The effects of health restrictions due to COVID-19 and the importance of using body approaches with people suffering from psychological distress and their families

Abstract

Objective

Results are presented on the importance of using corporal approaches with people with mental suffering and their families.

Method

The qualitative research developed with an ethnographic approach focused on the corporal dimension supported the development of the collaborative performance-investigation process. The philosophical support of Agnes Heller's Theory on the Daily Life on the practice of Psychosocial Rehabilitation allowed us to analyze the body experiments that used eight meetings where four users and two relatives of the Psychosocial Rehabilitation Center of Valdivia, Chile participated.

Results

The logic of progression of intensity and incorporation of learning allowed to identify four categories: Framing and beginning of the process; Knowing and becoming aware of one's own body; Between pain and pleasure; The importance of corporeality. The results allowed access to bodily perceptions that were silenced and even made invisible both due to the effects of the sanitary restrictions due to COVID-19, as well as the stigmatization associated with mental suffering. Agnes Heller's Theory of the Everyday allowed an approach to the understanding of the daily life of people with mental suffering with the positive assessment associated with group dynamics and bodily praxis, making it possible to visualize the interface between pleasant bodily activities with the perspective of rehabilitation effective psychosocial.

Conclusion

Body practices managed to generate reflective spaces that were central to the effective incorporation of empowerment and autonomy. In this sense, it becomes essential to provide support for therapeutic experiences with a body perspective, in a (re)educational framework, which allows the restructuring of healthy mental habits.

Keywords:
Occupational Therapy; Mental Health; COVID-19; Activities of Daily Living; Ethnography

Resumen

Objetivo

Se presentan resultados sobre la importancia del uso de los abordajes corporales junto a personas con sufrimiento psíquico y sus familiares.

Método

La investigación cualitativa desarrollada con enfoque etnográfico centrado en la dimensión corporal sustentó el desarrollo del proceso de performance-investigación colaborativa. El soporte filosófico de la Teoría sobre el Cotidiano de Agnes Heller sobre la práctica de la Rehabilitación Psicosocial permitió analizar las experimentaciones corporales desarrolladas en ocho encuentros donde participaron cuatro usuarias y dos familiares del dispositivo Centro de Rehabilitación Psicosocial de Valdivia, Chile.

Resultados

La lógica de progresión de intensidad y de incorporación de aprendizajes permitió identificar cuatro categorías: Encuadre e inicio del proceso; Conociendo y concientizando el propio cuerpo; Entre el dolor y el placer; La importancia de la corporalidad. Los resultados permitirán acceder a percepciones corporales silenciadas e incluso invisibilizadas tanto por los efectos de las restricciones sanitarias por COVID-19, como también por estigmatización asociada al sufrimiento psíquico. La Teoría del Cotidiano de Agnes Heller permitió un acercamiento a la comprensión del cotidiano de personas con sufrimiento psíquico con la valoración positiva asociada a la dinámica grupal y la praxis corporal siendo posible visualizar la interface entre actividades corporales placenteras con la perspectiva de la rehabilitación psicosocial efectiva.

Conclusión

Las prácticas corporales lograron generar espacios reflexivos que fueron centrales para la incorporación efectiva de empoderamiento y autonomía. En tal sentido, se vuelve fundamental entregar apoyo para las experiencias terapéuticas con perspectiva corporal, en un marco (re)educativo, que permita reestructurar los hábitos mentales saludables.

Palabras-clave:
Terapia Ocupacional; Salud Mental; COVID 19; Actividades Cotidianas; Etnografía

Resumo

Objetivo

Se apresentam resultados sobre a importância do uso de abordagens corporais junto a pessoas com sofrimento mental e seus familiares.

Método

Pesquisa qualitativa desenvolvida com abordagem etnográfica com foco na dimensão corporal, que subsidiou o desenvolvimento do processo de investigação-ação colaborativa. O suporte filosófico da Teoria do Cotidiano de Agnes Heller sobre a prática da Reabilitação Psicossocial permitiu analisar as experimentações corporais que utilizaram oito encontros onde participaram quatro usuários e dois familiares do Centro de Reabilitação Psicossocial de Valdivia, Chile.

Resultados

A lógica de progressão da intensidade e incorporação da aprendizagem permitiu identificar quatro categorias: Enquadramento e início do processo; Conhecendo e conscientizando o próprio corpo; Entre a dor e o prazer; A importância da corporeidade. Os resultados possibilitaram acessar a percepções corporais que foram silenciadas e até invisibilizadas tanto pelos efeitos das restrições sanitárias decorrentes da COVID-19, quanto pela estigmatização associada ao sofrimento mental. A Teoria do Cotidiano de Agnes Heller permitiu uma aproximação à compreensão do cotidiano das pessoas com sofrimento mental com uma avaliação positiva associada à dinâmica grupal e à práxis corporal, possibilitando visualizar a interface entre atividades corporais prazerosas com a perspectiva da reabilitação psicossocial efetiva.

Conclusão

As práticas corporais geraram espaços reflexivos centrais para a efetiva incorporação do empoderamento e da autonomia. Neste sentido, torna-se fundamental apoiar experiências terapêuticas com uma perspectiva corporal, em um marco (re)educativo, que permita a reestruturação de hábitos mentais saudáveis.

Palavras-chave:
Terapia Ocupacional; Saúde Mental; COVID 19; Atividades Cotidianas; Etnografia

Introduction

The COVID-19 pandemic puts us at the mercy of many doubts, fears, anxieties and uncertainties, permeated by important changes and transformations in our daily lives, stressing health, and in particular mental health in all its conditions, circumstances and life cycles (Sánchez-Dávila, 2022).

In this sense, it was necessary to devise institutional strategies and techniques that would enable to fully address people’s health, considering the challenge of maintaining those care processes that were interrupted by social distancing. There was a temporary closure of health centers or a restriction of access to them, as well as the emergence of meeting the new needs detected within this scenario of global impact (Zapata et al., 2022).

The previous situation implied the exponential increase in the use of remote technological strategies for treatment, intervention and support in people's mental health, being necessary to resort to the online format of health care known as Telehealth (Telesalud), which enabled to think about strategies targeted to those who need support and a follow up in these circumstances (Alva-Arroyo et al., 2021).

In relation to the above, the World Federation of Occupational Therapists (2014), by its acronym in English, validates Telehealth as the use of Information and Communication Technologies applied in remote health processes for Occupational Therapy, in circumstances in which it is necessary to provide health services where face-to-face care is not possible.

