Deinstitutionalization process in the city of Maceió , Alagoas : documental study Processo de desinstitucionalização no município de Maceió , Alagoas : estudo documental

| OBJECTIVE: To describe how the deinstitutionalization process and the implementation of therapeutic residential services in the city of Maceió-AL took place. METHODS: A documentary study of an exploratory nature and qualitative approach, carried out in the Psychosocial Care Management of the municipal health department, from July to September 2020. Official documents from primary written sources relevant to the deinstitutionalization process, as well as their legislations. RESULTS: Seven therapeutic residential services were implemented by 2018, and four more are needed. The entire process took place through public civil action. The municipality points to the prospect of expanding this service to continue the deinstitutionalization process. FINAL CONSIDERATIONS: The deinstitutionalization process has been taking place gradually in the city of Maceió-AL, and the implementation of therapeutic residences was a great advance for the mental health area in the region. However, the number of services offered and the implementation of other territorial devices are still insufficient to meet the demand of the population with psychiatric disorders. DESCRIPTORS: Mental health services. Deinstitutionalization. Mental Health Care. RESUMO | OBJETIVO: Descrever como ocorreu o processo de desinstitucionalização e a implantação dos serviços residenciais terapêuticos no município de Maceió-AL. MÉTODOS: Estudo documental de natureza exploratória e abordagem qualitativa, realizado na Gerência de Atenção Psicossocial da secretaria municipal de saúde, no período de julho a setembro de 2020. Foram utilizados documentos oficiais de fontes escritas primárias, pertinentes ao processo de desinstitucionalização, assim como suas legislações. RESULTADOS: Foram implantados sete serviços residenciais terapêuticos até 2018 e há necessidade de mais quatro. Todo o processo ocorreu por meio de ação civil pública. O município aponta perspectiva de ampliação desse serviço para continuar o processo de desinstitucionalização. CONSIDERAÇÕES FINAIS: O processo de desinstitucionalização vem ocorrendo gradativamente no município de Maceió-AL e a implantação das residências terapêuticas foi de grande avanço para a área de saúde mental da região. Contudo, o número de serviços ofertados, assim como a implantação dos outros dispositivos territoriais, ainda é insuficiente para atender à demanda da população com transtorno psiquiátrico. DESCRITORES: Serviços de saúde mental. Desinstitucionalização. Assistência à Saúde Mental. 1Autora para correspondência. Universidade Estadual de Ciências da Saúde de Alagoas (Maceió). Alagoas, Brasil. andrielyszoliveira@gmail.com 2,3Universidade Estadual de Ciências da Saúde de Alagoas (Maceió). Alagoas, Brasil. helcimara@hotmail.com, ise.tszesnioski@gmail.com How to cite this article: Oliveira AS, Gonçalves HM, Tszesnioski LC. Deinstitutionalization process in the city of Maceió, Alagoas: documental study. J Contemp Nurs. 2021;10(2):215-224. http://dx.doi. org/10.17267/2317-3378rec.v10i2.3811 Submitted 05/05/2021, Accepted 09/06/2021, Published 10/18/2021 J. Contemp. Nurs., Salvador, 2021 October;10(2):215-224 http://dx.doi.org/10.17267/2317-3378rec.v10i2.3811 | ISSN: 2317-3378 Deinstitutionalization process in the city of Maceió, Alagoas: documental study Processo de desinstitucionalização no município de Maceió, Alagoas: estudo documental Original Article Andriely de Souza Oliveira1 Helcimara Martins Gonçalves2 Luíse de Cássia Tszesnioski3


Introduction
In Brazil, the deinstitutionalization of people with severe mental disorders and their reintegration into the community began with the anti-asylum struggle, allied to the Psychiatric Reform movement in the 1970s. 1 In the 1980s, this movement intensified and was consolidated in 1988 by creating the Unified Health System (SUS), which has universality, integrality, and equity as guiding principles. 1 The proposal of the psychiatric reform arose to break the hospital-centered mental health care model, from the progressive closure of psychiatric hospitals, replacing them with services that are components of the Psychosocial Care Network (RAPS), among them, highlighting those on a territorial basis such as Therapeutic Residential Services (SRTs), favoring the expansion and strengthening of the National Mental Health Policy (PNSM). 2 In this feeling, the SRTs have constituted themselves as places of social transformation, despite the stigma that madness still causes, because the individual needs social interaction. This psychosocial support network works aiming at the protagonism of subjectivity in the rescue of their autonomy. 3 This service is characterized as houses located in the urban space, aimed at the rehabilitation of people with chronic mental disorders, whose objective is to rebuild the autonomy that was lost due to a long time of hospitalization, reshaping their relationship with the world, where these individuals take the place of protagonists of their stories. 2 In recent years, the country has made great advances in quality and access to mental care, enabling SRTs, but insufficient numbers. 4 For example, according to the last electronic information Mental Health in Data, released in 2015 by the Ministry of Health (MS), in Brazil, 610 therapeutic residences were working by the end of 2014, of which only 289 were already qualified and distributed as follows: 20 in the Midwest, 121 in the Northeast, 2 in the North, 431 in the Southeast and 36 in the South. 5 Currently, in some states and municipalities, the implementation of SRTs is still in the process of being effective 5, evidencing the relevance of these urban spaces to provide interventions in a biopsychosocial aspect. Given the above, this study aims to describe how the deinstitutionalization process and the implementation of therapeutic residential services occurred in the municipality of Maceió-AL.

