da história natural da doença ao quadro da vulnerabilidade e direitos humanos. In: PAIVA, V.; AYRES, J. R.; BUCHALLA, C. M. (Coord.). Vulnerabilidade e Direitos Humanos - Prevenção e promoção da saúde: da doença à cidadania. Curitiba: Juruá, 2012. p. 43-94. (Coletânea Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro 1).). According to the authors, the understanding of the individual dimension should consider social interactions, subjective/intersubjective dynamics, physical and psychological aspects, sociodemographic characteristics, personal experiences and values, the style of administration of circumstances, the way it absorbs/elaborates/incorporates/has resources and interpersonal relationships.

Within the social dimension of vulnerability, the connection of specificities that shape the different social relations, such as the ethnic-racial, of gender, of social class, generational, of physical and psychological conditions, among others, result in the embodiment of the social relations. For example, between a black, old, self-employed woman who lives in a low-income neighborhood, and her neighbor, a white woman who is an adult and a public server, both coming from families supported by women. These social relations are permeated by a context of greater equality/inequality within the sphere of protection or deprivation of rights, social inclusion or exclusion, autonomy or limitation, symmetry or asymmetry, which influence the access (or not) to employment, health, education, culture, recreation, information and revelant knowledge.

Finally, the programmatic dimension, that other models include as part of the social dimension, within the V& HR framework should be considered as a separate dimension. In the programmatic analysis the relationships between people and services, policies, institutions and programs are considered, in different sectors − such as health, education, culture, social welfare, justice, job market or housing - regarding the access to or the negligence and deprivation of rights that sustain or decrease the vulnerability to illness.

This understanding of the health-illness process has benefited from the constructionist socialpsychological approach adopted by the Brazilian perspective of the vulnerability and human rights framework which, in short:

Race relations and the psychosocial perspective in Brazil

The recognition of racism and sexism as determinants of health conditions, as well as the consideration of the consequent production of racial and gender inequalities, require innovation to face them in the field of health promotion and, therefore, expanding old perspectives, reformulating theories, techniques and practices. The strong inspiration in the social movements of resistance and efforts to mitigate racism, inequalities and violation of rights calls for a psychology in the health field marked by a psychosocial perspective. But what does that mean?

The term psychosocial has different meanings in the health literature and it is rarely substantively defined. It is yet to be constituted as an independent descriptor in the various databases. (Paiva, 2013PAIVA, V. S. F. Psicologia na saúde: sociopsicológica ou psicossocial? Inovações do campo no contexto da resposta brasileira à aids. Temas em Psicologia, Ribeirão Preto, v. 21, n. 3, p. 531-549, 2013.) On the other hand, it has frequently qualified other terms such as "attention", "risk", "rehabilitation", "readaptation", intervention", "evaluation", "aspect", "adequacy", "integration". "Psychosocial development", for example, is frequently associated with "risk" when it addresses progressive stages of maturation, stages that would "naturally" have increased risks, especially in light of specific social contexts. Psychosocial also appears conjugated to other terms, lending them specific meanings. "Psychosocial care", for example, usually means the care addressed towards mental impairments or suffering that harm social coexistence; it may also describes strategies for dealing with problems arising from social vulnerability and poverty or a set of palliative forms of care.

When "psychosocial factors" are described and analyzed, the meaning is more frequently related to socioeconomic and demographic data, factors that can result in "psychosocial effects" - and those would produce some risk groups and risky contexts. Because macroanalysis or population studies are basing these definitions, in translating interpretation to its practical meaning or to inform health practices, the individual may be loaded with responsibility: through individually focused prevention and health care actions the individual is either generic or typified by the "socioeconomic", "sociodemographic", a "social psychological" entity.

Regarding Brazilian literature, the "psychosocial" also refers to the new practices that should replace the asylum model in mental health policies after Health and Psychiatric Reform, like in the Centers of Psychosocial Care (CAPS/NAPS). ( Paiva, 2013PAIVA, V. S. F. Psicologia na saúde: sociopsicológica ou psicossocial? Inovações do campo no contexto da resposta brasileira à aids. Temas em Psicologia, Ribeirão Preto, v. 21, n. 3, p. 531-549, 2013.) The psychosocial term also qualifies, in the texts produced for thinking the Unified Health System (SUS), a form of work in which care actions are guided by "integralidade", as opposed to the exclusively biomedical model; or, also, with reference to the association and complementarity between the individual and social dimensions. More recently, in the Brazilian literature the term psychosocial is used for qualifying social relations (for example, between classes, genders and ethnicities/races, in groups and institutions), naming the sociohistorical context, and moreover, to giving meaning to the consideration of the social context and disapprove theories and practices restricted to the individual psychic dimension.

