Desafios da reabilitação profissional desenvolvida pelo Instituto Nacional do Seguro Social (INSS): uma perspectiva histórico-cultural / Challenges of the vocational rehabilitation developed by the Brazilian Social Security Institute (INSS): a cultural-historical approach

Resumo Introdução: transformações ocorridas na prestação do serviço de Reabilitação Profissional (RP) pelo Instituto Nacional do Seguro Social (INSS) fizeram emergir contradições entre seus resultados e o que se espera de uma política pública de inclusão social. Objetivo: compreender como tais transformações afetaram a atividade de trabalho e como o serviço de RP está lidando com as mudanças e problemas decorrentes. Métodos: realizada análise histórica das contradições entre elementos do sistema de atividade da RP em serviço do INSS localizado no interior do estado de São Paulo. Foram utilizados dados etnográficos e discursivos de intervenção baseada no método Laboratório de Mudança. Resultados: evidenciou-se que o objeto da RP foi historicamente reduzido à orientação e capacitação profissional. Foram identificadas dificuldades do sistema de atividade da RP em lidar com determinações judiciais, além da diminuição da capacidade instalada e acúmulo de tarefas que impactam no atendimento aos trabalhadores. Conclusão: a redução administrativa do objeto da RP, bem como o sistema de atividades apoiado em ações de atores externos à Previdência Social, sem articulação institucional e protocolos de cooperação entre os serviços, demonstra o descompasso entre o desmonte histórico da RP no INSS e a demanda social dos trabalhadores com incapacidades para o trabalho

Abstract Introduction: changes in the Vocational Rehabilitation (VR) service provided by the Brazilian Social Security Institute (INSS) led to contradictions between their results and what is expected from a social inclusion policy. Objective: to investigate how these changes affected work activity and how the VR service is facing the consequent issues. Methods: we conducted a historical analysis of the contradictions between the VR system elements based on the provision of this service by an INSS agency in the state of São Paulo. Ethnographic and discursive data were collected using the Change Laboratory method. Results: we evidenced that the VR service was historically reduced to vocational guidance and professional training. We identified the VR system had difficulties in addressing judicial orders, as well as there was a diminished installed capacity and task accumulation that hinder a proper assistance to workers. Conclusion: administrative reduction of the VR service, and the system of activities supported by social actors outside Social Security, without institutional articulation and cooperation protocols between services, demonstrates there is a gap between the VR historical dismantling and the disable workers' social demands.

A short history of individual placement and support in Norway.

OBJECTIVE: Norway is a high-income and high-cost society with a generous welfare system, and it has the largest mental health-related unemployment gap of the OECD countries. The aim of the current article was to present a short history of Individual Placement and Support (IPS) services to increase work participation in Norway. METHOD: We provide a narrative overview of the developments and research on IPS in Norway, from the introduction of supported employment to recent and ongoing randomized controlled trials (RCTs) investigating the effectiveness of IPS for various target groups. FINDINGS: While vocational rehabilitation services in Norway have traditionally followed a train-then-place approach, the introduction of supported employment in the early 1990s led to a range of new initiatives to increase work participation. Early implementations were inspired by supported employment but did not follow the evidence-based IPS methodology. More recent developments include a shift toward evidence-based IPS, and the first Norwegian RCT of IPS showed effectiveness on both work- and health-related outcomes among people with moderate to severe mental illness. Several ongoing trials are currently investigating IPS for new target groups, including chronic pain patients and refugees. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results suggest that IPS is more effective than traditional approaches to increase work participation, even in the Norwegian context of a high-cost welfare society. IPS has shown effectiveness in severe as well as more common types of mental illness in Norway, and results from ongoing trials will further reveal whether IPS may be expanded to various new target groups. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

[Aspects of the current workers' rehabilitation scenario in Brazil: strides and setbacks]. / Aspectos do cenário atual da reabilitação profissional no Brasil: avanços e retrocessos.

