Saúde mental: concepções e práticas profissionais de um campo em tensão

A Reforma Psiquiátrica, atual política de saúde mental, redireciona os recursos da assistência psiquiátrica para o modelo de base comunitária, substituindo o modelo asilar. A abordagem proposta pela Reforma Psiquiátrica procura conjugar o esforço teórico e prático para a construção da Rede de Atenção Psicossocial. O presente trabalho objetivou desvelar concepções e práticas de trabalhadores da saúde mental, construídas na práxis de suas trajetórias profissionais e contextos de vida, em relação à incorporação do modelo de atenção psicossocial ou manutenção de princípios asilares, caracterizadores da tradicional prática profissional em saúde mental. Objetivou também identificar pontos de tensão, que caracterizam interesses de diferentes naturezas, como obstáculos e desafios à implementação da Reforma Psiquiátrica. A pesquisa, de natureza qualitativa, contou com 10 entrevistas de profissionais atuando na área, baseada na técnica de depoimento oral e em roteiro do tipo temático, sendo 3 enfermeiros, 3 psicólogos, 3 psiquiatras e 1 terapeuta ocupacional. Os relatos dos profissionais foram organizados em categorias gerais e específicas tendo em vista a interpretação das narrativas à luz da literatura especializada. Através dos discursos dos profissionais do campo da saúde mental é possível observar que um tensionamento ideológico marca fortemente o espaço da saúde. Alguns profissionais relataram a busca por construir práticas em equipe interdisciplinar, pautadas pelo modelo psicossocial; porém, referem à resistência de outros profissionais da equipe. Praticamente todos os profissionais apresentam discursos de humanização no campo da saúde mental, mas alguns não enunciam visões críticas aos modelos asilares. Alguns trabalhadores revelam a crença na possibilidade de coexistência integrada entre o Modo Asilar e Modo Psicossocial. Para estes trabalhadores de CAPS, é desejável a permanência dos hospitais psiquiátricos e é possível a humanização dos mesmos. Essa questão indica, ao que parece, que as práticas em saúde mental ainda operam sobre premissas epistemológicas diferenciando sujeitos que podem ou não circular no meio social. A existência dos hospitais psiquiátricos, considerados como instituições totais, é problematizada e questionada pela Luta Antimanicomial, indica a permanência da lógica asilar que respalda a continuidade dos hospitais, exclusivamente psiquiátricos, entre os serviços de atendimento, com o apoio de parte dos profissionais da rede de saúde mental. Concordantes com a possibilidade de coexistência do modelo asilar e modelo psicossocial, estes profissionais permitem-nos demonstrar que mesmo uma visão clínica pretensamente humanizadora, que defenda em seu discurso um tratamento digno, pode operar no modelo teórico-metodológico positivista e não está necessariamente vinculada a uma postura política de sujeitos de direitos e de cidadania. Os profissionais que apresentaram em suas narrativas a não concordância com a permanência dos hospitais psiquiátricos, defendem que as transformações sejam clínicas e políticas nos saberes e nas práticas em Saúde Mental. Estes trabalhadores já fizeram ou fazem parte de movimentos sociais, apontados como lugares de reflexão crítica sobre ideias instituídas contribuindo, ao que parece, para o processo de desnaturalização de concepções construídas culturalmente e orientadoras de práticas profissionais. Diante de tais constatações podemos indagar e refletir se a desinstitucionalização, concreta e simbólica, encontra-se no horizonte de uma política pública de atenção em Saúde Mental que realmente tenha como projeto a sua real implementação e se a permanência dos hospitais psiquiátricos e das comunidades terapêuticas estaria descaracterizando as propostas iniciais da construção da Atenção Psicossocial, considerando os interesses privados e a manutenção da lógica asilar, contrários aos princípios do SUS.

