SOUZA, Jean Carlos Marques. FERRARI, Andressa de França Alves. Art for therapeutic purposes in patients of a CAPS Ad in df. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 03, Vol. 06, pp. 05-16. March 2020. ISSN: 2448-0959, Link de acesso: https://www.nucleodoconhecimento.com.br/health/art-with-ends-therapeutics
Due to the psychiatric reform movement, which sought to replace the nursing home institutions with a territorial care network, the CAPS emerged. They are fundamental health units to assist people in mental distress. The present work aims to report the experience of an arts group of one of these units: CAPS Ad of the Federal District as well as aims to expose the therapeutic effects observed from the use of art, having as target audience patients in abusive use of psychoactive substances. This is a qualitative, descriptive and experience report format, and thus has the main perceptions of the eight meetings. In view of the need to use alternative ways to adet treatment, art is configured as an important therapeutic resource. In addition, art is shown as a means for expressing the singularity of the individual from the externalization of feelings, experiences and their pretensions. Therefore, it assists in social reintegration as well as psychosocial rehabilitation of people in mental distress.
Keywords: Art therapy, mental health, drug abuse, social reintegration, psychosocial rehabilitation.
According to Feitosa et al (2010), psychiatric reform began in some European countries. Its main objective was to change the care logic of mental health, which until then was marked by segregation. It was necessary to rethink and replace the manicomiais institutions, in addition to modifying the way society understood madness. This movement gave way to the discussion of the stigma of madness and problematized the historical exclusion of the madman. Also according to Feitosa et al (2010), in England, after The Second World War, transformations were sought in the mental health model, having as one of the principles the qualification of psychiatry, with changes coming from within the hospital. Aiming at these changes, therapeutic communities were created, whose employees involved with the assistance discussed, in groups, the functioning of the institution and the therapeutic process.
It does not refer here to the term homonym and currently known in Brazil. These are based on treatment the mandatory abstinence, with a religious and hygienist character, and thus promote social exclusion due to long periods of hospitalization, according to Bolonheis-Ramos and Boarini (2015). On the other hand, they aimed to bring the patient closer to the discussions related to their treatments, decentralizing the physician’s power, involving nurses, family members and the patient himself and stimulating the autonomy of these individuals (FEITOSA et al, 2010). According to Feitosa et al (2010), in France, during World War II, the Saint-Alban Hospital welcomed refugees from this war, and was also from where François Tosquelles led the movement of the French experience of reform, known as Institutional Psychotherapy.
In this movement, we sought the ideals and therapeutic function that, according to Tosquelles, had been lost. Another French movement that should be mentioned is Sector Psychiatry, which had the intention of structuring a public service and also performing treatment from multidisciplinary teams, working in a geographical area through local demands, focusing on the prevention and treatment of mental illnesses, including after hospital discharge, thus avoiding hospitalization and readmission. According to Feitosa et al (2010), in Italy, the psychiatric reform movement is Democratic Psychiatry, known to be the only one that abolished hospitalizations in psychiatric hospitals, in a process of hospital discharges, and, thus, there was a gradual reduction in the number of beds and the creation of services in the community, which is the definition of deinstitutionalization.
Franco Basaglia, the main precursor of the Italian movement, proposed, in the 1960s, changes in the Psychiatric Hospital of Gorizia, with the aim of transforming it into a therapeutic community, along the lines of what occurred in England. However, it observed the need for deeper changes in the care model. In the 1970s, as director of the Psychiatric Hospital in the city of Trieste, he began the process of closing that hospital, proposing the replacement of hospital and mental treatment with a territorial care network. The Brazilian psychiatric reform movement had a strong influence and followed the Italian model (VIEIRA et al, 2018). Bill No. 3,657, from 1989, was presented by Paulo Delgado in the Federal Chamber and processed for twelve years until the sanction of the Psychiatric Reform Law, known as Law No. 10,216/2001.