The field of work rehabilitation in Brazil recently incorporated changes in its underlying concepts and principles, expanding the definition of incapacity for work based on the biopsychosocial health model and adopting a territorial approach and inter-sector practices, with a view towards backing the implementation of an integrated inter-sector work rehabilitation model. However, these conceptual and normative advancements have still not been implemented in practice; they have actually come under threat from Brazil's on-going political crisis. This article discusses the current scenario in the work rehabilitation program under the Brazilian National Social Security Institute (INSS), presents the strides in the underlying theoretical premises and the concerns of work rehabilitation in the face of recent measures that reinforce the biomedical basis and the compensatory policy that led the program over the years, and signal the impending privatization of this social security service and right. The article suggests that work rehabilitation faces a scenario of uncertainties and concerns, intensified by the institutional undermining of the INSS. Rapid structural changes in the INSS and in the work rehabilitation program have undermined the gains that had promoted the initial development of a comprehensive, inter-sector work rehabilitation program aimed at healthy return to work.

A reabilitação profissional brasileira incorporou recentemente mudanças nas concepções e princípios que a regem, ampliou-se o conceito de incapacidade baseado no modelo biopsicossocial de saúde, como também adotou-se a abordagem territorial e práticas intersetoriais, com vistas a fornecer subsídios para a implementação de um modelo integrado e intersetorial de reabilitação profissional. Entretanto, esses avanços não adentraram o campo da prática e encontram-se ameaçados frente a atual conjuntura política do país. Este artigo discute o cenário atual do programa de reabilitação profissional do Instituto Nacional de Seguro Social (INSS), apresenta os avanços nos pressupostos teóricos que o norteiam e as preocupações que a reabilitação profissional enfrenta em virtude das recentes medidas que reforçam o caráter biomédico e de política compensatória que conduziu o programa ao longo dos anos, além de sinalizar uma eminente privatização desse serviço/direito previdenciário. Sugere-se que a reabilitação profissional vivencia um panorama de incertezas e preocupações, intensificado pelo processo de enfraquecimento institucional do INSS. Desse modo, as rápidas alterações realizadas na estrutura do INSS e no programa de reabilitação profissional prejudicaram as conquistas que fomentaram o início do desenvolvimento de um programa de reabilitação profissional integral e intersetorial, a fim de favorecer um retorno real e saudável ao trabalho.

La rehabilitación profesional brasileña incorporó recientemente cambios en los conceptos y principios que la rigen. Se amplió el concepto de incapacidad, basado en el modelo biopsicosocial de salud, además de adoptarse también un enfoque territorial y prácticas intersectoriales, con el fin de proporcionar subsidios para la implementación de un modelo integrado e intersectorial de rehabilitación profesional. Sin embargo, estos avances no se profundizaron en la práctica y se encuentran amenazados ante la actual coyuntura política del país. Este artículo discute la perspectiva actual del programa de rehabilitación profesional del Instituto Nacional de Seguro Social (INSS), presenta avances en los presupuestos teóricos que lo dirigen, así como las preocupaciones a las que se enfrenta la rehabilitación profesional, en virtud de las recientes medidas que refuerzan el carácter biomédico y de política compensatoria que rigieron el programa durante el trascurso de los años, además de señalar una eminente privatización de ese servicio/derecho a la seguridad social. Se sugiere que la rehabilitación profesional vive en un panorama de incertidumbres y preocupaciones, intensificado por el proceso de debilitamiento institucional del INSS. De este modo, las rápidas alteraciones realizadas en la estructura del INSS y en el programa de rehabilitación profesional perjudicaron las conquistas que fomentaron el inicio del desarrollo de un programa de rehabilitación profesional integral e intersectorial, a fin de favorecer una vuelta real y saludable al trabajo.