Methods
This is a study of documentary analysis of exploratory nature and qualitative approach. Documentary studies are characterized by official materials from primary sources, which have not yet received analytical treatment. According to the authors, exploratory research is used, which aims to identify a fact or phenomenon more accurately in order to present something new. 6 It was carried out in the psychosocial care management (GAP) sector of the municipal health department of the municipality of Maceió -AL, from July to September 2020. Data from the following documents were analyzed: the local level, SRT implementation project, municipal health plan, deinstitutionalization plan, annual management report, psychosocial clinical census, memoranda, dispatches, draft sands, and reports. In addition, at the national level, Federal Law n° 10.216/2001 provides for the protection and rights of people with mental disorders, redirecting the mental health care model; Ordinances n° 106/2000 that introduces SRTs into the SUS for graduates of long hospitalizations; Federal Laws, Ordinances n° 52 and 53/2004 that establish the progressive reduction of psychiatric beds in the country.
Documents relating to the period that occurred the implementation, between 2013 and 2017 and its successive reports until the year 2020, were included, and the duplicate documents with incompatible data were excluded.
Data collection was performed based on the following steps: Step 1: The sources related to the deinstitutionalization process, and in them, the documents were located on the website of the Ministry of Health and in the archives of the Psychosocial Care Management of the municipality of Maceió-AL; Step 2: To select the documents, readings and records were performed, following the criterion of thematic and conceptual aspects; Step 3: Later, a critical analysis of the facts was performed, and the data were organized and described chronologically.
This stage occurred after authorization from the municipal secretary of health of Maceió -AL, through a letter of authorization of scientific research. It is notable that in order to have access to documents located in the Psychosocial Care Management of the Municipal Health Department of the municipality, there was no need for approval by the Research Ethics Committee (CEP), since it is a documental analysis and does not involve human beings, as set out in Resolution nº 510 of April 07/2016 MS/CONEP, Article 1°, single paragraph (items I to VIII). 7 The information in this research is confidential, disclosed only in publications and scientific events.

Results and discussion
Thus, after the stages of selection, identification, registration, synthesis of documents, and interpretative reading respecting the criterion of thematic and conceptual aspects, a critical analysis of the facts resulted in the establishment of three categories. According to DATASUS 10 , in 2013, in the State of Alagoas, there were 1.000 psychiatric beds. Of these, 120 are in the municipality of Arapiraca and 880 in Maceió. There is still a significant number because the state has 714 psychiatric beds distributed in the following municipalities: Arapiraca 120; Rio Largo 16; São Miguel dos Campos 10; Theotonius Vilela 8, and Maceió 560. This number of beds in psychiatric institutions demonstrates how much the State of Alagoas still operates based on a hospital-centered model.

Path of deinstitutionalization in Maceió-AL
According to the Municipal Health Plan of Maceió 11 , RAPS has been implemented since 2012 and gained greater visibility since 2014, when the municipal plan treated the mental health network as a priority. The municipality of Maceió has only 5 CAPS. However, this amount is insufficient to provide psychosocial care to the population. It is noteworthy that other municipalities also have insufficient CAPS availability, causing work overload, compromising the quality of care and the work process, as pointed out by the study developed in Recife. 12 It is emphasized that the CAPS Children and Youth and Alcohol and other drugs meet the entire demand of the municipality, while the three CAPS II are divided between specific territories, to meet the population that is closer to each one.