This law deals with the protection and rights of people with mental disorders, in addition to reviewing the mental health care model. It provides, among other things, the right to be treated with humanity and respect, only for the benefit of its health, aiming at its recovery by social reintegration. Therefore, the Brazilian psychiatric reform denounces asylums, social exclusion, violence and the pathological eye. Bringing the proposal of a care network within a community, aims to reinsert, socially, through work, culture and leisure, enabling freedom of choice, in relation to treatment, the individual in mental suffering, now adopting a biopsychosocial look (BARROSO; SILVA, 2011). For this to be possible, mental health in Brazil has substitute services for psychiatric hospitals, which are Centros de Atenção Psicossocial (CAPS), specialized care services for people in severe psychological distress, with the objective of favoring the exercise of citizenship and the social inclusion of users and their families.
According to Amarante and Nunes (2018), the CAPS is defined as a local health unit responsible for covering a population defined by the local level, and thus offers intermediate care between the outpatient network and hospitalization. CAPS Ad is a specialized service in the care of people who abuse alcohol and other drugs, with a focus on the disorders resulting from this use and dependence on psychoactive substances (BRASIL, 2004). This type of CAPS performs daily receptions, individual care, therapeutic workshops, besides having rest beds with the main purpose of comprehensive follow-up, aiming, among other things, detoxification. Currently, one of the problems faced by society refers to the problematic use of alcohol and other drugs, considered a challenge in terms of public health and the development of public policies to assist these people.
It is known that the consumption of psychoactive substances has always existed in the historical-cultural evolution of man, however the increase in the abusive and problematic use of these substances and their repercussions have been recurrent and worrying, according to Lima et al (2009). The complexity of treating people who abuse psychoactive substances indicates the need to consider the use of alternative practices. Integrative and Complementary Health Practices can be used as a natural mechanism for disease prevention, health recovery, and manage symptoms related to the diagnosis and treatment of the disease (BRASIL, 2015). In Brazil, the Política Nacional de Práticas Integrativas e Complementares in the SUS (PNPIC) began from the compliance with the guidelines and recommendations of several national health conferences and based on the recommendations of the World Health Organization (WHO).
This policy was born from the need to know, support, incorporate and implement experiences that were already developed in the public network of the country (BRASIL, 2015). So, Ordinance No. 849, of March 27, 2017, effectively incorporated some integrative practices (such as Art Therapy, Music Therapy, Reike, Biodance, Circular Dance, Meditation, among others) into the SUS, including them in the National Policy of Integrative and Complementary Practices. One of the alternative ways that help in the treatment is the use of art, especially for those who have some difficulty verbalizing their emotions and feelings, or even for those who have some difficulty in the adhering to conventional therapies. Thus, art can become an important resource for individuals with needs due to the abuse of psychoactive substances (CORREIA; TORRENTE, 2016).
According to Lima et al (2009), the use of art as a therapeutic resource in individuals with problems due to drug use is a predominantly non-verbal therapeutic process, based on the visual arts, and thus welcomes the human being and all its diversity, complexity, dynamism and helps him to find new meanings for his life, aiming at his social reintegration. In an experience report, about an open painting studio in a psychiatric hospital in 1946, Nise da Silveira addressed the importance of using painting in schizophrenic patients. In view of the difficulty of verbal communication of these patients, because verbalizations are rare at that time, activities were offered that allowed the expression of experiences, thoughts, emotions and impulses out of reach of the elaborations of reason and word, according to Silveira (1992).
Experience also shows us that painting can be used by the patient as a true instrument to reorganize the internal order and at the same time reconstruct reality (SILVEIRA, 1992). The intention was to find a way to access the patient, but it was also possible to verify that the act of painting had therapeutic effects, in so thing of straining the internal riots. The artistic works performed by the patients proved to be rich in symbols and images, because they are expressions full of meanings and constitute their own symbolic language, the main objective of that studio’s main study. Jungian theory uses artistic language and associates it with psychotherapy. Jung considered artistic creativity a natural and structuring psychic function, whose healing capacity was to form and transform unconscious contents into symbolic images (JUNG, 1977).
This theory uses drawings or paintings made freely by patients, their feelings, dreams or situations of conflict that are analyzed as a symbolization of the unconscious of the individual or society. The use of music as a therapeutic resource has an influence on the human being in several aspects, whether physical, cognitive, emotional or social. Musical stimuli can alter breathing, blood circulation, digestion, oxygenation and nervous and humoral dynamism. It also stimulates muscle energy and reduces fatigue. It can increase attention, stimulate memory, lower the pain threshold and reduce fear and anxiety (BERGOLD; ALVIM, 2009). Meditation, in turn, is a practice of harmonization of mental states and consciousness that brings benefits to the cognitive system, promoting concentration, assisting in the perception of physical and emotional sensations, stimulating well-being, relaxation and reduces stress, hyperactivity and depressive symptoms (BRASIL, 2017).