Aspectos do cenário atual da reabilitação profissional no Brasil: avanços e retrocessos / Aspects of the current workers' rehabilitation scenario in Brazil: strides and setbacks / Aspectos de la perspectiva actual de la rehabilitación profesional en Brasil: avances y retrocesos

A reabilitação profissional brasileira incorporou recentemente mudanças nas concepções e princípios que a regem, ampliou-se o conceito de incapacidade baseado no modelo biopsicossocial de saúde, como também adotou-se a abordagem territorial e práticas intersetoriais, com vistas a fornecer subsídios para a implementação de um modelo integrado e intersetorial de reabilitação profissional. Entretanto, esses avanços não adentraram o campo da prática e encontram-se ameaçados frente a atual conjuntura política do país. Este artigo discute o cenário atual do programa de reabilitação profissional do Instituto Nacional de Seguro Social (INSS), apresenta os avanços nos pressupostos teóricos que o norteiam e as preocupações que a reabilitação profissional enfrenta em virtude das recentes medidas que reforçam o caráter biomédico e de política compensatória que conduziu o programa ao longo dos anos, além de sinalizar uma eminente privatização desse serviço/direito previdenciário. Sugere-se que a reabilitação profissional vivencia um panorama de incertezas e preocupações, intensificado pelo processo de enfraquecimento institucional do INSS. Desse modo, as rápidas alterações realizadas na estrutura do INSS e no programa de reabilitação profissional prejudicaram as conquistas que fomentaram o início do desenvolvimento de um programa de reabilitação profissional integral e intersetorial, a fim de favorecer um retorno real e saudável ao trabalho.

The field of work rehabilitation in Brazil recently incorporated changes in its underlying concepts and principles, expanding the definition of incapacity for work based on the biopsychosocial health model and adopting a territorial approach and inter-sector practices, with a view towards backing the implementation of an integrated inter-sector work rehabilitation model. However, these conceptual and normative advancements have still not been implemented in practice; they have actually come under threat from Brazil's on-going political crisis. This article discusses the current scenario in the work rehabilitation program under the Brazilian National Social Security Institute (INSS), presents the strides in the underlying theoretical premises and the concerns of work rehabilitation in the face of recent measures that reinforce the biomedical basis and the compensatory policy that led the program over the years, and signal the impending privatization of this social security service and right. The article suggests that work rehabilitation faces a scenario of uncertainties and concerns, intensified by the institutional undermining of the INSS. Rapid structural changes in the INSS and in the work rehabilitation program have undermined the gains that had promoted the initial development of a comprehensive, inter-sector work rehabilitation program aimed at healthy return to work.

La rehabilitación profesional brasileña incorporó recientemente cambios en los conceptos y principios que la rigen. Se amplió el concepto de incapacidad, basado en el modelo biopsicosocial de salud, además de adoptarse también un enfoque territorial y prácticas intersectoriales, con el fin de proporcionar subsidios para la implementación de un modelo integrado e intersectorial de rehabilitación profesional. Sin embargo, estos avances no se profundizaron en la práctica y se encuentran amenazados ante la actual coyuntura política del país. Este artículo discute la perspectiva actual del programa de rehabilitación profesional del Instituto Nacional de Seguro Social (INSS), presenta avances en los presupuestos teóricos que lo dirigen, así como las preocupaciones a las que se enfrenta la rehabilitación profesional, en virtud de las recientes medidas que refuerzan el carácter biomédico y de política compensatoria que rigieron el programa durante el trascurso de los años, además de señalar una eminente privatización de ese servicio/derecho a la seguridad social. Se sugiere que la rehabilitación profesional vive en un panorama de incertidumbres y preocupaciones, intensificado por el proceso de debilitamiento institucional del INSS. De este modo, las rápidas alteraciones realizadas en la estructura del INSS y en el programa de rehabilitación profesional perjudicaron las conquistas que fomentaron el inicio del desarrollo de un programa de rehabilitación profesional integral e intersectorial, a fin de favorecer una vuelta real y saludable al trabajo.

[An Early Social-Psychiatric Work in the GDR]. / Eine frühe sozialpsychiatrische Schrift in der DDR.

