O RIGINAL Involuntary commitment: implication for psychiatric nursing practice* A RTICLE INTERNAÇÃO INVOLUNTÁRIA: AS IMPLICAÇÕES PARA A CLÍNICA DA ENFERMAGEM PSIQUIÁTRICA INTERNACIÓN INVOLUNTARIA: IMPLICACIONES PARA LA CLÍNICA DE ENFERMERÍA PSIQUIÁTRICA Lilian Hortale de Oliveira Moreira1, Cristina Maria Douat Loyola2 ABSTRACT RESUMO RESUMEN The characteristics of involuntary psychiat- Quando nos deparamos com Internação Psi- Cuando nos encontramos con Internación ric commitment (IPI) may cause implica- quiátrica Involuntária (IPI), percebemos que Psiquiátrica Involuntaria (IPI), percibimos tions on the nursing/patient relationship. as características dessa internação podem que las características de internación pue- The objectives of this study were to list the causar implicações para a relação enferma- den causar implicaciones en la relación en- forms of nursing care delivered to psychi- gem/paciente. Relacionar os cuidados de fermería/paciente. Relacionar los cuidados atric patients, according to the type of com- enfermagem prestados ao paciente psiqui- de enfermería brindados al paciente psi- mitment; analyze the reaction of the nurs- átrico, considerando o tipo de internação; quiátrico, considerando el tipo de interna- ing team towards the IPI patient, and dis- analisar a reação da equipe de enfermagem ción; analizar la reacción del equipo de en- cuss on the implications that IPI have on the em relação ao paciente de Internação Psi- fermería en relación al paciente de IPI, y practice o psychiatric nursing. A field re- quiátrica Involuntária (IPI), e discutir as im- discutir las implicaciones de la IPI para la search was performed with the nursing plicações da IPI para a clínica da enferma- clínica de enfermería psiquiátrica. Investi- team of a psychiatric institution in Rio de gem psiquiátrica. Foi realizada uma Pesqui- gación de Campo realizada con equipo de Janeiro. After 50 hours of participant ob- sa de Campo com a equipe de enfermagem enfermería de institución psiquiátrica del servation and 9 of focal group meetings, we de uma instituição psiquiátrica do municí- Municipio de Río de Janeiro. Luego de 50 found that the teams are concerned with pio do Rio de Janeiro. Após 50 horas de Ob- horas de Observación Participativa y 9 ho- the clinical evolution of the patients. No servação Participante e 9 horas de realiza- ras de realización de Grupo Focal, determi- references of the nursing team to the IPI ção de Grupo Focal sinalizamos que há uma namos que hay preocupación del equipo patient were observed. There are no preocupação das equipes com a evolução con la evolución clínica del paciente. No se records or actions of any kind that would clinica das pacientes. Não foi observada qual- observaron manifestaciones del equipo en suggest a specific look towards this type of quer manifestação da equipe de enferma- relación al paciente de IPI. No hay registro patient. Nursing professionals are not able gem em relação ao paciente de IPI. Não há ni acción que determine una mirada espe- to clearly identify this type of patient, thus registro, nem qualquer ação que aponte cífica sobre este tipo de pacientes. La en- the care is provided as per the patient's haver um olhar específico sobre esse tipo de fermería no consigue identificar claramen- needs or requests. paciente. A enfermagem não consegue iden- te al paciente, orientando el cuidado según tificar claramente esse paciente na enferma- demanda o solicitud del paciente. ria, direcionando o cuidado pela demanda ou solicitação do paciente. DESCRIPTORS DESCRITORES DESCRIPTORES Psychiatric nursing Enfermagem psiquiátrica Enfermería psiquiatrica Nursing care Cuidados de enfermagem Atención de enfermería Commitment of mentally ill Internação compulsória de doente mental Internación compulsoria del enfermo mental Mental disorders Transtornos mentais Trastornos mentales * Extracted from the thesis “Enfermagem psiquiátrica e internação involuntária: a clínica do fato existente”, Anna Nery School of Nursing, Federal University of Rio de Janeiro, 2008 1 PhD in Nursing. Adjunct Professor of the Medical-Surgical Nursing Department of the Anna Nery School of Nursing of the Federal University of Rio de Janeiro. Researcher of the Projects and Research in Mental Health Laboratory. Rio de Janeiro, RJ, Brazil. [email protected] 2 PhD in Nursing. Full Professor of the Anna Nery School of Nursing of the Federal University of Rio de Janeiro. Coordinator of the Projects and Research in Mental Health Laboratory. Rio de Janeiro, RJ, [email protected] Rev Esc Enferm USP Received: 05/28/2009 Involuntary commitment:Portuguese implication / English: for 2011; 45(3):690-7 Approved: 08/31/2010 psychiatric nursingwww.scielo.br/reeusp practice 690 www.ee.usp.br/reeusp/ Moreira LHO, Loyola CMD INTRODUCTION sometimes timidly, the ideas have matured and the com- prehension of the benefits of these changes has been (3) The central idea that has organized mental health over sought . After almost fifteen years and tireless discussions, the past 200 years, was that the mental disorder sufferer is the Law 