In the vulnerability and human rights framework the psychosocial approach transcends the psychological (more common in clinical practice) and sociopsychological (more common in epidemiology) approaches and considers the individual, social and programmatic dimensions to organize, for example, health practices directed at black women. This challenge was faced in some theoretical, technical and practical productions developed in the area of psychology and race relations. The adoption of this perspective became very productive because it gave greater breadth to studies and actions, and found harmony with traditional political and academic conceptions about black people, as shown below.

The definition of institutional (or systemic) racism, which in 1967 was designed by members of the American group Black Panthers, has been adopted also in Brazil, in various anti-racism practices of the black social movement; it has broadened the restricted conception of racism and its confrontation as individual coping and an interpersonal phenomenon (Geledés; Cfemea; Werneck, 2013GELEDÉS - INSTITUTO DA MULHER NEGRA; CFEMEA - CENTRO FEMINISTA DE ESTUDOS E ASSESSORIA; WERNECK, J. Racismo institucional: uma abordagem conceitual. São Paulo: Geledés; Cfemea, 2013.; Werneck, 2010WERNECK, J. (Org.) Políticas públicas para negras e negros. Rio de Janeiro: Criola; Fundação Heinrich Boll, 2010.; Goulart; Tannús; Lopes, 2007GOULART, F. A.; TANNÚS, L; LOPES, F. (Coord.); Subsídios para o enfrentamento do racismo na saúde. Brasília, DF: Ministério do Governo Britânico para o Desenvolvimento Internacional, 2007.). This definition dialogues with the vulnerability and human rights perspective, and with the Brazilian critical thinking that have been arguing that institutional equipment and programs have the duty of ensuring rights.

Institucional racism has two dimensions. In its interpersonal dimension, through the dynamics of the synergy between stigmas, stereotypes, prejudices and discrimination that occur between peers, between professionals and patients, or between different hierarchical positions, functions and roles. In the programmatic level, the same dynamics appear in work environments and processes, contaminating standards, procedures, and also causing negligence in relation to specific needs and rights (Santos, 2012SANTOS, A. O. Superar o racismo e promover a saúde da população negra: desafios para o trabalho de prevenção ao HIV/Aids no Brasil. In: PAIVA, V.; AYRES, J. R.; BUCHALLA, C. M. (Org.). Vulnerabilidade e Direitos Humanos - Prevenção e promoção da saúde: da doença à cidadania. Curitiba: Juruá, 2012. p. 145-164. (Coletânea Vulnerabilidade e direitos humanos: prevenção e promoção da saúde. Livro 1). ). In addition to these, the disqualification, devaluation and invisibilization of black population demands in services culminate in health care procedures and programs (attention and prevention) that are not guided by the principles of equity and equality, as reports Lopes (2005LOPES, F. Experiências desiguais ao nascer, viver, adoecer e morrer: tópicos em saúde da população negra no Brasil. In: BRASIL. Fundação Nacional de Saúde. Saúde da população negra no Brasil: contribuições para a promoção da equidade. Brasília, DF: Funasa, 2005. p. 9-48.).

Both the constructionist social psyshcology applied to health and the psychology of racial relations value a psychosocial approach in their academic productions and make it easier to understand how institutional racism also influences technical-scientific knowledges and practices that pervade many areas of everyday life (education, work, among others) resulting in the violation or negligence of health rights for black women.

A document published in 2007, by the DFID/AMMA Psique e Negritude Institute, a non-governmental organization for black women and the black movement, was emblematic of the psychosocial approach adopted in theories and practices devoted to the documentation and confrontation of institutional racism³3The Program of Combat Against Institutional Racism (PCRI) lasted seven years and had the following steps: (1) Construction of the Program, (2) Formation of the Intersectoral Group (national and international public institutions) and of the Foundation Team (civil society organizations), (3) Sensitization of the Intersectoral Group, and (4) Diagnosis of Institutional Racism. In this last step, the activities included workshops of identification and addressing of institutional racism, which considered as dimensions of analysis the one of interpersonal relationships and the political-programmatic one..

In the interpersonal dimension, described interventions centrally focused on interactions between supervisors and subordinates, between peers, and between professionals and users. The actions in the political-programmatic dimension targeted inequalities, discriminations, omissions in the ensuring of rights and also aimed at the implementation of standards, mechanisms and confrontation strategies against institutional racism for the promotion of equality and equity. In addition to courses and political negotiatons, workshops to identify and address institutional racism were developed, encouraging employees and managers to exchange testimonies and improve their perception of the racism that influences daily life and public policies. In these spaces, participants were encouraged to identify: their own prejudices and stereotypes, the experiences of discrimination and race relations in the workplace, resources and difficulties of public bodies in relation to the subject, the mechanisms of oppression; they were also encouraged to understand racism as a determinant of inequalities and to think about possible coping strategies.

Subsequently, the AMMA Psique e Negritude Institute defined the psychosocial (and not sociopsychological) approach as very important:

This definition states, therefore, the need for consideration of the sociocognitive aspects integrated to the intra-psychic, interpsychic, social, political aspects, among others, contextualizing the dynamics of race relations and of attitudes and actions, aspects that may be associated with the individual and social dimensions of vulnerability.