The bond between professional and patient can be conceptualized as a close personal relationship between professional and patient, in order to establish relations of listening, dialogue and respect. These factors facilitate the continuity of treatment, thus altering the quality of care (BRUNELLO et al, 2010). In turn, the definition of the term “understand” can be summarized in the ability to put oneanother in the place of the other. To understand, it is necessary to take into account the singularity of the individual, because his subjectivity is a manifestation of total living (MINAYO, 2012). Based on the theoretical framework presented, it is possible to launch the fundamental question of this work: How can art, used for therapeutic and coexistence purposes, cooperate in the treatment of people with needs resulting from the abuse of psychoactive substances?
2.1 OVERALL OBJECTIVE
This work has as general objective to report the experience of the use of art in a group created for this purpose, observing possible therapeutic effects in people with needs arising from the abuse of psychoactive substances, accompanied by a multidisciplinary team in a Psychosocial Care Center Alcohol and other Drugs III of the Federal District.
2.2 SPECIFIC OBJECTIVES
- Provide a space for cultural practice and coexistence of users;
- Perceive the link between users and professionals;
- Understand the outsourcing of feelings from art; And
- Observe possible therapeutic effects of art-mediated expression.
This work is a qualitative, descriptive and in the form of an experience report, and, for this, it is proposed to understand the patients’ statements, the final products of each meeting and the experience of facilitators after the experience of such activity. Experience reporting was used, because, in this way, it would be possible to describe the relevance of the use of art for therapeutic purposes when reporting the experiences. The Art and Interaction group began in December 2018 and its end was in April 2019, at CAPS Ad de Samambaia-DF, with the initial intention of being a space for the cultural practice of patients, aiming at various therapeutic purposes. In a total of eight meetings, they took place weekly, on Wednesdays, from 2 pm to 4 pm.
After the meetings, a field diary was prepared, with the impressions of the professionals and perceptions of the benefits for the patients. The target audience was patients who used problematic alcohol or other drugs, welcomed in the 24-hour care regimen, living in the Unidade de Acolhimento (UA), located next to the CAPS, and those who had in their singular therapeutic plan follow-up in the “daytime” model. The only criterion for inclusion in the therapeutic group was to be followed up in the institution by the multidisciplinary team. One of the CAPS Ad group rooms equipped with tables and chairs was used, as well as sound equipment and materials for artistic production: paper, crayons, crayons, gouache paint and brush.
4. DISCUSSION AND RESULTS
Regarding the experience with the target audience, it should be reiterated that some difficulties were encountered during the activities that should be mentioned, such as, for example, the low group’s support, both of the patients of full reception and day-to-day follow-up; the lowering in the level of consciousness due to the psychotropic drugs used in the treatment; the refusal to perform any proposed activity and the decreased concentration during the meetings. The meetings had pre-elaborated and semi-structured activities. Only a theme was proposed with the intention of guide artistic productions, leaving patients free to express their emotions through art. At the end of the meetings, the patients were asked to make an interpretation of their work, reflecting on its meaning and exposing it to the group.
The group started without a defined name, and therefore we invited patients to explain the proposal of upcoming meetings and to conduct a survey of ideas for possible group names. It was suggested, by one of the patients, the name “Art and Interaction”, in view of the proposal of artistic production and the coexistence between professionals and patients themselves, as occurred in England after the emergence of therapeutic communities, whose involved with the assistance discussed in group the functioning of the institution and the treatment of patients (FEITOSA et al, 2010). The then named group “Art and Interaction” proposed to think about the process of psychosocial rehabilitation and social reintegration. According to the provision of Law 10.216 of 2001, a landmark of psychiatric reform in the country, it was necessary to rethink the manicomial model and the history of social exclusion that this model represents (BARROSO; SILVA, 2011).