The expansion of mental health services in the municipality only began in 2013, due to the reduction of psychiatric beds of the Unified Health System (SUS) and subsequent closure of one of the institutions. From the change of these beds, the municipality faced the urgency in ensuring psychosocial assistance on a territorial basis, people from long hospital stay, in accordance with national standards.
The municipality had the following psychiatric institutions: Dr. José Lopes de Mendonça Rest Clinic, School Hospital Portugal Ramalho (HEPR), Ulisses Pernambucano Rest Home and Miguel Couto Health Home. The first institution informed the municipal health department, the beginning of the progressive reduction of psychiatric beds of the SUS, at the time that requested the transfer of people considered residents, to another health unit.
Therefore, the team of the Municipal Mental Health Coordination and the State Psychosocial Care Supervision (SUAP) together with social service interns (Federal University of Alagoas -UFAL), with the objective of defining strategies to enable the deinstitutionalization process, conducted a technical visit to the clinic, where the urgency was found to be taken to take action, due to the conditions in which people were found (poor hygiene and idleness, without purpose of any daily functional activity).
Then, the teams requested a hearing with the State Public Prosecutor's Office (MPE), to provide information about the technical visit and present the measures outlined by the municipal management, which were: realization of the Psychosocial Clinical Census; linking of people who were discharged from the hospital to the reference CAPS; home visit and meeting with families; training of caps teams and visits raps Recife -PE and Santo André -SP, to know their experiences of deinstitutionalization. 1 The Psychosocial Clinical Census was built based on that of the psychiatric hospital of Recife-PE and São Paulo and adapted to the reality of the municipality, with the following information: identification, benefits, socioeconomic status, legal status, social ties, institutional path and resource needs. 13 The collection of the census was initiated by the Dr. José Lopes de Mendonça Rest Clinic, because it started the reduction of psychiatric beds, followed by the School Hospital Portugal Ramalho (HEPR), Ulysses Pernambucano Rest Home and Miguel Couto Rest Home.
During the visits, the team identified that the medical records, especially of long-term patients, contained insufficient and confusing data, such as personal identification, family references, the current and total length of hospitalizations, social aspects (benefits, retirement, among others), diagnostic data, absence of records of an interdisciplinary approach and Singular Therapeutic Project (PTS). In addition, it was found that several people had already been discharged in the period before the visit without articulation with the components of the RAPS for continuity of care. The most worrisome factor was the finding of deaths that occurred in the first half of 2015. It was identified that there had been nine deaths, all of them from cardiorespiratory complications, and of these, four had been in March 2015. It should be attention to the fact that there was no clinical physician. The resources for rehabilitation of organic functions were limited because there was only one room for clinical complications for both sexes, where the supplies used were basically serums and palliative medications. All these factors were reported to the MPE.
It is emphasized that the Psychosocial Clinical Census of the institutions was updated during the years 2014 and 2015, and concomitantly with this, the other strategies were performed. In 2015, the Project for the Implementation of the Therapeutic Residential Service was built to promote the psychosocial rehabilitation of people with suffering or long-term mental disorder in a psychiatric hospital who did not have social autonomy, family ties, andhousing. 14 Psychosocial rehabilitation is based on the rescue of the dignity of being subject, the exercise of citizenship and inclusion in the various social media, through the promotion of interpersonal and collective relationships, enabling the experience of sharing their suffering, understood as the product of a set of factors, and not as a sign of social dangerousness to be repressed. Therefore, it is necessary to integrate habitat, social network, and work. 15 In the first half of the same year, the Dr. José Lopes de Mendonça Rest Clinic made official to the municipal health department about the definitive closure of the care to SUS users, notifying it so that in 24 hours it would provide for the transfer of patients to another hospital unit. This circumstance once again highlighted the urgency of the municipality in ensuring territorial assistance. 16 Due to the emergency and the delay in bureaucratic procedures, the State Attorney General's Office (PGE) directed the health department to sign an agreement to provide administrative and care services, with a private non-profit institution, for complementary participation within the Scope of the SUS, as recommended through Ordinance n° 1.034 of May 5, 2010 (Art. 1, the item I and II). 17 At the beginning of 2016, the Deinstitutionalization Plan18 was built, whose objectives were: to identify the possibilities of family/social reintegration; identify the needs of SRAS for the reception of these persons; monitor the implementation of the devices in the expansion of RAPS; structure the flow of assistance in the network. It had an action program, divided into the following stages: I -Situational diagnosis (psychosocial census; individual assessment of health conditions; identification of people without family bond for conduct therapeutic conduct necessary for the deinstitutionalization process; identification of people with family ties for referral to the reference CAPS; identification of possible beneficiaries of the Return Home Program).