Telehealth was considered a technically valid replacement for face-to-face care, demonstrating with the time that, it was not highly feasible, but also corresponded to high satisfaction and clinical results equivalent to face-to-face care (Zapata et al., 2022). However, this process required the continuous training of professionals and users to maintain high standards of quality in the services provided, as well as to ensure the sustainability of this type of provision (Payán et al., 2022).

There are several local devices that have incorporated the Telehealth modality for the provision of mental health services, and among them is found in Chile, in particular in the city of Valdivia, the Psychosocial Rehabilitation Center¹ (from now on CRPS - Spanish Acronym), which provides psychosocial and specialized health care support for people who maintain a mental health diagnosis.

The CRPS is a center, dependent on the Universidad Austral de Chile (UACh), which carries out psychosocial rehabilitation programs for people in situations of mental disability, from a focus on rights and citizenship, in agreement with the Valdivia Health Service, based on what was proposed by the National Mental Health Plan in its third version (Ministerio de Salud de Chile, 2017).

In accordance with what is stated in the Third National Mental Health Plan (2017-2025) for devices such as the CRPS, the focus on human rights and citizenship is a central part of its actions, since the consideration of associated issues together with the deepening of community and family health issues aspects support the inclusion of health social determinants. That, with it a comprehensive approach to health problems in general and mental health in particular (Salvo, 2022).

In this sense, it is essential to reflect on the subjectivity/particularity in which health constructions are developed, even more so if they are built from bodily experiences associated with mental suffering (Manríquez, 2019). This is because health practices must be contextualized and situated in every day life, considering that these problems result from inequalities and social vulnerabilities (Galheigo, 2012, 2014; Bezerra & Trindade, 2014).

In relation to the above, it becomes essential to reflect on how the work of health professionals is carried out with respect to the centrality of the individuals and their subjective experience, above all, with a population in a situation of inequality, oppression and social exclusion (Giraldo Gärtner, 2016). It is also important to consider that the Mental Health Law promulgated in 2021 (Ministerio de Salud de Chile, 2021) gives special emphasis on the comprehensive and humanized right to mental health care, highlighting the right to specialized care and reintegration of the family and community, among other things.

In this scenario, Occupational Therapy is the professional area that can support the construction and significance of the subjectivity of people with mental suffering, using various strategies. Thus, Assad & Pedrão (2013) state that body experiences and approaches enhance the therapeutic bond and creative construction processes in search of solutions of daily life problems, thereby valuing daily life in order to minimize inequalities and social vulnerabilities.

Therefore, Justa & Holanda (2012) propose that the experimentation of body practices can offer the individual the perception of their potential for transformation, creativity, and ability to transcend the limits that are imposed on them, thus reflecting a more active and empowered posture regarding solutions or adaptations to the problems of their daily life. Based on this statement, Ferigollo & Angeli (2017) emphasize that body experimentation can enable the suspension of the everyday life, giving flow to awareness and thereby facilitating the resolution of problems that arise in daily life.

As stated above, this study presents research assumptions, establishing differentiated evaluation paths that used bodily practices/tools as methodology instruments so that new forms of analysis can emerge through interventions in the daily life of the participants, allowing sociocultural participation in a context of social distancing and other health restrictions resulting from the COVID-19 pandemic.

In this way, four research assumptions are raised that focus on: 1) the use of bodily practices, can enable new health states and facilitate access for users to different social teams such as health, education, culture, leisure, among others; 2) bodily practices, in addition to valuing aspects relevant to health, disease, therapies, policies, programs and any action used by health services, favor the expansion of human and social rights, as well as the improvement of the quality of life ; 3) bodily practices influence 'positively' the processes of corporeality and sociocultural participation in the daily life of heterogeneous groups of people in situations of vulnerability and; 4) the implementation of mental health and Psychiatry policies has not necessarily achieved the purposes proposed in the National Mental Health and Psychiatry Plan for people receiving care in terms of sociocultural participation.

In this sense, the objective of this article is to analyze the effects of the health restrictions due to COVID-19 and the importance of the use of bodily approaches with people with mental suffering and their relatives belonging to the CRPS device in the city of Valdivia. It should be emphasized that this study was carried out in a virtual telehealth modality and carried out during the COVID-19 pandemic in a period of four months at the end of 2021 and the beginning of 2022. The study evidenced the impact of health restrictions, such as social distancing and the sociocultural participation in the daily life of heterogeneous groups in situations of vulnerability and stigmatization.

Agnes Heller's theory: a descent into the daily life of people with mental suffering

For this study, the philosophical framework of Agnes Heller's Theory of Everyday Life was used since it offers important conceptual elements such as: heterogeneity, hierarchy, spontaneity, analogy, pragmatism, probability, economism, precedents, ultrageneralization, provisional judgments, imitation and intonation. . All these elements are dynamic and articulate with each other, being essential for daily life. In contrast, the crystallization of these elements in people's lives can be understood as a state of alienation characterized by passive attitudes in the face of adverse or unfair circumstances, unconsciously assuming roles that are imposed by the social context (Heller, 2008).

The elements of the Theory of Everyday Life that emerged and were used in this study were the following:

• Heterogeneity: Different segments of human activity with different degrees of importance and meanings (Heller, 2008) that characterize the different activities that take place in the course of individual history (Salles, 2011).

• Hierarchy: Occurs when a certain activity assumes a central and decisive place in relation to other activities (Heller, 2008), since it is not possible to do everything at the same time (Guimarães, 2002).

• Analogy: It arises from experiences already lived and/or known (Heller, 2008), that is, it is one that “manifests itself to maintain the repetition of the same procedure”, (Guimarães, 2002, p. 17), without considering reflection on actions.

• Pragmatism: It arises from an empirical thought with a tendency not to reflect and not reproduce something that has not been successfully confirmed in practice, that is, there is no rationality and it does not need a theory that closely justifies daily practice (Guimarães, 2002). They are related to faith and trust (Heller, 2008).

• Precedents: It is a “useful indicator for our behavior, for our attitude” (Heller, 2008, p. 55), this element has an interface with routine procedures, that is, an automatic and/or repetitive action that occurs from an action that preceded others (Guimarães, 2002).