In another publication concerning the project to face institutional racism by Geledés and Cfemea (2013GELEDÉS - INSTITUTO DA MULHER NEGRA; CFEMEA - CENTRO FEMINISTA DE ESTUDOS E ASSESSORIA. Guia de enfrentamento do racismo institucional. São Paulo: Geledés; Cfemea, 2013.), these other feminist/anti-racism organizations, together with the Federal Government and United Nations agencies, offered subsidies for the diagnosis of institutional racism discussing conceptual frameworks of analysis and social indicators to identify how racism influences inequalities, how to assess the levels of social protection or negligence of black women. This project indicated replicable methodologies of monitoring, evaluation and confrontation of institutional racism, made available to ensure rights to black women. As in Prestes (2013PRESTES, C. R. S. Feridas até o coração, erguem-se negras guerreiras: resiliência em mulheres negras: transmissão psíquica e pertencimentos. 2013. Dissertação (Mestrado em Psicologia Social) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 2013.), this text recognizes the value ot the vulnerability and human rights framework, and especially, how productive is the programmatic vulnerability analysis to describe institutional racism. The publication highlights how institutional racism impacts on the vulnerability of affected people and social groups.

Costa (1986COSTA, J. F. Violência e psicanálise. Rio de Janeiro: Graal, 1986.), in turn, contributes to the reflection on how racism and its stereotypes, prejudices and discriminations, permeate actions of institutions (programmatic dimension) and of everyday life (social dimension), eventually contaminating the inter and intrapsychic dynamics. The author discusses the effects of racist ideology as a significant interference over personal dimensions such as the body, psyche and identity. In a very productive perspective in this field, he argues that the idealized social model of "whiteness" generates damages for white people − an unreal exalting perfection − and for black people − the unattainable fetish. The denial of the black body and identity arises as an expression of the internalization of racism.

Nogueira (1998NOGUEIRA, I. B. Significações do corpo negro. 1998. Tese (Doutorado em Psicologia Escolar e do Desenvolvimento Humano) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 1998.) gives a significant contribution from the psychoanalytic field to the subject of race relations, in considering both intrapsychic characteristics and historical, social and intersubjective characteristics. He understands the black body and subjectivity as signs that respond to social dynamics and ideological marks. In this context, the black body, at the same time, fulfils the desire of black individuals and carries pejorative marks that compromise its acceptance and recognition.

In the same perspective of consideration of the psychic contents as interrelated to a context, Reis Filho (2005REIS FILHO, J. T. Negritude e sofrimento psíquico. 2005. Tese (Doutorado em Psicologia Clínica) - Programa de Estudos Pós-Graduados em Psicologia Clínica da Pontifícia Universidade Católica de São Paulo, São Paulo, 2005.) deals with the social and psychological condition of black individuals as a "social and individual symptom" of racism. He questions the fact that there is very low numbers of black people who are psychoanalysts or their customers within the clinic practices. He also explains the invisibility of the racial theme as a result of the unpreparedness of professionals to accommodate this demand when expressed, so they can identify it spontaneously and contextualize intra and interpsychic issues linked to social and historical dimensions. This panorama increases the specific programmatic vulnerability of the black population.

Souza's book (1990SOUZA, N. S. Tornar-se negro: as vicissitudes da identidade do negro brasileiro em ascensão social. 2. ed. Rio de Janeiro: Graal, 1990.), a classic in the area of psychology and race relations, relates psychoanalysis to the social and historical contextualization. The author discusses the process of becoming black as a trajectory starting from a common history, and also includes political awareness, respect to difference and dignity, in a context free from exploitation.

Still according to the author, being black would imply loss of personal prospects under the imposition of demands and expectations of others, and massacring identity. As a result of this context and in spite of it, highlights the author, being black means being able to resist through reclaiming of history and achieving of potentials.

Hooks (2006HOOKS, B. Vivendo de amor. In: WERNECK, J.; MENDONÇA, M.; WHITE, E. C. (Org.). O livro da saúde das mulheres negras: nossos passos vêm de longe. 2. ed. Rio de Janeiro: Pallas; Criola; San Fracisco: Global Exchange, 2006. p. 188-198.), who is a reference in the field of black feminism, discusses the possibilities of reversal of the damage produced by racism and sexism on the mental health of black people. She claims that these two ideologies of dominance may lead to difficulties in experiencing and expressing love bonds, at a loss of emotional, family relationships, and impairing the ability to love. The author emphasizes that for black people whose heart has been injured, love is an act of resistance. If resilience, as exposed in the next section of this article, is associated with transcendence, new meaning of life and good family and interpersonal relationships, this conception ratifies the thesis that healthy love bonds, through their transforming power, contribute to a satisfactory integral health and to the confrontation of existing social structures.