Constructing a Neuroscientific Pastoral Theology of Fear and Hope

Contemporary therapeutic circles utilize the concept of anxiety to describe a variety of disorders. Emotional reductionism is a detriment to the therapeutic community and the persons seeking its help. This dissertation proposes that attention to the emotion of fear clarifies our categorization of particular disorders and challenges emotional reductionism. I propose that the emotion of fear, through its theological relationship to hope, is useful in therapeutic practice for persons who experience trauma and PTSD. I explore the differences between fear and anxiety by deconstructing anxiety. Through this process, I develop four categories which help the emotion of fear stand independent of anxiety in therapy. Temporality, behaviors, antidote and objects are categories which distinguish fear from anxiety. Together, they provide the impetus to explore the emotion of fear. Understanding the emotion of fear requires an examination of its neurophysiological embodiment. This includes the brain structures responsible for fear production, its defensive behaviors and the evolutionary retention of fear. Dual inheritance evolutionary theory posits that we evolved physically and culturally, helping us understand the inescapability of fear and the unique threats humans fear. The threats humans react to develop through subjective interpretations of experience. Sometimes threats, through their presence in our memories and imaginations, inhibit a person's ability to live out a preferred identity and experience hope. Understanding fear as embodied and subjective is important. Process theology provides a religious framework through which fear can be interpreted. In this framework, fear is developed as an adaptive human response. Moreover, fear is useful to the divine-human relationship, revealing an undercurrent of hope. In the context of the divine-human relationship fear is understood as an initial aim which protects a person from a threat, but also preserves them for novel future relationships. Utilizing a "double-listening" stance, a therapist hears the traumatic narrative and counternarratives of resistance and resilience. These counternarratives express an orientation towards hopeful futures wherein persons thrive through living out a preferred identity. A therapeutic practice incorporating the emotion of fear will utilize the themes of survival, coping and thriving to enable persons to place their traumatic narrative within their meaning systems.

China's Strategic Choices towards North Korea and Iran

This study tests two hypotheses. First, China cooperates with the United States only when it is able to obtain material rewards. Second, without material incentives from the United States, China straddles between the United States on one hand and Iran and North Korea on the other. My findings show that neither Structural Realism, which holds anti-hegemonism alliance, nor Constructivism, which holds positive assimilation of the nuclear nonproliferation norm explains Chinese international behavior comprehensively. My balance of interest model explains Chinese foreign policy on the noncompliant states better. The cases cover the Sino-North Korean and Sino-Iranian diplomatic histories from 1990 to 2013 vis-à-vis the United States. The study is both a within-case comparison—that is, changes of China’s stance across time—and a cross-case comparison in China’s position regarding Iran and North Korea. My comparisons contribute to theoretical and empirical analyses in international relations literature. Theoretically, the research creates different options for the third party between the two antagonistic actors. China will have seven different types of reaction: balancing, bandwagoning, mediating, and abetting that foster strategic clarity versus hiding, delaying, and straddling which are symptomatic of strategic ambiguity. I argue that there is a gradation between pure balancing and pure supporting. Empirically, the test results show that Chinese leaders have tried to find a balance between its material interests and international reputation by engaging in straddling and delaying inconsistently. There are two major findings. First, China’s foreign policy has been reactive. Whereas prior to 2006, balancing against the U.S. had been a dominant strategy, since 2006, China has shown strategic ambiguity. Second, Chinese leaders believe that the preservation of stability in the region outweighs denuclearization of the noncompliant states, because it is in China’s interest to maintain a manageable tension between the U.S. and the noncompliant states. The balance of interest model suggests that the best way to understand China’s preferences is to consider them as products of rough calculation of risks and rewards on both the U.S. and the noncompliant states.

Outsourcing and strategy in Spanish town halls: a field study

Purpose – This study seeks to analyse the links between strategies, structures and processes in the case of the largest Spanish town halls, using the Miles and Snow's models about organisational strategies, and asking the following questions: “What is the situation of municipal services' outsourcing in the largest Spanish town halls?”; “Do Spanish town halls follow the strategies suggested in Miles and Snow's model?”; and “Is there a relationship between the strategic position adopted by town halls and their stance on outsourcing?”. Design/methodology/approach – In order to achieve these aims a questionnaire was administered to the human resource managers in the town halls of the largest Spanish cities. Findings – The paper finds that outsourcing is a complement, which seeks to improve the services delivered, and local institutions do not resort to it due to a lack of internal resources but as a way to complement their own capabilities. Originality/value – The paper has identified three distinct strategic profiles in the town halls interviewed which coincide with the profiles that Miles and Snow call prospective, defensive and reactive strategies. It reveals that town halls which outsource to a greater extent are the ones which identify more with the prospective or reactive strategy, whereas those which outsource less are closer to the defensive strategy.