• Ultra-generalization or ultra-generalizing judgments: They arise from the occurrence of a belief that has already happened and tends to repeat itself (Guimarães, 2002). They are based on trust, that is, they are “provisional judgments that practice confirms, at least, does not refute, as long as, based on them, we are able to act and guide ourselves” (Heller, 2008, p. 53).

• Intonation: It refers to the tone in which the person is located in human relationships, configuring from the communication that enables the individuality of each one (Heller, 2008).

In accordance with what has been described above and since it is a research that fits into the precepts of qualitative analysis, Agnes Heller's Theory of Everyday Life becomes adequate to understand the object of study.

Methodology

This study dealt with a qualitative research with an ethnographic approach focused on the corporal dimension, which allowed contacting and valuing the knowledge and experiences of people with mental suffering, thus enabling the expansion of knowledge. That happened through the exchange of experiences and reflections through observation and participation in daily life, being it feasible to support the development of the collaborative performance-research process.

This methodology is understood as a collaborative research process in the social and human sciences, being a participatory strategy that allows expanding the possibilities of accessing other experiences and meanings and with it the generation of new knowledge and reflexivity (Citro et al., 2020).

The approach from other perspectives, not exclusively verbal or textual, typically developed through interviews and participant observation, allowed access to situated, contemporary and innovative information and reflections regarding the daily life of the participants in this study, simultaneously and progressively promoting their active engagement in the bodily sessions that were developed.

This occurs in the context of the direct benefit associated with the bodily practice in which the researching process was anchored, which also reduced the possibilities of building utilitarian links based exclusively on epistemological extractivism that generally characterize health research processes (Katzer & Chiavazza, 2020).

As a theoretical foundation, the philosophical support of Agnes Heller's Theory of Everyday Life on the practice of Psychosocial Rehabilitation was used. While Psychosocial Rehabilitation is premised on enabling the social insertion of the vulnerable person through extended treatment and community actions (Amarante, 2007), Agnes Heller's theory shows that daily life occurs in the productions and exchanges of the environment between people, emphasizing that this insertion of the individual constitutes a web of relationships in the different day-to-day activities (Heller, 2008). In this way, the Psychosocial Rehabilitation and Agnes Heller's Theory of Everyday Life complement each other, becoming adequate and complementary for the understanding of the object of study.

Considering the health restrictions in which the research was carried out, it became necessary to consider the preventive measure of physical distancing, for which Information and Communication Technologies were used, particularly Telehealth. In this sense, the research was carried out virtually, through the ZOOM platform, involving users and family members from the city of Valdivia (XIV Region de los Ríos - Chile) who attended or had links to CRPS and who prior to sanitary restrictions attended the physical activation workshop in person. The connection process to the ZOOM platform was carried out using cell phones, tablets and laptops, whose connection link was permanent and sent to a WhatsApp group during the day prior to each session. This communication format made it possible to monitor attendance, progress and the need for adaptations, being an important feedback channel for researchers and participants.

The recruitment process was facilitated in the first stage by the CRPS team of professionals who previously contacted a group of users and family members who were interested in bodily practices. This process allowed giving greater formality to subsequent contacts by researchers, evidencing security and interest from the users and family members to get involved in the process.

After the development of initial interviews via telehealth, it was possible to confirm the total number of research participants included in the data collection, consisting of four users of the CRPS device and two relatives. The inclusion criteria were related to the people who were accompanied and/or linked to the CRPS, with the possibility of adding a third person close to them to facilitate participation, all of whom must be 18 years of age or older, with an interest in to approach bodily practices and with technical and/or human possibilities to carry out the telehealth connection process.

Participants

The participants consisted of six females, four users of the CRPS device, and two main family caregivers. The average age of the group was 33 years with ranges of 24 years and 44 years, the four CRPS users being single and the two family members married; the school background is distributed from incomplete elementary education (1), complete basic education (2), complete high school education (1) and incomplete technical course (2). The main productive activity was related to domestic work and caring for other people, with the majority of family income generated through disability assistance pension and sporadic and informal activities such as selling items at open fairs and driving by mobile app.

Ethical aspects

The research respected the bioethical principles in force in the National Regulations that delimit the guidelines that involve human beings in vulnerable situations, being submitted and approved without ethical, methodological or legal objections by the Research Ethics Committee of the Los Ríos Region in the Ordinary No. 173 dated May 13, 2021.

The Informed Consent was sent via email for the prior knowledge of the participants and then signed in person through home visits, integrating all the safeguards associated with the current health restrictions, leaving one copy with the participant and another with the researchers. In said instance, the objectives and methodology were also explained, leaving the option of participating or not in the research with a guarantee of secrecy and anonymity to the discretion of free choice, as well as the right to withdraw without the need for expression of cause. Likewise, it was expressly communicated that there are no negative repercussions of any kind in case of not agreeing to participate in the research process.

Instruments

Initially, to collect data from the research participants, a brief questionnaire was applied on socio-demographic data that contained questions about age, sex, marital status, education, productivity, main personal and family source of income, family composition at the time of the interview, number of habitual persons in the household, type of dwelling and its characteristics. This procedure allowed knowing in detail the housing, connectivity, socio-family conditions and the impact of health restrictions on the daily routine of the participants, facilitating the understanding of the respective regular performance environments of each participant by the researchers.

Procedures

Subsequently, to carry out the bodily experimentation, eight group meetings were used for four weeks, where two weekly meetings lasting one hour each were held, whose periodicity and intensity allowed us to identify the impact of the methodologies used in the daily life of the participants.

The groups were of the “closed group” type and for the activities and actions developed in the meetings, theatrical games were used (Novelly, 1994; Boal, 2001, 2002, 2005; Spolin, 2008), practices based on the referents of spontaneous theater and psychodrama (Aguiar, 1998; Moreno, 1975) together with active and passive relaxation methods (Payne, 2007) such as stretching, physical exercises for joint mobility and conscious breathing, as well as exercises corresponding to Edmund Jacobson's Progressive Relaxation Technique (Jacobson, 1976).

All the meetings were based on collaborative performance- research through the Zoom virtual platform, since this format allows recording. At the end of the experiential process, an in-depth interview was conducted to find out the perceptions of the participants regarding the impact of the COVID-19 pandemic on the processes of corporeality and sociocultural participation in daily life, as well as the impact of what that they learned in their daily lives.