10.216 of 06/04/2001 was approved, which pro- a dangerous individual and at the same time irresponsible, vides protection and rights to people suffering from men- not answering for their acts, and should therefore be ex- tal disorders and redirects the care model for mental health. cluded from living in society, for safety reasons, through This law is considered to be the Psychiatric Reform Law, hospitalization This need for safety in any society evokes a noting that the original text, the Law 3.657/1989 Project, fear that the madness brings in itself, according to the so- resulting in Law 10.216, was taken from what the author of called dangerousness of the mad. Here the fear that ac- the Project intended as the basis for the reform, which was companies the man throughout his whole existence is talked the substitution of the asylums, and was also responsible about(1). The same author describes the fear as a known for the strong opposition raised, initiated and orchestrated object, which has the specific aim of being able to cope. by the Brazilian Federation of Hospitals. Fear is a habit present in a human group, fearing any threats Law 10.216 has thus far graded much the dangerous- (real or imaginary). It is appropriate to say, however, that it ness about the nonimputability of this individual, through is not any fear that the mental disorder evokes. It is not an two major referrals: the creation of programs for the inte- abstract fear, but one fear in particular: the fear of being gration of these patients into the community, with treat- physically assaulted. It is common sense, for any group (so- ment in non-hospital therapeutic provisions, such as Thera- ciety, family, health professionals, including mental health peutic Residences, outpatient care, and the technicians), that this individual is unpredict- Psychosocial Care Centers (CAPS), as well as able, impulsive and aggressive. From the un- the Going Back Home Program, which under- derstanding of this fear and to ensure safety, The Involuntary took the management of the network; and the Involuntary Psychiatric Hospitalization Hospitalization is a with the careful regulation of the procedures could be justified. This fear sustains society’s reality, and the for psychiatric hospitalization, through the arguments about the dangerousness of the psychiatric institutions creation of Regulation No. 2.391 of Decem- mental disorder sufferer and ensured the le- adopt, as a treatment ber 26, 2002, which regulates the control of gitimacy of the social exclusion, through many measure, the psychiatric hospitalizations, in accordance involuntary hospitalizations, in the context of hospitalization of a with the provisions of Law 10.216, and the the safety of the patient, the family and the involuntary hospitalization notification pro- community. Stressing the concept of the dis- mental disorder cedures of the Public Ministry, by the health ease based on the concept of dangerousness, sufferer often using establishments, whether or not members of civil incapacity and liability, the hospice has physical and the Brazilian National Health System (SUS). created a culture of production of the stig- mechanical restraint, Three decades ago there was already talk mas in the social imagery that are now much as a way to contain the about the indignity of an involuntary commit- more difficult to modify than the asylum it- agitation and hostility ment. Guided in their explanation by medi- self. Therefore it is important to dismantle the cal, moral, historical and literary evidence, mental asylums and the mentalities that cor- of the patient. and stating that the confinement, i.e. the roborate our clinical view and compose our detention of people in mental institutions clinic. With all the culture, other symbolic systems need to against their will, would be a form of impris- be determined, other truths that enable subjectivity, free- onment, with the practice of healthy men imprisoning their dom and dignity for all(2). insane counterparts in psychiatric hospitals, and a crime against humanity. The Involuntary Hospitalization is a real- Psychiatry in Brazil is undergoing a process of change ity, and the psychiatric institutions adopt, as a treatment that has become more effective since 1987, from the Na- measure, the hospitalization of a mental disorder sufferer tional Anti-Asylum Movement, which had as its basis the often using physical and mechanical restraint, as a way to denial of the hospitalization as a first treatment and pro- contain the agitation and hostility of the patient(4). posed new forms of care for the individual suffering from a mental disorder. Since then, policy initiatives of elabora- Throughout history medicalization has not stopped, in tion and discussion of laws and government actions have reference to the patient whose clinical framework is attrib- been created, searching for policies that guarantee digni- uted to madness. The evidence in this process was the con- fied care and consolidate respect and citizenship. The Bra- struction of the psychiatric asylum model.