Selected characteristics of gait in women of different ages

In our research we have attempted to find out and compare force and time characteristics of gait in women. We measured and compare women in two age groups - 18-30 (group 1) a 46-60 (group 2). The average height of both groups was same, 167 cm, while the average weight and average body mass index were different (group 1 - weight 62 kg, BMI 22,3, group 2 - weight 68 kg, BMI 24,6). For measuring, pressure shoe insoles were used (Pedar Mobile, Novel Munich, 99 sensors, 100 Hz). Each person had three attempts: two trial attempts, the third one was measured. For observation, we selected three stances of each leg, always between the third and eighth stride. We measured force characteristics F1, F2, F3 and time characteristics t, t1, t2, t3. Significant differences between both groups were found in t3 on the left leg (time between peak force in active part of stance and peak force in passive part of stance). With applied force (F1, F2, F3) during stance, after recalculating per a kilogram of weight, no statistically significant differences were found.

Fenomenología: una visión investigativa para enfermería

La disciplina de enfermería necesita identificarse con una filosofía que le permita otorgar un sentido interpretativo a los fenómenos sociales o individuales; y la investigación cualitativa ofrece la metodología necesaria para llevar a cabo la interpretación de los significados bajo un análisis crítico y reflexivo. El objetivo del presente trabajo fue reflexionar sobre diferentes tradiciones filosóficas en torno a la fenomenología, al explorar los pensamientos de Edmund Husserl, Martin Heidegger y Alfred Schütz. Se realizó un ensayo teórico cuyo insumo literario se obtuvo de repositorios y fuentes de datos electrónicas, se incluyeron artículos publicados de los años 2010 al 2014, se utilizaron combinaciones de ocho palabras clave y se excluyeron aquellos artículos que no mencionaron el enfoque teórico de los filósofos de interés. Se concluye que las tres perspectivas filosóficas plantean una estrategia metodológica factible de ser utilizada dentro de la investigación cualitativa en enfermería, ya sea bajo la escuela descriptiva de Husserl, la postura interpretativa de Heidegger o la visión social de Schütz.

A statement of facts, relative to the late proceedings in Harvard College, Cambridge, published by the students, Boston, April 10, 1807

Written in defense of the students’ actions, this publication sought to clear the students in the eyes of the public. They argued against the stern disciplinary stance of the Corporation, warning that "it is possible to kill the spirt by too rigorous an adherence to the letter of the law." According to the students, the cause of the upheaval was the "black, nauseous and intolerable" food served in Commons. Although they admitted that there were some students who "delight in mischief, anarchy, and confusion," they argued against the whole student body being charged for the crimes. Instead, they held that their offense, "retiring peaceably from the hall," should be punished, as usual, only by the "small fine of fifty or one hundred cents."

Emergent Brazil and the Curse of the ‘Hen’s Flight’. CEPS Working Document No. 379, 27 February 2013

The ‘Emergent Brazil’ growth model is reaching its limits. Its main engines have been slowing significantly since the beginning of the global financial and economic crisis. Even its much-praised predictable macroeconomic policy has been eroded by political interference. Inflationary pressures are growing and GDP performance is anaemic. As ominous, Brazil cannot compensate for its domestic deficiencies with an export drive. Commodity exports are suffering with the world economic slow-down and the manufacturing industries’ competitiveness is in sharp decline. Brazil has put all its trade negotiation eggs into the South American and WTO baskets, and now its export market share is threatened by the Doha Round paralysis, the Latin American Alianza del Pacífico, and the US-led initiatives for a Trans-Pacific Partnership and a trade and investment agreement with the EU. Paradoxically, this alarming situation opens a window of opportunity. There is a mounting national consensus on the need to tackle head-on the country’s and its industries’ lack of competitiveness. That means finding a solution to the much-decried ‘Brazil Cost’ and stimulating private-sector investment. It also entails an aggressive trade-negotiating stance in order to secure better access to foreign markets and to foster more competition in the domestic one. The most promising near-term goal would be the conclusion of the EU–Mercosur trade talks. A scenario to overcome the paralysis of these negotiations could trail two parallel paths: bilateral EU–Brazil agreements on ‘anything but trade’ combined with a sequencing of the EU–Mercosur talks where each member of the South American bloc could adopt faster or slower liberalisation commitments and schedules.