Finally, transcriptions were made based on the activities carried out, oral reports and discussions of the members, with all the information collected and recorded in a digital field diary located in a virtual cloud for remote access by researchers.

Analysis method

For data analysis, the qualitative approach was used, based on collaborative performance- research, where the socio-demographic data was entered into a structured database in the spreadsheet format, in the Excel program, which were used to characterize the participants of the study.

Next, an exhaustive reading of the material was carried out, coming from the oral reports and discussions of the members, which were transcribed by the researchers and collaborators, obtaining categories of analysis based on the philosophical support of Agnes Heller.

Results

The development of the research process was characterized by the execution of eight bodily practice sessions of 60 minutes each, which were developed twice a week for four weeks. In this sense, the process and its contents for each week (or two sessions) are described below, pointing out the four categories that emerged, according to the logic of progression of intensity of what was executed and the incorporation of learning visualized by the participants:

Category 1 - Framing and beginning of the process: COVID-19 as a bridge for bodily practices (First week)

The first week was characterized by the framing of the process, its duration and objectives that allowed the participants to recognize and meet again in a space other than the health facility, but that was complementary to the CRPS activities, since they had previously met and shared in face-to-face and online workshops on the device. From this perspective, it was possible to generate an active space that was comfortable and not very invasive.

Agreements were made regarding the execution in remote modality such as breaks, volume, repetition of instructions, location and preparation of work spaces to facilitate the participation and performance of activities where caregivers participated as spokesperson or sounding board of the needs that their mentally suffering relatives were not able to express verbally.

The practical activities focused on identifying bodily experiences related to tension, illness or discomfort and their relationship with previous bodily experiences prior to the COVID-19 pandemic. Active mobility and stretching exercises focused on the lower back, upper back and neck areas were also developed, and they were complemented with passive relaxation techniques of conscious breathing, which favored self-perception regarding the level of anxiety and basal irritability associated with the health context of the moment and its respective restrictions.

The suggestion and need to incorporate dynamic bodily activities into their daily life was highlighted based on the feedback received from the participants, which indicated to the researchers that the factor with the greatest coincidence was due to a high sedentary lifestyle, interrupted mainly by the execution of housework and the pandemic factor.

Regarding the experiences in environments of sociocultural participation, the objective of this study, it was observed that this performance was already reduced prior to the health restrictions and not exclusively associated with preventive methods for the spread of COVID-19, but rather with the social stigma related to the mental health condition of each participant, and in particular to the presence of chronic psychiatric diagnoses.

However, during the process of bodily experience in this first week, it was possible to access the bodily memory (Le Breton, 2002; Feldenkrais, 2009) of each participant, which helped to raise awareness of other assumed or normalized experiences of abandonment of bodily awareness within the daily life, thereby enabling reflection on the multifactorial impact of modern life on corporeality and its relationship with its felt and recognized impacts in each part of the body.

It was also possible to identify how the health restrictions due to COVID-19 accentuated these ailments, which were mainly associated with the absence of rest self-care practices, social interaction and access to recreational spaces. In this sense, social participation developed in sociocultural environments was identified as one of the areas with the greatest negative impact due to physical distancing, restriction of meetings in community spaces and places of mass meeting.

Likewise, it was observed within the results obtained in these first two meetings, the positive assessment associated with the group dynamics, which made possible the interaction between the participants and that, even in remote or online format, positively favored experiences of shared approach with other people and with it social interaction in times of pandemic, enabling the empathic identification of similar problems and potentialities among participants and researchers.

Category 2 - Knowing and becoming aware of one's own body: potential of bodily practices in everyday life (Second week)

In the second week, it was possible to follow up on the incorporation of the bodily practices learned in the previous week, highlighting the practices of conscious breathing and passive and active elongation of the cervical area, mainly in the morning period.

The opening of both sessions consisted of a ten-minute warm-up composed of conscious breathing, an activity that favored the identification of areas of discomfort/discomfort, which were subsequently consciously activated.

The contents included dynamic body activities of medium/moderate intensity, segmental gymnastics and elongation of affected areas and shoulder and hip joints. Regarding the increase in intensity or demand of the activities carried out, the need to incorporate adaptations that facilitated the execution of those who presented greater difficulty was evidenced, especially in those movements that require static balance and greater elongation.

It was also possible to observe, in this second week, the impact of the side effects of long-standing psychotropic drugs, due to the difficulties associated with psychoorganic impairment, particularly mobility, static and dynamic balance, and following instructions.

Category 3 - Between pain and pleasure: interface between pleasurable activities and bodily practices (Third week)

It was characterized by the increase in the intensity of bodily techniques. Minor adaptations were made, since in general the participants managed to incorporate movements into their routine, evidencing significant progressions.

The body awareness work focused on identifying the body areas of discomfort before and after the session, in such a way as to gradually reinforce all the progressions. Self-massage activities were incorporated, which were well received by the participants, so it was decided to keep them for subsequent sessions.

From this perspective, the bodily experiences enabled the emergence of various discoveries, sensations and emotions, many of them linked to rest, fun, joy and pleasure, in contrast to the perceptions prior to the practice that were more related to the tiredness, sedentary lifestyle, pain, deterioration or dysfunction.

The general feedback from the participants focused on evidencing the difficulties associated with a sedentary lifestyle and pain. In particular, on the part of people with mental suffering, the difficulty in executing instructions is evident mainly due to stiffness and decreased range of joints, an aspect that researchers associate both with a sedentary lifestyle and with the side effects of antipsychotic psychoactive drugs consumed for a long time.

Category 4 - The importance of corporality: incorporation of body practices in the daily activities of people with mental suffering (Fourth week)

In the fourth and last week, movement activities to the rhythm of music and dramatic games were used with greater intensity.

The group raised the need to incorporate this type of practice as part of mental health and psychiatry treatment, as well as in the programmatic offer of the CRPS device. The foregoing in order to identify that the vast majority of their bodily experiences are reduced to tasks and domestic spaces. In this sense, the contents experienced were highly novel to them, and therefore, the participants pointed out the need to maintain their participation in similar instances. Considering this information, it was suggested to the coordination of the CRPS device that, as described, body practices were recognized as highly necessary spaces to be incorporated into the programmatic offer of both the CRPS device and mental health and psychiatry treatments.