OBJECTIVE: In 1966 the Leipzig neuropsychiatrist and psychotherapist Christa Kohler qualified as a university lecturer on social-psychiatric problems in patients aged 40 + suffering from psychoses and neuroses. This paper acknowledges this habilitation thesis in its historical context as an early contribution to East German social psychiatry. METHODS: First the thesis itself is searched for points characteristic of Kohler's approach to social psychiatry. Parallel to that, her views are contextualised with other primary sources from or secondary sources about GDR psychiatry at that time. Finally archival sources and oral testimonies of eye witnesses have been considered to substantialise the study. RESULTS: The habilitation thesis is based on data from several hundreds of patients with regard to their demographic, medical and sociological features. Her approach to how older patients suffering from mental illnesses should be treated and rehabilitated is still highly relevant. Yet one must critically assess that many of Kohler's results as well as her psychotherapeutic treatment were ideology-based or oriented on the GDR system. CONCLUSIONS: Kohler's approach shows a clear, yet improper amalgamation of medical science and political ideology. Future research must show in how far this is typical for her concept only or for the whole of GDR social psychiatry.

Deinstitutionalization and vocational rehabilitation for mental health consumers in Nova Scotia since the 1950s.

In this paper we explore the broader policy determinants of the de-hospitalization of mental patients in Nova Scotia between the 1950s and 1980s and trace the background to the development of occupational rehabilitation programs in the community. For employment programs, the government chose to rely on non-profit NGOs as the suppliers of services. As a case study of such an organization, we examine the evolution of LakeCity Employment Services Association as a resource for people living with mental disabilities.

Chapter 53: rehabilitation therapies.

This chapter retraces the history and evolution of rehabilitative efforts by physicians and other health professionals to alleviate the symptoms and disabilities associated with neurological disorders. Rehabilitation therapies often provide interventions that go beyond traditional medical treatment aimed at treating impairments, and help those with neurological injuries and illness to re-establish themselves as productive and socially-integrated citizens by reducing their functional disabilities. The chapter considers the early history of practical treatments developed in Greek and Roman times, reviews the scattered attempts at treatment during the Middle Ages and Renaissance, examines the more recent development of specific rehabilitative techniques and disciplines in the 20th century, and also provides discussion of the contemporary application of empirically validated rehabilitation strategies and techniques that emphasize treatment efficacy. The evolution of medical and physical rehabilitation, occupational and vocational rehabilitation, aphasia and cognitive rehabilitation, are all discussed, with additional review of the influence of some of the military conflicts and wars in history that have stimulated the advancement of the clinical practice of rehabilitation. A critique of the benefits of comprehensive rehabilitative programs for traumatic brain injury and stroke is specifically included. The varied skepticism and optimism of treating neurological disorders throughout history is also highlighted.

[Company centredness in the rehabilitation system of the German Democratic Republic, GDR]. / Die Betriebszentrierung im Rehabilitationssystem der DDR.

This article describes major aspects of the rehabilitation system of the former German Democratic Republic, GDR. Based on presentation of the actors in the medical and occupational rehabilitation system, differences are pointed out in comparison to the notion of rehabilitation in the former Federal Republic of Germany, FRG. The article focuses on the system of rehabilitation after stroke, which is outlined with relevant scientific literature. The health and rehabilitation system of the GDR was company-centred. Patients in rehabilitation received comprehensive care and guidance, and especially the companies played an integrative part and adjusted the occupational activity of the patients in rehabilitation to their physical and mental abilities in order to avoid early retirement. On account of the political and social transformation process as well as transfer of the health and rehabilitation legislation of the old FRG, the company-centred rehabilitation system of the GDR was replaced, implementing West German rehabilitation structures in East Germany as well.

[For the good of the nation's economy: therapeutic work and public assistance at La Castañeda asylum in Mexico City, 1929-32]. / Por el bien de la economía nacional. Trabajo terapéutico y asistencia pública en el Manicomio de La Castañeda de la ciudad de México, 1929-1932.