Does the European Semester deliver the right policy advice? Bruegel Policy Contribution 2013/12, 20 September 2013

The July 2013 European Council recommendations to the euro area recognise a number of fiscal and macrostructural challenges, but do not fully exploit the options made possible by the European economic governance framework. There are particular problems with the Council's suggestions for the euro area as whole, which are not (or not adequately) reflected by the country-specific recommendations. A major drawback is that the Council recommendations do not give sufficient importance to symmetric intra-euro area adjustments. Reference to the euro area's ‘aggregate fiscal stance’ is empty rhetoric. Insufficient attention is paid to demand management. The most comprehensive recommendations are made on structural reforms. The July/August 2013 Article IV IMF recommendations on macroeconomic policies could also have been more ambitious, but they correspond better to the economic situation of the euro area than the Council’s recommendations. The President of the Eurogroup should continue discussions on the completion of the economic governance framework, including completion of the banking union and the setting-up of a euro-area institution responsible for managing the euro area’s aggregate fiscal stance.

Have the Germans lost their trust in Europe? CEPS Commentary, 20 September 2013

In the final days before the German federal elections, some observers are asking whether a change in government would portend a shift in the country’s consistently strong support of the euro. Even if a more eurosceptic government is elected to office, this commentary finds it highly unlikely that the German public would radically change its stance.

Subsidiarity between Law and Economics. Research Papers in Law, 1/2005

From the Introduction. The present contribution is an attempt to raise awareness between the 'trenches' by juxtaposing the two approaches to subsidiarity. Subsequently, I shall set out why, in economics, subsidiarity is embraced as a key principle in the design and working of the Union and how a functional subsidiarity test can be derived from this thinking. Throughout the paper, a range of illustrations and examples is provided in an attempt to show the practical applicability of a subsidiarity test. This does not mean, of course, that the application of the test can automatically "solve" all debates on whether subsidiarity is (not) violated. What it does mean, however, is that a careful methodology can be a significant help to e.g. national parliaments and the Brussels circuit, in particular, to discourage careless politicisation as much as possible and to render assessments of subsidiarity comparable throughout the Union. The latter virtue should be of interest to national parliaments in cooperating, within just six weeks, about a common stance in the case of a suspected violation of the principle. The structure of the paper is as follows. Section 2 gives a flavour of very different approaches and appreciation of the subsidiarity principle in European law and in the economics of multi-tier government. Section 3 elaborates on the economics of multi-tier government as a special instance of cost / benefit analysis of (de)centralisation in the three public economic functions of any government system. This culminates in a five-steps subsidiarity test and a brief discussion about its proper and improper application. Section 4 applies the test in a non-technical fashion to a range of issues of the "efficiency function" (i.e. allocation and markets) of the EU. After showing that the functional logic of subsidiarity may require liberalisation to be accompanied by various degrees of centralisation, a number of fairly detailed illustrations of how to deal with subsidiarity in the EU is provided. One illustration is about how the subsidiarity logic is misused by protagonists (labour in the internal market). A slightly different but frequently encountered aspect consists in the refusal to recognize that the EU (that is, some form of centralisation) offers a better solution than 25 national ones. A third range of issues, where the functional logic of subsidiarity could be useful, emerges when the boundaries of national competences are shifting due to more intense cross-border flows and developments. Other subsections are devoted to Union public goods and to the question whether the subsidiarity test might trace instances of EU decentralisation: a partial or complete shift of a policy or regulation to Member States. The paper refrains from an analysis of the application of the subsidiarity test to the other two public functions, namely, equity and macro-economic stabilisation.2 Section 5 argues that the use of a well-developed methodology of a functional subsidiarity test would be most useful for the national parliaments and even more so for their cooperation in case of a suspected violation of subsidiarity. Section 6 concludes.