As previously described, the sessions based on body performance allowed the participants to develop reflections that were more and more complete and less dichotomous regarding their bodily praxis, all of them vivid, warm and evidenced in situ impressions by the group and the researchers. In the same way, the ethnographic approach focused on corporality made it possible to know more clearly those body areas that the participants identified as the most affected and that, coincidentally, were associated with: lower back, upper back and posterior cervical area. These body segments formed the centrality of the approach, but not the exclusivity of each practical session.

Discussion

Through methodological strategies based on the ethnographic approach focused on the body dimension (Katzer & Chiavazza, 2020) that supported the development of the collaborative performance- research process in accordance with what was proposed by Citro et al. (2020), it was possible to gain access to the knowledge of bodily perceptions that were silenced and even invisible both due to the effects of the health restrictions due to COVID-19 and also due to the effects of stigmatization associated with the mental suffering of the participants and how this impacted in their relatives as main caregivers. The above in addition to the research assumptions.

This type of strategy allowed access to experiences and meanings located directly in the daily life of the participants, favoring mutual understanding regarding the intensity of the impact of the health restrictions due to COVID-19 in the reconfiguration of the daily life of each one of them and in their respective bodily impact (Citro et al., 2020). In this sense, the most affected body areas managed to be positively activated, thereby generating greater body awarenesss and experiential knowledge for the development and use of the tools learned.

In a complementary way, the direct benefit associated with the bodily practice in which the research was anchored, favored the collaborative construction of the process of choosing content and methodologies used in order to enhance the sense of usefulness regarding what was experienced, which strengthened parallel and progressively the active engagement in the bodily sessions developed evidencing high motivation, engagement and energy throughout the entire process. In this sense, the ethnographic approach focused on the corporal dimension, as proposed by Katzer and Chiavazza (2020), made it possible to put in contact and value the knowledge and experiences of people with mental suffering, thus enabling the expansion of knowledge, through the exchange of experiences and reflections of daily life.

Agnes Heller's Theory of the Everyday allowed an approach of this study to the understanding of the daily life of people with mental suffering, since it considers daily life as the life of each and every person, that is, people participate with all aspects of their individual life, of their personality, putting into it all his senses, all their capacities, abilities, feelings, passions, ideas and ideologies (Heller, 2008). In this sense, the daily life of the participants was considered as a complex space made up entirely of various elements that interact dynamically.

In the first week, there was framing of the participants for the beginning and approach to the body practices. It was possible to fluidly observe the programmed contents as a substantial part of the components that characterize collaborative performance- research (Citro et al., 2020). There was favoring of self-perception regarding the level of anxiety and basal irritability associated with the health context of the moment and its respective restrictions, as was also observed by Hernández Rodríguez (2020)in his study.

Here, it is also important to relate to the concept of analogy proposed by Heller (2008), since everyone emphasizes their own experiences based on knowledge already lived and/or known, a fact that occurred in this initial phase of the two first sessions. In this sense, it is also possible to highlight COVID-19, experienced very closely, as a traversal for the execution of bodily practices.

In addition, it was possible to visualize the concept of hierarchy, which proposes that there are certain activities that take a central and decisive place in relation to others, which would occur because the participants were able to associate their current experiences with previous ones. With this, they were able to classify their level of anxiety and irritability, to a greater or lesser degree (Heller, 2008).

It was evidenced that the presence of psychiatric diagnoses is accompanied by social stigma related to the mental health condition of each participant (González Bellés & Dámaso Vega, 2022), which may be related to the concept of ultra-generalization judgments, which are based on faith, being considered as provisional judgments and difficult to change, in which practice confirms (Heller, 2008).

In the same way, the concept of heterogeneity proposed by Heller (2008) was observed, since several segments of the occupation (human activity) with different degrees of importance and meaning were impacted by the restriction towards face-to-face socio-cultural participation in closed, open and especially massive spaces as the open fairs for example.

In this sense, the group dynamics generated in this virtual space for participation was understood as a positive and motivating meeting place, coinciding with what was described by Schwartzberg et al. (2013) on the use of grouping in Occupational Therapy regarding the construction of therapeutic groups. They are characterized by developing group dynamics transversally based on the voluntariness of the permanence of the participants and in the framework of a respectful and friendly coexistence.

For the second week, the participants were able to know and become aware of their body and their corporality in their daily activities. Jacobson's (1976) progressive relaxation technique was proposed, in an adapted modality, in order to work with large muscle groups, in accordance with the dynamics of progressive demand associated with conscious bodily practices of self-awareness, the latter proposed by Feldenkrais. (2009).

Despite the above, the adaptations made allowed those who felt over-demanded to be able to carry out the activities and meet the proposed objectives in a calmer and more relaxed manner, which the participants pointed as positive. In this sense, as described by Feldenkrais (2009), adapting bodily practices to the characteristics of each participant made it possible to enhance the intrinsic motivation associated with satisfactory performance, favor the sense and practical meaning of what was experienced and thereby reinforce the incorporation of bodily practices in everyday life. The foregoing reveals the element of pragmatism raised by Heller (2008), since the effective use and positive experience of what was experienced allowed its validation and incorporation into daily life as a necessary practice. From this perspective, it is emphasized that bodily practices were promoted in daily life.

In a complementary way, by impacting or stimulating affected, hurt or unaware body areas, through the exploration of guided movements, it was possible to show positive feedback from the participants regarding the novelty, pleasantness and necessity of the experience. This enabled to nurture and expand their repertoire of bodily sensations, and thereby have a positive impact on the integrity of their body schema (Le Breton, 2002; Feldenkrais, 2009); progressions that became clearly more evident in the following weeks.

For the third week, movement activities to the rhythm of music and dramatic games were incorporated (Novelly, 1994; Boal, 2001, 2002, 2005; Spolin, 2008), practices based on the referents of spontaneous theater and psychodrama (Aguiar, 1998; Moreno, 1975). To this end, conscious breathing exercises and segmental gymnastics were added, generating a greater demand for concentration, eye-motor coordination, and static and dynamic balance (Payne, 2007).

Many techniques had to be adapted for this week, facilitating the activities with some technique that could be known or recognized by the participants, giving space to movements that could be easily memorized, automated and easily applicable in daily life. It highlights Heller's concept of precedents, which is a useful indicator of our behavior and attitude that interfaces with the learned routine procedures, i.e., an automatic action and/or repetitive action that occurs from an action that preceded others (Heller, 2008).