The choice of the name of the group, performed, therefore, together with the patients, took into account the history of segregation of patients in mental suffering, seeking, for this, to stimulate autonomy by placing them in an active position, from the point of view of the therapeutic process. In the first meeting, in addition to choosing the name of the group, it was proposed to make a free theme design. From this produced an abstract drawing, with blue and yellow gouache paint, which represented the water and sun of his homeland, another drawing portrayed people who represented family members and there was another drawing of a comic book character. The drawings addressed memories of family members and childhood memories, besides evidencing a difficulty of the participants to talk about the final product of the proposed activity.
Like what occurred with Nise da Silveira in his painting studio, it was possible to perceive the therapeutic function of art, seen as an alternative form of expression of experiences and emotions, which would not be rationally elaborated, that is, they would be in the unconscious (SILVEIRA, 1992). Even with the difficulty of verbal communication observed during the explanation of what was produced, it was possible to perceive the importance of using art as a therapeutic resource, enabling patients to access their feelings, forming them. Due to the need to address feelings, at the second meeting it was proposed that the participants draw freely on some theme related to their life. Occasionally, there was refusal to participate, due to the theme or the way of participating, but during the meeting, seeing that everyone was involved in some way with the activity, they decided to participate.
Works evidencing traumas and distancing from family life were produced. Manifesting feelings using art is a playful, predominantly non-verbal, form of communication, which provides the necessary tools to externalize emotions that may not have a place, giving meaning to them, thus helping in the social reintegration of the individual in mental suffering (LIMA et al, 2009). In view of the agitation of the patients perceived at the beginning of the meetings, it was necessary to seek alternative relaxation techniques. Therefore, at the beginning of the third meeting, a guided meditation for relaxation was proposed that would be used as a trigger of artistic production, whose patients would need to reproduce a moment in their lives that would bring good memories. All drew a green landscape, with lakes or rivers, according to the theme brought in the guided meditation. They also reported a feeling of well-being and calm after the activity.
Meditation was incorporated into the SUS from Ordinance n.849 of March 27, 2017, and was included in the National Policy of Integrative and Complementary Practices. It brings several benefits to the cognitive system by stimulating well-being, assisting in the perception of physical and emotional sensations, improving concentration and reducing stress and depressive symptoms (BRASIL, 2017). Such benefits were essential for the choice of this practice as triggerof activities, so that it helped in the relaxation process and provided greater connection with feelings. In the fourth meeting, an artistic production was requested regarding his profession. There were drawings that demonstrated previous work activity, in addition to the exhibition of desire to return to the professions already exercised at some point in life, through comments made during the interpretations of the drawings.
It was possible to perceive a lowering of the cognitive functions of the patients due to medication, which hindered the continuation of activities. Then came the idea of using the sound feature. Also included in the SUS in 2017, from the PNPIC, music, used as a therapeutic resource, can alter breathing and blood circulation, thus reducing fatigue, among other benefits (BRASIL, 2017). In addition, it stimulates memory and attention, fighting fear and anxiety (BERGOLD; ALVIM, 2009). When verifying the increase in attention of patients, accompanied by greater interest in performing the proposed activities, the sound resource was used in all subsequent meetings. In the fifth meeting, collectively and freely in a single card, a single final product was requested to work cognitive issues as well as time organization and space sharing.
Drawings of their own and unique meanings were produced, referencing childhood memory, family and loving relationships, conflicting or not, in addition to some lived stories. There was a movement by the facilitators to consider all the works produced valuable. This point is important in the search to understand the patient, because each work represents the meaning of the individual as a whole, even if a work approaches a specific feeling or experience. According to the literature, to understand the individual it is necessary to understand its singularity, and its subjectivity is a manifestation of total living, according to Minayo (2012). In the sixth meeting, several figures cut out of magazines were offered beforehand, and thus each patient chose the figure of interest and produced a related drawing: a continuation of this figure or part of it.
The free imagination made it possible to meet the individual stories. It was possible to perceive joys, sufferings and reflections about daily activities and human life, such as hunger and the aging process. Eventually, there was extravasation of emotions through crying during the activities, due to memories of family conflicts, and individual care was required after the end of the group. The sensitization in too much, accompanied by crying or not, was verified at some times during the activity, being present both during the process of making the work, and when reporting its meaning to the group. Observing the demotion of humor and anguish of some individual participant, a qualified listening was offered, individually, to address such sufferings and give referrals to the multidisciplinary team or other services, if necessary.