Fanon (2008FANON, F. Pele negra, máscaras brancas. Salvador: Edufba, 2008.), an important author in the field of psychology and race relations, offers productive psychoanalytic foundation for analyzing contexts of oppression, colonialism, racism, among other enhancers of vulnerability to psychic distress. In the process of elaboration in detriment of the racist context, the healing of wounds and awareness must be accompanied by the overcoming of the attachment to a past of pain and the abandonment of the notion of a "black essence". Freedom is reached to achieve harmony with the present, with social reality, with the personal and social commitment, with acts against oppression and for equality. He aligns himself to the psychosocial perspective when conceiving the overcoming of vulnerabilities as a process that goes beyond personal dimension, complemented by social engagement for collective benefits.

Personal satisfaction and individual health extend the possibilities for the exercise of other aspects of life, such as autonomy and citizenship. The perspective defended here, assumes that the opposite direction is also possible, i.e. autonomy and citizenship open the possibility of the exercise of personal satisfaction and individual health. Coping strategies engaged by black women to achieve personal satisfaction or for taking care of their kin are recurrent in history, as pointed out by Lopes (2008LOPES, H. T. Mulher, cultura e identidade afro-brasileira. In: NASCIMENTO, E. L. (Org.). Guerreiras de natureza: mulher negra, religiosidade e ambiente. São Paulo: Selo Negro, 2008. p. 85-96. (Coleção Sankofa: matrizes africanas da cultura brasileira. Volume 3). ), Oliveira and Brito (2011OLIVEIRA, M. A. B.; BRITO, A. M. B. B. A trajetória do racismo e a violência sofrida pela mulher negra: uma questão de saúde pública. In: RISCADO, J. L. S.; OLIVEIRA, M. A. B. (Org.). Quilombolas, guerreiros alagoanos: aids, prevenção e vulnerabilidades. Maceió: Edufal, 2011. p. 85-96.) and Werneck (2006WERNECK, J.; MENDONÇA, M.; WHITE, E. C. (Org.). O livro da saúde das mulheres negras: nossos passos vêm de longe. 2. ed. Rio de Janeiro: Pallas; Criola; San Fracisco: Global Exchange, 2006.). Since the post-abolition period and in spite of the contexts in which they usually find themselves in, black women are often responsible for family support, keepers of traditions, organized in groups in search of freedom and equality for their kin. In other words, they form a population segment that has historically led individual and group strategies of coping, resilience and resistance, as sujeitos (agents) of their everyday life and as social actors. These aspects encourage resilience processes, as explained below.

Thus far it has been discussed how the psychosocial approach is relevant for mitigating illnesses of the black population and that this approach can be sophisticated by the perspectives adopted in the vulnerability and human rights framework. In the following excerpt, the power of the psychosocial approach, in this perspective, linked to the theme of the health of black women, will be illustrated by a broadening of the concept of resilience.

Psychosocial approaches of resilience in black women

The different concepts of resilience and their consequent theoretical specificities, that derive techniques and practices, are a good examples of the difference between individualizing perspectives and a psychosocial approach.In a previous work, Prestes (2013PRESTES, C. R. S. Feridas até o coração, erguem-se negras guerreiras: resiliência em mulheres negras: transmissão psíquica e pertencimentos. 2013. Dissertação (Mestrado em Psicologia Social) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 2013.) listed different definitions of resilience by authors who are references in the field, such as Angst, Barbosa, Benevides-Pereira, Bortoletti, Cicchetti, Delongis, Flach, Folkman, Garcia, Grotberg, Lazarus, Luthar, Pesce, Selye, Sequeira, Vasconcellos, Wagnild, Young and Yunes. The definitions were then classified into two perspectives: the first defines resilience with a structural bias, and was named "constitutional conception"; the second perspective conceives resilience with a more dynamic and contextual meaning, and was named "processual conception". The constitutional conception definitions address:

In the processual conception, on the other hand, resilience "is no longer considered a quality or an individual capacity but understood as a dynamic, systemic interrelational process, inserted into the historical, social and cultural context" (Souza, 2009SOUZA, M. T. S. Terapia familiar e resiliência. In: OSÓRIO, L. C.; VALLE, M. E. P. (Org.). Manual de terapia familiar. Porto Alegre: Artmed, 2009. p. 193-207., p. 193). The field can, therefore, move towards a psychosocial approach integrated to the analyses of the health-illness process in the vulnerability and human rights framework.