The high energy and motivation for the themes worked were highlighted, identifying progressions in body awareness according to the experiences carried out in subsequent weeks, which, strengthened in a containing group dynamic (Schwartzberg et al., 2013), made possible new comprehensive body learning supported in the activation of neural plasticity associated with body work (Feldenkrais, 2009).

In this sense, it has become essential to provide support for therapeutic experiences with a bodily perspective, in a (re)educational framework, which allows the restructuring of mental habits (Feldenkrais, 2009) associated both with the experiences of people with mental suffering and with the health restrictions by COVID-19 that, consequently, have hindered or limited the development of skills and aptitudes for the maximum potential development of each participant.

During this week, the participants reported a lot of joint and muscle stiffness, decreased psychomotor coordination, tremors at rest and activation (Xavier et al., 2014), which, associated with stigma, in addition to the physical and mental overload of the caregivers, has generated low esteem emotions linked to their daily bodily experiences, characterized mostly by the performance of domestic tasks.

For the participation of bodily practices, it is important to point out that each participant was able to report experiences of difficulties and/or facilities in their execution, making an interface between pleasant activities and bodily practices.

Based on this observation, it was also relevant to associate the concept of intonation, referred to by Heller (2008) as the way in which people present themselves in relation to human relations, configuring from communication, the way in which the activity is developed and also how it is perceived by other people, allowing the individuality of each one.

In the fourth and last week, displacement activities to the rhythm of music and dramatic games were used with greater intensity (Novelly, 1994; Boal, 2001, 2002, 2005; Spolin, 2008). They were added to movements of elongation of the affected areas, horizontal and circular displacements and also free movements, which once again challenged the abilities of concentration, visuomotor coordination and static and dynamic balance, evidencing noticeable progress in the quality of execution as well as in the satisfaction regarding their individual performance,. This enhanced the harmony of the contents with the learning and bodily needs of the participants.

Therefore, based on the importance of corporality, there was a better acceptance and incorporation of bodily practices in the daily activities of people with mental suffering.

Based on this perspective, and on studies carried out, the importance of learning, understanding and incorporating the activities carried out into the daily life of each person was also observed, thus relating the intervention of bodily praxis with the perspective of the effective psychosocial rehabilitation (Assad et al., 2016). From this perspective, everyday life must be understood and recognized as a place for the activation of political and social projects, which seek a home where different types of inequalities can be minimized (Souza et al., 2014).

Once again, steps adapted from Jacobson's progressive relaxation technique (1976) were incorporated, focusing the work on the upper and lower limbs, progressively advancing towards the segmentation of both extremities. The execution of this procedure did not require further adaptation, which coincides with the progressions evidenced in body awareness made during the first encounters.

Thus, the stimulation of such body segments evoked comments, gestures, laughter and complicit glances, sounds and other spontaneous inputs, which guided us in the understanding of considering this work group as invisible due to factors associated with stigma (González Bellés & Dámaso Vega, 2022), as well as the situation of health restrictions at the time (Hernández Rodríguez, 2020). It facilitated the use of incorporating bodily practices and their intensity, according to the link between their ailments and discomforts with their participation in activities that made up their daily lives.

In a complementary way, it was possible to establish additional links to orality, which favored integrality in the feedback processes after each session, the above favored largely by the collectivity and symmetry, similar to what was proposed by Citro et al. (2020).

This also facilitated the appearance of resources associated with body memory as a result of forgotten or normalized ailments or discomforts, allowing the generation of novel body experiences that supported the development of experiences of resignification and with it the reconfiguration of bodily-based meaning and emotionality (Le Breton, 2002; Feldenkrais, 2009).

Regarding Heller's (2008) categories, for this last week, the categories of heterogeneity, hierarchy and pragmatism associated with the positive assessment of bodily practice in daily life were observed with greater predominance.

The above is also consistent with what was proposed by Citro et al. (2020) in relation to the fact that, in situations of social exclusion and discrimination, bodily experiences allow promoting the resignification of experiences associated with pain or discomfort and with it the reformulation and adjustments of daily life, allowing new ways of organizing, doing or developing their daily life, being able to even integrate the practices experienced into their routine.

In this sense, the concept of ultra-generalization under the provisional judgments proposed by Heller (2008), both those based on faith and those based on trust, were associated with experiences of exclusion, discrimination and social stigma, and were identified as central components in the reduction of participation in socio-community environments. In a complementary way, body practice and the CRPS device were visualized as spaces in which it is possible to deconstruct the stigma.

It is of vital relevance to consider that the participants described their daily lives associated with experiences influenced by the effects of stigmatization/discrimination that have historically restricted their socio-community participation. In this sense, health restrictions due to COVID-19 were experienced as factors that negatively enhance these experiences, thereby further promoting social exclusion and therefore reducing dynamic, collective and integral body experiences that can promote health states and general well-being.

It is important to mention that all the concepts presented by Agnes Heller complement each other, articulate and are essential for daily life, especially when they are used to understand the experiences of people with mental suffering. Similarly, it is necessary to pay attention to these concepts described above to avoid the crystallization or alienation of the understanding of daily life (Salles, 2011; Guimarães, 2002), especially in situations where there are conditions associated with mental suffering, social exclusion and stigma. Heller (2008) proposes that everyday life is a propitious field for alienation when the individual lives a life restricted to rules and routines, characterized by conformism, in which they assume roles that society unconsciously imposes.

In this sense, what the author proposes is that “each one must appropriate their own form of reality and impose the mark of their own personality” (Heller, 2008, p.61), where body practices and their concomitant experiences can be visualized as powerful opportunities and means for a better participation of reflective spaces in a sociocultural context.

Final Considerations

The methodological strategies based on ethnographic approaches with a bodily perspective (Katzer & Chiavazza, 2020) that supported the development of the collaborative performance- research process in accordance with what was proposed by Citro et al. (2020), made possible the development of bodily practices that managed to generate reflective spaces where the participants were able to rethink their corporalities, preferably associated with individuality and sedentary lifestyle, in contrast to collective, active and vivid experiences that characterized the execution of this research, and that, in a complementary way, favored symmetrical or horizontal experiences, through the exchange of experiences and reflections through observation and participation in daily life.

In this way, it was possible to access the knowledge of bodily perceptions that were silenced and even invisible both due to the effects of the health restrictions due to COVID-19 and because of the effects of stigmatization associated with the mental suffering of the participants and their families as primary caregivers.