Founded in 1910, by 1930 Mexico City's La Castañeda insane asylum was grappling with the problem of a massive number of chronic patients, a situation that earned it an image as a warehouse for the sick more than a place of treatment. Psychiatrists endeavored to restore the asylum's legitimacy by publicizing a nineteenth-century treatment which projected the public image that the mentally ill could be as productive as anyone else: work therapy. The government born of the Mexican revolution supported this proposal because the guiding objective behind public assistance for underprivileged groups was to make them part of the country's productive life via the market.

[Housing and work as criteria of the "Social Integration" of the mentally ill - development in Germany between 1900 and 2000]. / Wohnen und Arbeit als Kriterien einer "sozialen Integration" psychisch Kranker - Entwicklungen in Deutschland von 1900 bis 2000.

AIM: This paper analyses, in what way psychiatrists considered housing and work as criteria of social integration of mentally ill people and what models of care were suggested in Germany throughout the 20th century. METHOD: Publications in 29 German professional and scientific psychiatric journals through the complete period from 1900 to 2000 and monographs were searched for papers on the above issues. RESULTS: Until the second half of the century, integrative initiatives related to housing and work generated in asylums without the aim of a full social integration of the patients. In the activistic concept of NS-psychiatry, work became an obligation for patients and a criterion for selection that decided on life and death. Not until the late 1950s, there again was an orientation towards integration in psychiatric care in both German states. Whilst already in 1963 the "Rodewisch Theses" outlined recommendations for the rehabilitation of the mentally ill already in the GDR (East Germany), a similar mark of reform ideas was published in the "enquete" in the FRG (West Germany) in 1975. In the GDR initiatives were limited to a small number of locations. In the FRG and the re-unified Germany various forms of sheltered housing and work were established - also with significant regional variation. However, a clear discussion of underlying aims and implications for the structure of mental health care was not found in the psychiatric literature. CONCLUSIONS: In the 20th century a tradition of psychiatric ideas related to housing and work did not develop in Germany. Particularly, there were only sporadic contributions from university psychiatry. Work was more frequently explicit subject of discussions than housing. Both areas were - slowly and in discontinuity - established as criteria of integration of people with mental illnesses, which was increasingly accepted as an aim of mental health care.

Occupational therapy's link to vocational reeducation, 1910-1925.

The development of occupational therapy is rooted in early 20th century medical reform. During the early 1910s, several members of the medical profession, human service workers, and the larger American society were increasingly disturbed by medical practices that did not consider the individual's personal experience of disability. Occupational therapy was developed, in part, out of this desire to provide persons with treatment that helped them to function in their communities despite their disability. Early occupational therapy leaders envisioned the fledgling profession as a societal service capable of assisting persons with disabilities to return to both work and community life. Vocational reeducation was initially considered to be an integral component of occupational therapy in the years from 1910 to 1920. However, the profession's early link to vocational reduction was challenged by vocational technical trainers during World War I. To prevent occupational therapy from being subsumed by vocational technical training, the early occupational therapy leaders implemented several strategies: adoption of physician prescription for all occupational therapy services, delivery of occupational therapy services primarily within hospital settings, and dissociation from vocational reeducation services. Reasons accounting for why the early occupational therapy leaders abandoned their initial commitment to vocational reeducation are explored. Suggestions about how this decision has affected present-day practice are also offered.

[Rehabilitation in former East Germany]. / Rehabilitation in der ehemaligen DDR.

The fundamentals of rehabilitation in the former GDR are described with particular reference to legal aspects. Interlinking of rehabilitation measures (medical, educational, occupational, social) was achieved by organisational structures on regional level (local rehabilitation centres, local rehabilitation committees) and by involving all levels of society, including employers (all the big companies worked on a nationalized basis). Difficulties are pointed out that resulted from political and ideological prejudices (children and adolescents not amenable to school education) and from inadequate financial and material resources.