The distinction between the two perspectives and definitions of resilience and the valorization of the process (with different designations) are also observed in authors such as Barlach (2005BARLACH, L. O que é resiliência humana? Uma contribuição para a construção do conceito. 2005. Dissertação (Mestrado em Psicologia Social) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 2005.), Cyrulnik (apud Sequeira, 2009SEQUEIRA, V. C. Resiliência e abrigos. Boletim Academia Paulista de Psicologia, São Paulo, v. 29, n. 1, p. 65-80, 2009.), Grotberg (apud Melillo; Ojeda, 2005MELILLO, A.; OJEDA, E. N. S. Resiliência: descobrindo as próprias fortalezas. Porto Alegre: Artmed, 2005.), Luthar e Cicchetti (2000LUTHAR, S. S.; CICCHETTI, D. The construct of resilience: implications for interventions and social policies. Development and Psychopathology, Cambridge, v. 12, n. 4, p. 857-885, 2000.) and Souza (2009SOUZA, M. T. S. Terapia familiar e resiliência. In: OSÓRIO, L. C.; VALLE, M. E. P. (Org.). Manual de terapia familiar. Porto Alegre: Artmed, 2009. p. 193-207.).

Adopting the processual conception, Prestes (2013PRESTES, C. R. S. Feridas até o coração, erguem-se negras guerreiras: resiliência em mulheres negras: transmissão psíquica e pertencimentos. 2013. Dissertação (Mestrado em Psicologia Social) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 2013.) defends that resilience is not a stage, a capacity, a state, a trait, a condition of invulnerability, or an attribute or ability of individuals or groups. Based on the psychosocial approach, resiliency is conceived as a process, a phenomenon with multiple determinations and that is, mainly, contextual. Resilience could present itself in different stages of life, stages of a person or group, in different population segments, in the presence of greater or lesser symptoms. It is as a systemic process that, through access to resources and support, may achieve the overcoming of major adversities with less devastating effects than what is found in similar situations. It might result in strengthening, transcendence and meaning through experience, even when facing great vulnerability to illness that predispose exhaustion. Women who mobilize resilience in their trajectories found resources that allowed them to not succumb and to overcome.

In the case of black women, what can be seized from this notion of resilience?

Analysing processes of resilience Prestes (2013PRESTES, C. R. S. Feridas até o coração, erguem-se negras guerreiras: resiliência em mulheres negras: transmissão psíquica e pertencimentos. 2013. Dissertação (Mestrado em Psicologia Social) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 2013.), discussed black women's trajectories based on interviews with four generations of black women in the same family (matriarch, daughter, granddaughter, great-granddaughter). All of them described how they coped with, confronted and overcome major adversities, to identify possible processes of resilience.The objective was to analyze processes of resilience and the influences resulting from intersubjective and psychic transmission (the psychic continuity of the black family, descendants, ascendants, ancestors), resulting from symbolisms associated with black women, and morever, resulting from shared meanings in traditional practices of black communities − cultural, political, intellectual or religious.

The matriarch, for example, reported how she handled the husband's death situation: she demonstrated to be committed to resolve logistical issues and to protect her son when giving the bad news. In describing her reactions, she remembered the decision that, from that moment on, she would focus on working and on "giving". She lists as the most frequent aspects that coincided with overcoming processes throughout her life: the Christian religious faith, the bond with the nuclear family, her persistence and self-confidence. The presence of these aspects as facilitators of processes of resilience supports what has been found in more traditional theories on the subject. Her daughter, on the other hand, recognized in her trajectory towards racial identification one of the most memorable influences of her processes of resilience. She described her connection to black political manifestations of black communities and her interest in history - of black people and of the black side of the family. She stressed how racial belongingness and knowledge of these histories contributed to overcoming processes.

The granddaughter, in turn, acknowledged the importance of the religious teachings of African origin and the network of support formed by black family members when she described situations in which she overcame major adversities. Finally, the great-granddaughter described a satisfactory outcome in light of events of racial discrimination, as an emblematic example of overcoming of a major adversity: she started wearing her curly hair in the black power style and was, at first, target of discriminations so she would, shortly after, gain the admiration of her peers. She identified the key support from black family members, the inspiration derived from significant black public figures and the encouraging to resistance based on shared meanings in black cultural manifestation (hip hop).

Over the generations, in processes moving towards the overcoming of internalized racism, the influence of psychic transmission of experiences of other generations, of symbolisms associated with black women and of shared meanings in black manifestations can be observed. The bonds of cohesion between black women, the cumulative networking, the social support of resistance movements has constructed the affirmative and collective identity, affirmative racial belongingness, increasing self-assurance. It shows how personal and collective resources favor processes of resilience (Prestes; Vasconcellos, 2013PRESTES, C. R. S.; VASCONCELLOS, E. G. Mulheres negras: resistência e resiliência ante os efeitos psicossociais do racismo. Pambazuka News, 2013.).

In the narratives of these four generations, it is notorious the repetition of the word "strength", meaning identification with the symbolism of "warrior" present in the social imagery and projected over black women. The declared intention of corresponding to this symbolism and honoring the strength of other black women subverts the lack of personal conditions. Behaving according to this stereotype, socially assigned and embodied/staged, can be understood as a choice, as necessity or even as a requirement contigent to the panorama of multiple adversities.