In this sense, the bodily approach that supported the execution of the research process, in a context of social distancing and other health restrictions resulting from the COVID-19 pandemic, allowed the development of experiences that contributed to the deployment of experiences related to sociocultural participation in life of the participants and with it, to partially reduce the impact of sociocultural deprivation resulting from such restrictions, providing experiences and tools that favored their incorporation into daily life.

Health care processes and, in particular, those related to mental health, must therefore be nourished by the bodily perspective, since in this way it would be possible to achieve a comprehensive approach to the phenomenon of occupation, as well as to understand the impact of people with mental suffering in the evolutionary development of each person. Only from this incorporation would it be possible to approach in a comprehensive manner the understanding of the various ways in which mental suffering reconfigures the bodily space of people.

Regarding the theoretical framework, it is important to emphasize that, while Psychosocial Rehabilitation, as a practice, was premised on enabling the sociocultural participation of the person with mental suffering through bodily approaches, Agnes Heller's theory evidenced that The everyday life of the participants has its plots of social relations restricted almost exclusively to domestic environments, whose insertion spaces configured the different day-to-day activities characterized by domestic work and sedentary lifestyle mainly.

For this, it is important to break with the stigma and enable spaces that facilitate independence, autonomy and ways of relating to oneself and to others, from a perspective of self-care production.

In this sense, it is also considered that a greater number of studies that point to the practice of health professionals are necessary, including occupational therapists, to accompany the discussions on the strengthening of current mental health demands in the Chilean context, especially associated with corporality and people with mental suffering.

Despite the limited number of participants, although it proposes us to contribute in this aspect, it does not manage to generate generalized or less massive projections towards other scenarios. However, the ethnographic findings are conclusive regarding situating this group of people with mental suffering and their relatives or main caregivers, as a sample in a condition of high risk or vulnerability associated both with stigma and with current health conditions. In this sense, it is important to consider the broad impact of COVID-19, not only on public health, but also on the consequent restrictions and social and economic disruptions that radically affected and still affect our daily lives and occupations.

In accordance with the foregoing, telehealth enabled the development of this therapeutic space, considering that it was the only possible alternative in accordance with the health restrictions of the moment, and in this sense, it was recognized as a highly significant space for group and body practice, which nurtured and stimulated social participation. However, we consider that this modality of work did not manage to impact with the intensity that it would have allowed in the face-to-face format and with physical contact, thereby restricting a large part of the methodologies and contents to be used since there is no possibility of bodily guiding or facilitating the performance of the participants through individualized contact.

Finally, the experimentation of bodily practices as a strategy associated with the researc performance is of the utmost importance for the effective incorporation of empowerment and autonomy of the participants, since this occurs in the context of direct benefit. In this sense, promoting proposals for daily transformations about the processes of corporeity, with awareness for comprehension and understanding about the importance of the body becomes relevant for the construction of meanings, production of subjectivity and sociocultural participation of heterogeneous groups of people with mental suffering.

Acknowledgements

Programa de internacionalización del Magíster en Ocupación y Terapia Ocupacional, Facultad de Medicina, Universidad de Chile - UChile.

• 1
  For further information visit the official page of the Facultad de Medicina de la Universidad Austral de Chile (Universidad Austral de Chile, 2017).
• How to cite: Cirineu, C. T., & Cárcamo Olivarez, L. (2023). The effects of health restrictions due to COVID-19 and the importance of using body approaches with people suffering from psychological distress and their families. Cadernos Brasileiros de Terapia Ocupacional, 31, e3493. https://doi.org/10.1590/2526-8910.ctoAO267834932

• Funding Source

  Internal Installation Project of the Research Department of the Universidad Austral - UACh, Valdivia Campus, Chile (VIDCA INS-INV-2020-08/ PROYECT NUMBER: 1316-32-40).