Saving the Monopsony: Exclusivity, Innovation and Market Power in the Media Sector. Research Papers in Law, 7/2006

From the Introduction. The Media Sector has experienced a technological revolution in the last 15 years. Digital encoding of television signals made possible a more efficient use of the radiospectrum. Digital terrestrial television (hereinafter, “DTT”) allows now for the reception of a significant number of free-to-air channels.1 Moreover, the use of new transmission platforms (hereinafter,“platforms”), namely cable and direct-to-home satellite (hereinafter, “DTH”) paved the way for the arrival in Europe of pay-TV operators, which finance their activities mainly via subscription fees. This changing technological landscape is subject to further evolution in the near future, as incumbent telecommunications operators become increasingly interested in making available broadcasting content2 as part of their broadband offer and 3G mobile handsets can be used for the reception of TV signals....The present paper seeks to ascertain whether the Commission “regulatory approach” towards the exclusive sale of premium content is a sound one, in particular in view of the constant technological evolution outlined above. The assumptions underlying landmark Commission decisions will be compared with recent developments of the media sector in Italy. In the NewsCorp./Telepiù case, decided in 2003, the Commission imposed very strict conditions to allow the merger giving birth to Sky Italia, on the assumption that the operation created a lasting near-monopsony in the different upstream markets for the acquisition of premium intervened against the media conglomerate Mediaset (which controls, inter alia, the main three private free-to-air channels in Italy) for an alleged abuse of dominant position.17 In fact, and contrary to the forecasts made by the Commission, Mediaset was in a position to acquire the broadcasting rights of the main Italian football teams, thereby excluding the incumbent (and near-monopolist) pay-TV operator, Sky Italia. This may go to show that the reality of the sector is more complex and evolves faster than one may infer from the Commission practice, thus putting into question its stance regarding exclusivity. The experience of the evolution of the Italian media sector will be used as the starting point for the evaluation of alternative regulatory options.

Impacts fonctionnels du traumatisme craniocérébral léger sur la vision et l'équilibre postural chez l'adulte