During the meetings, it became noticeable the creation of bonds between the actors that are part of the group, due to the number of meetings held and the themes addressed feelings in a playful way. Art productions full of experiences, which portrayed traumas, conflicts, ambitions and emotions in the patients’ lives, served as a bridge to the narrowing of the relationship between patient and professional. This bond plays an important role in psychosocial rehabilitation, as it facilitates gains in the follow-up of the therapeutic process (BRUNELLO et al, 2010). In the seventh meeting, the patients were organized in pairs and oriented about the activity, and each would start a drawing, taking 5 minutes for this artistic production. Later, the other member of the duo tried to interpret and continue the drawing for another 5 minutes. Finally, each pair explained the final product of their work.
With this, the organization of time and space was worked, in addition to the perception of feeling through the design of the other. In this meeting, the most portrayed production was from their homelands, with natural characteristics. Realizing that the patients always approached their homelands and family in the drawings, being very recurrent in practically all meetings, it was decided to perform, in the eighth and last meeting, an activity with this theme. The proposal was to read a poem addressing the family, the roots and homeland, using this poem to trigger the artistic production in this meeting. The desire to strengthen family bonds was portrayed.
From the activity, it was possible to perceive that the group did not aim to evaluate the artistic productions of patients from the psychological point of view or, still, it was not intended to define a meaning for the final products at each meeting, contrary to the focus of the Jungian approach. This is used by the production of arts performed by patients to analyze the symbolization of the unconscious of the individual (SILVEIRA, 1992). The group “Art and Interaction” intended to use art as a means for participants to access their feelings and shape their experiences, thus becoming an important therapeutic instrument in care.
In view of the purpose of this work of reporting the experience of an arts group of a CAPS Ad in the Federal District, we used the space for the cultural practice of patients to verify the therapeutic effects of art and its participation in the treatment of people who abuse psychoactive substances. Since the creation of the group, the objective has been to stimulate the autonomy of patients, placing them in an active position in their treatments, thinking about the psychosocial rehabilitation process as well as presupposes the logic of psychiatric reform (FEITOSA et al, 2010). Corrreia (2016) agrees with the therapeutic process of patients who abuse psychoactive substances in relation to the need to use alternative pathways for treatment adement, constituting an important therapeutic resource.
In the same direction, another theoretical framework ratifies the therapeutic effects of the use of art as a means of communication and expression of feelings, especially in people in psychological distress (SILVEIRA, 1992). As observed during the meetings of the group “Art and Interaction”. Still in this sense and taking into account the difficulty of verbalizing the feelings of these individuals (CORREIA; TORRENTE, 2016; SILVEIRA, 1992), the use of art could help in the therapeutic process, especially by bringing to the fore feelings and ideas that were out of the reach of words, organizing internally and sforming these feelings. It was fundamental for the experience of residents in mental health and organizers to perceive the group as an opportunity to provide the participants with a space for coexistence and promotion of bonds.
In view of the history of social exclusion of these individuals, the space is configured as an incentive for reinsertion and beneficial for the continuation of the therapeutic process, envisioning its psychosocial rehabilitation. In the context of the theoretical framework and through observation during the group meetings, it can be affirmed that art fulfills its therapeutic role by helping the person in mental suffering to express their uniqueness as well as their experiences, emotions and pretensions. It is based, then, on the statement brought in the theoretical framework that the expression of subjectivity is a total manifestation of an individual (MINAYO, 2016). The use of art as a therapeutic resource is a way to contribute to the treatment of people who abuse psychoactive substances. It is suggested that the mental health professional lean son on integrative practices as a whole, incorporating resources such as art into their daily practice. With this, they will provide benefits in the therapeutic process of patients, assisting in psychosocial rehabilitation.
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 Resident nurse in Mental Health, School of Health Sciences (ESCS).
 Nurse of the Health Department of the Federal District (SESDF). Advisor and tutor of the Residency program in Mental Health of ESCS.
Enviado: Fevereiro, 2020.
Aprovado: Março, 2020.