Referencias

• Aguiar, M. (1998). Teatro espontâneo e psicodrama. São Paulo: Editora Ágora.
• Alva-Arroyo, L. L., Murillo, J. N. P., Ancaya-Martínez, M. D. C. E., & Floréz-Ibarra, J. M. (2021). Experiencias de telesalud en un hospital especializado en salud mental durante la pandemia de COVID-19 en Perú. Revista Peruana de Medicina Experimental y Salud Pública, 38(4), 653-659.
• Amarante, P. (2007). Saúde mental e atenção psicossocial. Rio de Janeiro: Fiocruz.
• Assad, F. B., & Pedrão, L. J. (2013). O teatro espontâneo do cotidiano como um instrumento terapêutico nas ressignificações de ser um portador de transtorno mental. Texto & Contexto Enfermagem, 22(4), 1089-07.
• Assad, F. B., Pedrão, L. J., & Cirineu, C. T. (2016). Estratégias de cuidado utilizadas por terapeutas ocupacionais em centros de atenção psicossocial. Cadernos de Terapia Ocupacional da UFSCar, 24(4), 743-753. http://dx.doi.org/10.4322/0104-4931.ctoao0738
  » http://dx.doi.org/10.4322/0104-4931.ctoao0738
• Bezerra, W. C., & Trindade, R. L. P. (2014). Gênese e constituição da terapia ocupacional: em busca de uma interpretação teórico-metodológica. Revista de Terapia Ocupacional da Universidade de São Paulo, 24(2), 155-161.
• Boal, A. (2001). Jogos para atores e não-atores. Rio de Janeiro: Civilização Brasileira.
• Boal, A. (2002). O arco-íris do desejo: método Boal de teatro e terapia. Rio de Janeiro: Civilização Brasileira.
• Boal, A. (2005). Teatro do Oprimido e outras poéticas políticas. Rio de Janeiro: Civilização Brasileira.
• Citro, S., Greco, L., & Torres, S. (2020). Las corporalidades de la etnografía: de la observación participante a la performance-investigación colaborativa. In L. Katzer & H. Chiavazza (Eds.), Perspectivas etnográficas contemporáneas en Argentina (pp. 103-171). Mendoza: Edifil.
• Feldenkrais, M. (2009). Autoconciencia por el movimiento: ejercicios fáciles para mejorar tu postura, visión, imaginación y desarrollo personal. Barcelona: Paidós.
• Ferigollo, J. P., & Angeli, A. A. C. (2017). A interface entre o fazer teatral e a terapia ocupacional: reflexos no cotidiano. Saúde (Santa Maria), 43(2), 139-150.
• Galheigo, S. M. (2012). Perspectiva crítica y compleja de terapia ocupacional: actividad, cotidiano, diversidad, justicia social y compromiso ético-político. TOG (A Coruña), 9(5), 176-325.
• Galheigo, S. M. (2014). Sobre identidades, latinoamericanidades e construção de saberes em Terapia Ocupacional: diálogos com Boaventura de Sousa Santos. Cadernos de Terapia Ocupacional da UFSCar, 22(1), 215-221.
• Giraldo Gärtner, V. (2016). Reseña Antropología Médica y Terapia Ocupacional: reflexiones preliminares de una conversación promisoria. Revista Ocupación Humana, 16(1), 100-104.
• González Bellés, R., & Dámaso Vega, B. (2022). El estigma del trastorno mental como problema de salud pública: una revisión integradora. Agora de Salut, 8, 127-140.
• Guimarães, G. T. D. (2002). Aspectos da vida cotidiana: Agnes Heller em perspectiva. Porto Alegre: EdiPUCRS.
• Heller, A. (2008). O cotidiano e a história. São Paulo: Paz e Terra.
• Hernández Rodríguez, J. (2020). Impacto de la COVID-19 sobre la salud mental de las personas. Medicentro Electrónica, 24(3), 578-594.
• Jacobson, E. (1976). You must relax. Nueva York: McGraw-Hill.
• Justa, F. M. C., & Holanda, I. C. L. C. (2012). Teatro com adolescentes em risco social: práticas de promoção da saúde no contexto terapêutico ocupacional. Revista de Terapia Ocupacional da Universidade de São Paulo, 23(1), 16-23.
• Katzer, L., & Chiavazza, H. (2020). Perspectivas etnográficas contemporáneas en Argentina. Mendoza: Edifil.
• Le Breton, D. (2002). Antropología del cuerpo y modernidad. Buenos Aires: Nueva Visión.
• Manríquez, J. M. (2019). La evolución de la mirada médica sobre el cuerpo y la enfermedad, y el cambio de paradigma en la historia de la medicina: una visión desde América Latina. In C. T. Cirineu & F. B. Assad (Eds.), Corpo em foco: proposições contemporâneas (pp. 67-80). Batatais: Claretiano.
• Ministerio de Salud de Chile - MINSAL. (2017). Plan Nacional Salud Mental 2017-2025 Recuperado el 8 de enero de 2013, de https://www.minsal.cl/wp-content/uploads/2017/12/PDF-PLAN-NACIONAL-SALUD-MENTAL-2017-A-2025.-7-dic-2017.pdf
  » https://www.minsal.cl/wp-content/uploads/2017/12/PDF-PLAN-NACIONAL-SALUD-MENTAL-2017-A-2025.-7-dic-2017.pdf
• Ministerio de Salud de Chile - MINSAL. (2021, 11 de mayo). Ley N° 21331, de 11 de mayo de 2021. Del reconocimiento y protección de los derechos de las personas en la atención de salud mental Santiago: Biblioteca del Congreso Nacional de Chile.
• Moreno, J. L. (1975). Psicodrama. São Paulo: Cultrix.
• Novelly, M. C. (1994). Jogos Teatrais: exercícios para grupos e sala de aula. Campinas: Papirus.
• Payán, D. D., Frehn, J. L., Garcia, L., Tierney, A. A., & Rodriguez, H. P. (2022). Telemedicine implementation and use in community health centers during COVID-19: clinic personnel and patient perspectives. Qualitative Research in Health, 2, 100054.
• Payne, R. (2007). Técnicas de relajación: guía práctica. Buenos Aires: Paidotribo.
• Salles, M. M. (2011). Vida cotidiana de usuários de CAPS: a (in) visibilidade no território (Tesis de doctorado). Universidade de São Paulo, São Paulo.
• Salvo, G. (2022). Salud mental, una mirada desde los determinantes sociales de la salud: caracterización de la población en tratamiento por depresión de la Región Metropolitana de Chile, según datos de la encuesta CASEN 2017 (Tesis de maestría). Universidad del Desarrollo, Santiago de Chile.
• Sánchez-Dávila, K. (2022). Conservación e importancia de la salud en tiempos post pandemia. Revista Salud Amazónica y Bienestar, 1(2), 1-3.
• Schwartzberg, S. L., Trudeau, S. A., & Vega, V. (2013). Principles of occupational therapy group outcome assessment in mental health. Occupational Therapy in Mental Health, 29(2), 134-148.
• Souza, A. C., Guljor, A. P. F., & Silva, J. L. L. (2014). Refletindo sobre os centros de atenção psicossocial. Avances en Enfermería, 22(2), 292-298.
• Spolin, V. (2008). Jogos teatrais na sala de aula: um manual para o professor. São Paulo: Editora Perspectiva.
• Universidad Austral de Chile, Facultad de Medicina. (2017). Centro de Rehabilitación Psicosocial Valdivia Retrieved in 2023, July 20, from http://medicina.uach.cl/facultad/red-salud-uach/centro-de-rehabilitacion-psicosocial-valdivia
  » http://medicina.uach.cl/facultad/red-salud-uach/centro-de-rehabilitacion-psicosocial-valdivia
• World Federation of Occupational Therapists - WFOT. (2014). Declaración de Posicionamiento de Telesalud. Recuperado el 8 de enero de 2013, de https://apeto.com/assets/posicionamiento-en-telesalud-to.pdf
  » https://apeto.com/assets/posicionamiento-en-telesalud-to.pdf
• Xavier, M., Terra, M., da Silva, C., Souto, V., Mostradeiro, S., & Vasconcelos, R. (2014). El uso de psicofármacos en individuos con trastorno mental en seguimiento ambulatorio. Enfermería Global, 13(36), 114-125.
• Zapata, J., Gil, K., Lope, A., Ospina, L., Gutiérrez, P., Aristizábal, A., Gómez, M., & García, J. (2022). Descripción de un programa de telesalud mental en el marco de la pandemia de COVID-19 en Colombia. Revista Colombiana de Psiquiatría In press.

Edited by

Section editor

Prof. Dr. Rodolfo Morrison.

Publication Dates

• Publication in this collection
  04 Sept 2023
• Date of issue
  2023

History

• Received
  08 Jan 2023
• Reviewed
  13 Jan 2023
• Reviewed
  04 Mar 2023
• Accepted
  11 May 2023