In this study, the black women reported constant "strength" exercises while engaging in the struggle of everyday life or in political battles to face different contexts of vulnerabilities. It confirms Hooks (2006HOOKS, B. Vivendo de amor. In: WERNECK, J.; MENDONÇA, M.; WHITE, E. C. (Org.). O livro da saúde das mulheres negras: nossos passos vêm de longe. 2. ed. Rio de Janeiro: Pallas; Criola; San Fracisco: Global Exchange, 2006. p. 188-198.) statements about how black women assume the role of a strong warrior, under the strong moral demand of focusing on the overcoming of adversities at any cost, regardless of personal satisfactions, an uneven burden on them. Occupied with basic survival and with the care of those who depend on them, this sociocultural context, specific of their condition, can lead them to not leaving enough space, to not allowing themselves or to not finding opportunities for love or satisfactory experiences of conjugal, maternal ties, among others. "Love is for white people's, or men's, that have more possibilities of being fragile precisely because they are socially privileged." (Prestes, 2013PRESTES, C. R. S. Feridas até o coração, erguem-se negras guerreiras: resiliência em mulheres negras: transmissão psíquica e pertencimentos. 2013. Dissertação (Mestrado em Psicologia Social) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 2013., p. 156).

Therefore, the profile of a warrior, more than a natural trait or innate essence of the personality of black women, socially and historically constitutes itself as a practical necessity and part of the stereotype assigned to them, often internalized as identification. This profile and the history of constant overcoming processes result of compulsory coping and confrontation of repeated scenarios of major vulnerabilities to psychic distress and to illness, as reported by many authors quoted above.

This history of overcoming processes, nevertheless, should not be conceived as "training" for definitive protection (Prestes, 2013PRESTES, C. R. S. Feridas até o coração, erguem-se negras guerreiras: resiliência em mulheres negras: transmissão psíquica e pertencimentos. 2013. Dissertação (Mestrado em Psicologia Social) - Instituto de Psicologia da Universidade de São Paulo, São Paulo, 2013.), - which the traditional literature of resilience designates as "invulnerability". This questionable understanding, is linked to the constitutional conception of resilience, in texts which define it as a structure of personality or a level of development that would represent a capacity of the person getting away unharmed from future adversities. Nevertheless, going through processes of resilience in a particular stage of life does not mean reaching the stage of resilience. Thus, resilience cannot be conceived as an adjective or attributed to people or groups; it is better conceived as a "process in context".

The proposed processual conception of resilience that results of the critical reflection on the literature and the research data presented above, combined with a psychosocial perspective, indicates that the resilience experienced by black women can be linked to psychological and psychosomatic impairments such as illnesses and psychic distress, while still being processes of resilience.

The concept of resilience as a process does not restrict it to a positive balance resulted from the higher incidence of protection factors than of risk factors. Harmful effects can occur, but if the process also includes significant experiences of transcendence, meaningful life, resignification, better conditions of self-care and seeking of rights, it can still be defined as a process of resilience. Self-confidence, belongingness and good family/social relationships are valuable resources to produce processes of resilience. The analysis of the sources of these aspects suggests that self-confidence can result from prior confrontations and overcoming processes performed by black women or by groups and communities to which they belong. The sense of belongingness can arise from the network of black women that includes relatives from different generations.

Thus, these are resources to be considered in diagnosis and joint plannings of health care and self-care − the social and programmatic support and the experience of autonomy can be described as enablers of resilience processes. These should be considered, therefore, in the understanding of the context of care of black women, enhancing their access to programs, goods and services, the quality of treatment that ensures equity to their race and gender specificities, assuring experiences of protection and of the fulfillment of human rights and citizenship.

Other authors have called attention to the relevance of personal and collective aspects in enhancing processes of resilience. Luthar and Cicchetti (2000LUTHAR, S. S.; CICCHETTI, D. The construct of resilience: implications for interventions and social policies. Development and Psychopathology, Cambridge, v. 12, n. 4, p. 857-885, 2000.) highlight the specificities of ethnic-racial experiences in everyday life in multicultural societies, while Utsey (apud Omar et al., 2010OMAR, A. et al. Resiliência e enfrentamento do estresse em adolescentes: efeitos mediadores dos valores culturais. Psicologia em Revista, Belo Horizonte, v. 16, n. 3, p. 448-468, 2010.) highlights aspects such as self-confidence based on prior personal and group experiences, in addition to the aspects of collectivity, positive self-esteem and cultural values. Ungar (2006UNGAR, M. Nurturing hidden resilience in at-risk youth in different cultures. Journal of the Canadian Academy of Child and Adolescent Psychiatry. Ottawa, v. 15, n. 2, p. 53-58, 2006., ²⁰⁰⁸UNGAR, M. Resilience across cultures. British Journal of Social Work. Oxford, v. 38, p. 218-235, 2008.) stresses the mediation of culture.