II -Intra and intersectoral articulations (Articulation with SUAP for the mobilization of municipalities with CAPS devices; holding quarterly meetings with CAPS coordinators to monitor cases; articulation within the Urgency and Emergency Network and emergency care in regional reference hospitals; articulation of matrix support from CAPS and Family Health Center (NASF) to the Attention Points of RAPS; articulation with the judiciary about the necessary measures and clarifications to the cases of people in situation of guardianship and articulation of partnerships with social movements).
III -Expansion and strengthening of RAPS (hiring and qualification of the technical team; the opening of the planned substitute services; creation of the Center for Culture and Solidarity Economy; articulation of the process of opening 25 mental health beds in the University Hospital, according to the Raps Regional Plan, concomitant to the closure of beds in psychiatric hospitals).
IV -Monitoring and evaluation of actions (Impact survey of the deinstitutionalization process for evaluation and reprogramming actions).
The following year, May 2017, 40 people in a long-term stay who were still in the Dr. José Lopes de Mendonça Rest Clinic were transferred temporarily to the Ulisses Pernambucano Health Home, at a time that the clinic definitively ceased to provide services to the SUS, thus complying with Ordinance n° 1.727 of November 24/2016, which provides for the disaccreditation of the José Lopes de Mendonça Rest Clinic to the SUS.
Note that the Ulysses Pernambucano Rest Home did not have people in a long-term situation, and to receive the 40 people from the Dr. José Lopes de Mendonça Rest Clinic, it discharged 40 people to be treated in the CAPS and other RAPS devices.
In the same month, the Public Civil Action was filed by the Public Defender's Office, determining emergency measures by the municipal health department to guarantee decent treatment to people hospitalized in the Miguel Couto Health Home. This Civil Action occurred after complaints of relatives of hospitalized patients, reporting precarious conditions of the place. The measures were: technical visits together with health surveillance, preparation of reports, and appropriate guidance.
Also, in the same period, it was released in the Official Gazette of the State, the notice that provided for selecting a private non-profit entity interested in implementing and managing therapeutic residences. However, only the institution ASSUMA (Association of Users and Family Members of Users of Mental Health Services of Alagoas) presented a proposal. This institution has users and family members in the composition of the board and a history of support and social control with RAPS de Maceió.
It is noteworthy that the call notice had already been published that provided for the implementation of 7 RTS, aimed at people in long-term stay in psychiatric institutions. In June, the SMS received a subpoena from public civil action, which granted an emergency guardianship determining that the municipality of Maceió implement within 120 days, SRTs linked to the primary and psychosocial care networks, as well as maintaining them in a priority and continuous manner.

Implementation of Therapeutic Residential Services
The first SRTs were ready at the end of 2017, and from this, other challenges arose for deinstitutionalization in the municipality of Maceió. Through census data, the people who would go to these residences were defined. The 70 existing vacancies, referring to the seven houses, were initially designed for the 30 people of the Miguel Couto Health House due to the aforementioned Public Civil Action, which determined that supervision was carried out at this institution since it was functioning in a precarious and inhuman situation, and the remaining vacancies would be divided between the José Lopes Clinic and HEPR. 20 A previous list was built with the names of the people who would stay in each house, allowing caps professionals to approach those who would stay in homes located in their territory. This strategy adopted by the CAPS of the municipality was essential so that the process did not occur so abruptly. It is worth remembering that despite the difficulties present in psychiatric institutions, this was the reality known by the seventy people from a long time of hospitalization. Changing a place that produces subjection to a space with more freedom requires preparation by virtue or allows the resignification of the time he lived institutionalized. 19 In December 2017, the time came to transfer people from the Dr. José Lopes de Mendonça Rest Clinic and the Ulysses Pernambucano Clinic to the therapeutic residences. To this end, a call notice was launched for legal guardians or trustees of these people to attend within a maximum of 05 days counted from the publication of the notice, in the Psychosocial Care Management, in the SMS to become aware of the process and monitor the change. However, the transition from the psychiatric institution to the therapeutic residence still required judicial imposition since the institution's situation was very comfortable, with the financial additive paid by the municipality for each of the forty people. 20 The Ulysses Pernambucano Clinic refused to release people, placing the condition that it would only be possible through formal authorization from the families of each. Given the difficulty in locating all these family members, taking into account that the majority had no ties to the family or close relatives alive, the judge of the 14th Civil Court of the Capital issued a decision authorizing the transfer of people to the SRTs, implying a fine and even imprisonment of those who did not comply with the decision. So, at the end of the month, finally, the team was able to transfer thesepeople. 20 In early 2018, it was the turn of the transfer of people who were in the Miguel Couto Health House to the therapeutic residences. Once again, it all happened in court. It is emphasized that some people with mental disorders refused to leave the clinic, so their desire was respected at that time and worked later, individually, until they felt safe to leave the institution.