Le traumatisme craniocérébral léger (TCCL) a des effets complexes sur plusieurs fonctions cérébrales, dont l’évaluation et le suivi peuvent être difficiles. Les problèmes visuels et les troubles de l’équilibre font partie des plaintes fréquemment rencontrées après un TCCL. En outre, ces problèmes peuvent continuer à affecter les personnes ayant eu un TCCL longtemps après la phase aiguë du traumatisme. Cependant, les évaluations cliniques conventionnelles de la vision et de l’équilibre ne permettent pas, la plupart du temps, d’objectiver ces symptômes, surtout lorsqu’ils s’installent durablement. De plus, il n’existe pas, à notre connaissance, d’étude longitudinale ayant étudié les déficits visuels perceptifs, en tant que tels, ni les troubles de l’équilibre secondaires à un TCCL, chez l’adulte. L’objectif de ce projet était donc de déterminer la nature et la durée des effets d’un tel traumatisme sur la perception visuelle et sur la stabilité posturale, en évaluant des adultes TCCL et contrôles sur une période d’un an. Les mêmes sujets, exactement, ont participé aux deux expériences, qui ont été menées les mêmes jours pour chacun des sujets. L’impact du TCCL sur la perception visuelle de réseaux sinusoïdaux définis par des attributs de premier et de second ordre a d’abord été étudié. Quinze adultes diagnostiqués TCCL ont été évalués 15 jours, 3 mois et 12 mois après leur traumatisme. Quinze adultes contrôles appariés ont été évalués à des périodes identiques. Des temps de réaction (TR) de détection de clignotement et de discrimination de direction de mouvement ont été mesurés. Les niveaux de contraste des stimuli de premier et de second ordre ont été ajustés pour qu’ils aient une visibilité comparable, et les moyennes, médianes, écarts-types (ET) et écarts interquartiles (EIQ) des TR correspondant aux bonnes réponses ont été calculés. Le niveau de symptômes a également été évalué pour le comparer aux données de TR. De façon générale, les TR des TCCL étaient plus longs et plus variables (plus grands ET et EIQ) que ceux des contrôles. De plus, les TR des TCCL étaient plus courts pour les stimuli de premier ordre que pour ceux de second ordre, et plus variables pour les stimuli de premier ordre que pour ceux de second ordre, dans la condition de discrimination de mouvement. Ces observations se sont répétées au cours des trois sessions. Le niveau de symptômes des TCCL était supérieur à celui des participants contrôles, et malgré une amélioration, cet écart est resté significatif sur la période d’un an qui a suivi le traumatisme. La seconde expérience, elle, était destinée à évaluer l’impact du TCCL sur le contrôle postural. Pour cela, nous avons mesuré l’amplitude d’oscillation posturale dans l’axe antéropostérieur et l’instabilité posturale (au moyen de la vitesse quadratique moyenne (VQM) des oscillations posturales) en position debout, les pieds joints, sur une surface ferme, dans cinq conditions différentes : les yeux fermés, et dans un tunnel virtuel tridimensionnel soit statique, soit oscillant de façon sinusoïdale dans la direction antéropostérieure à trois vitesses différentes. Des mesures d’équilibre dérivées de tests cliniques, le Bruininks-Oseretsky Test of Motor Proficiency 2nd edition (BOT-2) et le Balance Error Scoring System (BESS) ont également été utilisées. Les participants diagnostiqués TCCL présentaient une plus grande instabilité posturale (une plus grande VQM des oscillations posturales) que les participants contrôles 2 semaines et 3 mois après le traumatisme, toutes conditions confondues. Ces troubles de l’équilibre secondaires au TCCL n’étaient plus présents un an après le traumatisme. Ces résultats suggèrent également que les déficits affectant les processus d’intégration visuelle mis en évidence dans la première expérience ont pu contribuer aux troubles de l’équilibre secondaires au TCCL. L’amplitude d’oscillation posturale dans l’axe antéropostérieur de même que les mesures dérivées des tests cliniques d’évaluation de l’équilibre (BOT-2 et BESS) ne se sont pas révélées être des mesures sensibles pour quantifier le déficit postural chez les sujets TCCL. L’association des mesures de TR à la perception des propriétés spécifiques des stimuli s’est révélée être à la fois une méthode de mesure particulièrement sensible aux anomalies visuomotrices secondaires à un TCCL, et un outil précis d’investigation des mécanismes sous-jacents à ces anomalies qui surviennent lorsque le cerveau est exposé à un traumatisme léger. De la même façon, les mesures d’instabilité posturale se sont révélées suffisamment sensibles pour permettre de mesurer les troubles de l’équilibre secondaires à un TCCL. Ainsi, le développement de tests de dépistage basés sur ces résultats et destinés à l’évaluation du TCCL dès ses premières étapes apparaît particulièrement intéressant. Il semble également primordial d’examiner les relations entre de tels déficits et la réalisation d’activités de la vie quotidienne, telles que les activités scolaires, professionnelles ou sportives, pour déterminer les impacts fonctionnels que peuvent avoir ces troubles des fonctions visuomotrice et du contrôle de l’équilibre.

Euro-enthusiasm, Euro-rejection, and various shades of grey: The 2014 European Parliament election campaign in the Netherlands. EPIN Commentary No. 18/29 April 2014

With less than a month to go to the European Parliament (EP) elections, campaigning has barely begun in the Netherlands. Whether the campaign will address concrete EU policies or the future of the European Union remains to be seen, but this author argues that the outcomes will probably have less to with the parties’ stance on Europe than with the unpopularity of the incumbent parties and the ‘second order’ character of EP elections.

A European sanctions compensation fund? CEPS Commentary, 12 August 2014

Daniel Gros explores in a new CEPS Commentary the feasibility of creating a common fund to provide compensation for the economic costs of sanctions as an integral part of the EU’s foreign-policy stance that is now emerging towards Russia, albeit slowly and painfully.