Other works which focus on the resilience of black people, complement these reflections. Baldwin et al. (2011BALDWIN, D. R. et al. Resiliency and optimism: an African-American senior citizen's perspective. Journal of Black Psychology, Washington, DC, v. 37, n. 1, p. 24-41, 2011.), Brown (2011BROWN, D. L.; TYLKA, T. L. Racial Discrimination and resilience in African-American young adults: examining racial socialization as a moderator. Journal of Black Psychology, Washington, DC, v. 37, n. 3, p. 259-285, 2011.) and Teti et al. (2012TETI, M. et al. "I'm a keep rising. I'm a keep going forward, regardless": exploring black men's resilience amid sociostructural challenges and stressors. Qualitative Health Research, v. 22, n. 4, p. 524-533, 2012.) note the incidence of processes of resilience in the presence of optimism, racial socialization (racial identification), self-confidence and rooting (belongingness and identification with groups). Efraime Júnior (2013EFRAIME JÚNIOR, B. Trauma e migração: os traumas psíquicos das crianças soldado. Diversitas, São Paulo, n. 1, p. 111-130, mar/set. 2013.), defends the adoption of psychotherapeutic and psychosocial practices accompanied by renovation of ties with the family and the community for the overcoming of major traumas and psychic development; moreover, the access to traditional therapies, rituals and other strategies for reorganization of the psyche and of the capability to love and establish bonds.

In the education sector, articulated to psychology, Martins (2013MARTINS, L. L. P. Afrorresilientes: a resiliência de mulheres afrodescendentes de sucesso educacional. 2013. Dissertação (Mestrado em Educação) - Programa de Pós-Graduação em Educação da Universidade Federal do Piauí, Teresina, 2013.) researched the resilience of "afrodescendant" women of educational success. With a perspective that swings between constitutional and processual conception, she lists self-confidence, empathy, optimism and meaning of life, among others, as personal elements that would explain educational success and other achievements of the black women in her study. Carvalho (2008CARVALHO, L. L. Mais do que 'levantar, sacudir a poeira e dar a volta por cima': um estudo sobre autonomia superativa e emancipatória de mulheres negras cariocas. 2008. Dissertação (Mestrado em Política Social) - Programa de Estudos Pós-Graduados em Política Social da Universidade Federal Fluminense, Niterói, 2008.) focused on the resilience and the empowerment of black women in overcoming experiences of discrimination. In analyzing the trajectory of black women exposed to myriads of vulnerabilities, the author proposed a term that would encompass resilience and empowerment, and suggest "overcoming and emancipatory autonomy" to explain how they developed strategies for overcoming discriminations, while benefitting from the interaction with family members and significant people. Differently from Martins, she expands the more common perspective from the personal dimension to the nearest network of relationships.

Nadal (2007NADAL, C. M. S. A resiliência ao longo da vida de afrodescendentes. 2007. Dissertação (Mestrado em Educação) - Programa de Pós-Graduação em Educação da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, 2007.) discusses resilience on the trajectory of "afrodescendant" people regarded as successful because of their resilient results throughout life. Analyzing the contribution of the State, family and school, the author cathegorizes experiences, attitudes and procedures as either harmful or beneficial over processes of resilience of afrodescendant people.

This systemic perspective of resilience is interesting when addressing personal, family, community, culture and political system, in addition to including proposals for intervention within the programmatic sphere and actions in public policies. Adopting a processual concept of resilience, illustrates a critical reflection in the same direction proposed by the approaches within the V & HR framework. According to the author, the most influential elements over the enhancement of resilience would be moral values, family, emotional and other types of bonds, a learning process inspired by models, that, in turn, contribute to positive self-esteem, self-confidence and motivation, from a personal point of view. From a professional point of view, persistence, competitiveness, high spirits, respect, solidarity, ethics, among others.

Likewise, Guimarães and Podkameni (2007PODKAMENI, A. B.; GUIMARÃES, M. A. C. Afro-descendência, família e prevenção. In: MELLO FILHO, J.; BURD, M. (Org.). Doença e família. 2. ed. São Paulo: Casa do Psicólogo, 2007. p. 123-140.; 2008) discuss the psychic/psychosocial consequences of racism and the resilience of black people. They use the psychoanalytic perspective to analyze the psychological effects of racism on black children in their interactions with family, school and society. In all these areas, the black child can be subject to welcoming, support, exchange, or to disqualification, censorship, humiliation.

The family, with initial potential to be "sufficiently good", often cannot be open to children who return from school after being subjected to negativeness, and they fail to give support precisely because the family itself reissues non elaborated traumas. The psyche of black people subjected to the effects of racism can function in a dynamic that undermines the potential for creativity, transformation and hope, while the investments that contributed to that are reverted, redirected, for example, to the defense of their integrity, so only then they can be made available for new possibilities.