It is worth mentioning that despite all the actions in this process of deinstitutionalization in the municipality, 4 SRTs are still needed to provide psychosocial rehabilitation of the 35 people with mental disorders who remain institutionalized in existing psychiatric hospitals. In this context, the municipality points out a desire to open new services to continue the psychosocial rehabilitation of these people. For this, actions are being taken, such as updating the census of other institutions and dialogue with the Ministry of Health.

Characteristics of Therapeutic Residential Services in Maceió-AL
To date, 7 type II SRTs have been implanted in the municipality of Maceió -AL, destined for people who need intensive care, due to the loss of their autonomy, because of the long hospital stay. Of these services, 3 are women's and 4 are men's housing. The SRTs are distributed and located as follows: It is emphasized that each of the seven therapeutic residences is linked to a specialized reference mental health service, which provides necessary professional technical support and has a team of reference caregivers, nursing technicians, nurses, and psychologists. Therefore, for each group of 10 people, it is oriented that the RTS is composed of 5 caregivers on a scale and one daily nursing technical professional. 21 Rehabilitation strategies in therapeutic residences were structured to promote social reintegration, taking into account global health, culture, and leisure actions. Thus, rehabilitation is a slow process because it concerns the rescue of formal rights and involves the affective, housing, relational, material, and productive construction of each person. In this sense, there needs to be a connection between other urban spaces. 3 The deconstruction of hospital-centered logic needs to be done daily by disseminating the care performed in the territory, educating and deconstructing stigmas and prejudices related to people with psychological suffering and mental disorder, not only the population but also for health professionals and managers. 22 Thus, actions were planned to be carried out by professionals and others to be developed by users of the service. 18 Actions to be carried out by professionals: -Promote the autonomy of residents by teaching and stimulating the execution of hygiene habits, food, and care for the environments of the residences; -Develop therapeutic accompaniment to promote progressive resocialization of the person with actions of urban mobility, recognition, and use of the spaces of the territory; -Encourage interaction with other residents of the houses and the processes of problem-solving and collective decision-making; -Support the network of family support, community resources, and social protection; -Promote the redemption of citizenship by acquiring identification documents, proof of residence, benefits, among others. Actions to be developed by users 1,18 -Perform the actions of personal hygiene and food with autonomy; -Preserve the cleanliness and organization of the home environment; -Recognize and explore the spaces available in the territory (bakeries, squares, shopping malls, markets, theater, etc.); -Interact with other residents and professionals in the division of household tasks, respect for individual space, play activities, etc.; -Continue care in the linked Psychosocial Support Centers and Basic Health Units; -Interact with family members seeking the rescue of their ties.
The study had as a limitation the absence of data on the number of people in a long stay in each psychiatric institution mentioned and planning to follow up the opening to the next SRTs.

Conclusion
The deinstitutionalization process has been taking place gradually in the municipality of Maceió-AL, and the implementation of the SRTs was of great advance for the mental health area of the region. However, the number of existing services is still insufficient to meet the population's demand for a psychiatric disorder.
It was observed that the trajectory was not easy because the whole process resulted from legal action, accompanied by the Public Prosecutor's Office. Furthermore, it was noticed that there were many obstacles, resulting mainly from long bureaucratic procedures, scarcity of municipal financial resources, and lack of counterpart of the State.
It is emphasized that the implementation of these services does not guarantee the overcoming of the asylum model since, despite the closure of a psychiatric hospital institution, there are still three that continue to receive the region's demand. Psychosocial rehabilitation permeates the architectural barriers because it is in people, professionals, health services, and managers.
It is perceived that there is a need to study other aspects in the field of psychosocial care in order to provide elements capable of contributing to the constitution of the network and territorialization, contributing to actions to plan mental health policies. It is expected that this study can contribute as a documentary source for researchers, professionals, and managers involved in the field of mental health and particularly in the implementation of Therapeutic Residential Services.