As Guimarães and Podkameni (2007PODKAMENI, A. B.; GUIMARÃES, M. A. C. Afro-descendência, família e prevenção. In: MELLO FILHO, J.; BURD, M. (Org.). Doença e família. 2. ed. São Paulo: Casa do Psicólogo, 2007. p. 123-140., 2008) state, resiliency processes starts before any technical action and influences of the expanded social environment, in the psycho-affective trajectory, experienced within the family and derived from the first bonds; they emphasize the value of the quality of the look of the mother, father and family in general. From there, the internal resources that facilitate resilience will be available or not: self-confidence, positive self-esteem, healthy interpersonal relationship, empathy, among others. They also indicate the value of symbolism/meanings perpetuated by psychic transmission or shared in black cultural and traditional expressions.

In addition to examining the effects of the hostile social environment that instigates illnesses, generating greater social and individual vulnerability, the authors indicate coping paths through which black people may give new meaning to blackness and repair psychological damage, reducing their vulnerabilities by programmatic interventions.

A good example is the experience of a project with black and non black pregnant women in a health center. (Podkameni and Guimarães, 2008GUIMARÃES, M. A. C.; PODKAMENI, A. B. A rede de sustentação coletiva, espaço potencial e resgate identitário: projeto mãe-criadeira. Saúde e sociedade, São Paulo, v. 17, n. 1, p. 117-130, 2008.). Following action research and participant observation, they used weekly group meetings, meant for therapeutic, prophylactic effects, and rehabilitation, assuming the association of the vulnerability of being pregnant to the vulnerability caused by a context of racism. Aiming at reversal and prevention of impairments, a collective support network was proposed, to provide shelter, support, exchange, and is meant for the maintenance and refeeding of spaces, which enable psychic tension drainage and elaboration. In this technical proposal, they included social and programmatic resources from various sectors (in the field of education, health and culture) to facilitate all dynamics: of continuity, confidence, identity regaining and resilience.

Which medical, social work or psychology schools teach that the color/race/ethnicity of users and patients is relevant, or consider such conceptions of their vulnerability or human rights context? Which of them address psychosocial techniques and practices in the disciplinary training of their students?

Different from most educational capacity building and ongoing professional practices, templates of the framework defended above appear, for example, in the Brazilian public health system, as in the AIDS response among the most affected segments. Health care and prevention actions aiming at sexual and reproductive health have addressed the individual, social and programmatic spheres of vulnerability to HIV infection and illnesses caused by AIDS.Based on this perspective, these actions have considered the impact of sexism and racism over the vulnerability of black women to infection caused by sexually transmitted diseases, sexual violence and abuse, and unplanned pregnancy.

Beyond good professional and academic practices, beyond public and private institucional action, innumerous initatives of the black people social movements (and black women's movements) are responsible for significant contributions to the well being and rights fulfillment of black women and men. The contributions of the various authors presented in this article and the many actions suggested above, inspired an ongoing project that has described and analyzed interventions among black men and women aiming at enhancing the overcoming and transcendence, agency and empowerment, autonomy and emancipation, among other processes. This project will describe and systematize methodologies and working processes that are in the scope of a psychosocial approach to improve black women's resilience.

Final thoughts: reviewing perspectives is to expand horizons

Different Brazilian population segments face contexts of increased vulnerabilities associated with human rights deprivation. The enhancement of current approaches and conceptual innovation in health care practices should draw the attention of those dedicated to mitigate the social, programmatic and individual vulnerability associated to mental suffering and illness of back women. Focusing on the harmful effects of discriminations based on racism and sexism, and analysing rights negligence or violations only through its individual level can be a narrow approach. The prescription of treatments, non-dialogical education, training and modeling of preventive behaviors and of pre-defined attitudes without the input of affected people and communities may have limited results.

We need to expand the understanding that the health-disease process is historical (not natural) and integrate the contribution of both research and existing social experiments, of pioneering actions that conceptualize the impact of racial and gender relations, among other social cathegories.

Moreover, the necessary innovation should include the promotion of practices that involve both black women and their wisdom, the resources of their communities and of their group belongingness, expanding the typical and traditional public and private care and assistance services provided by health professional and educators, among others. An expanded network of care that suport black women to surpass their exposure to harmful contexts may enhance processes of resilience.

In this direction, the definition of resilience conceived as a process shaped by autonomy, a meaningful life, resignification, overcoming and transcendence, among others, calls for innovation in techniques and practices that should consider the importance of the exercise of citizenship and rights fulfillment, agency and social commitment, as discussed throughout the text.

The very notion of what would be satisfactory results of technical interventions should be expanded, as well as the conception of health, to become contextualized and politicized. In the proposed perspective it is necessary to consider not only the people being taken care of (black women) but also their networks, territories, trajectories and instances of belongingness.

Based on the finding that the black population, especially the black women segment, is quite exposed to the deprivation of human rights, inefficiency of governmental programs in the ensuring of education and health, in addition to the regular incidence of racism and sexism that damages health, the adoption of the psychosocial perspective that result in innovation of techniques and practices of potentiation of resilience and promotion of health in general looks promising.

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