Promoting Mental Health and Community Participation: A

The purpose of this paper is to describe and analyze a participative health experience involving art, creativity and play, in articulation with the strategy of Comprehensive Primary Health Care focused on mental health. This experience is conducted by a network of institutions in Buenos Aires City. This is an exploratory and descriptive case study based on qualitative research methodologies. From an ethnographic perspective, the fieldwork revolved around interviews and participant observation records. The systematization process followed qualitative analysis content techniques. The outcomes describe a practice cored in intersectoral work, community participation, occupation of public space, creation of community gathering spaces and conformation of solidarity ties for addressing complex psychosocial issues. The main participatory processes focused on community organization and collective artistic creations are described. It is concluded that such experiences evidence substantial transformative potential, creating community conditions suitable for joint decision-making within the health-illness care process itself.


I. Introduction
The latter half of the Twentieth Century brought about a questioning of asylum-based psychiatric care and prolonged hospitalization (Basaglia, 1968;Galende, 1997;Goffman, 1961).The development of mental health policies since that time proposed a shift toward a comprehensive and integrational model of therapeutic habilitation treatment focused on disease prevention and health promotion (Caplan, 1964;PAHO/WHO, 1990).To that end, the structure of services became more inclusive and participatory by integrating new community mental health problems (WHO, 2001).
The beginning of the 21st Century converges with a return to Primary Health Care principles (PAHO/ WHO, 2007) where CPHC (Comprehensive Primary Health Care) is seen to emerge as a strategy reordering systems under the tutelage of a universal logic grounded in Human Rights.From this perspective, community-based mental health policies reaffirm the need for a strong connection between CPHC strategy and promotion and prevention in community mental health (Stolkiner &Solitario, 2007).
According to the World Health Organization, promoting mental health activities does not only involve preventing mental disorders, but also creating individual, social and environmental conditions to enable an optimal psychological and psychophysiological development, in full compliance with Rights (WHO, 2004).
Since the Ottawa Charter for Health Promotion, these policies have progressively placed a high priority on the strengthening of community actions (WHO, 1986).Social involvement works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health.For reform processes in mental health, it is critical to resume the principles included in the Ottawa Charter for an effective transformation of the asylum model.Such reforms, however, will not be successful if solely restricted to transforming mental healthcare.
In Argentina, reform processes in mental health are marked by a strong tension and conflict among the different actors involved.Similarly to other Latin American countries, Argentina's healthcare system is historically characterized by segmentation, fragmentation and heterogeneity, which makes it difficult to design intervention strategies to be articulated among different effectors (Stolkiner, 2009).In the field of mental health practices, these features are manifested by the coexistence of multiple actors, financiallly wise just as service providers, lacking all interrelation and forms of coordination.As a consequence, the appropriate distribution at different healthcare levels is hindered by overlapping or unavailability.A National Law for Mental Health sanctioned by late 2010 offers a legal framework that boosts a transformation from the asylum logic to a comprehensive approach model.However, this law has been enforced to variable degrees and forms throughout the country.In the city of Buenos Aires there is a mental health law that was sanctioned more than ten years ago.The tensions caused by medical corporations and the pharmaceutical industry have consequently stalled the regulation and implementation of this law.
Amidst this complex context of friction and fragmentation, some experiences in mental health promotion arise outside official discourse and official programs, and sooner occur within alternative spaces.These are isolated initiatives, stemming from healthcare and mental health professional teams working jointly with community organizations; together they have found a way to develop participatory and comprehensive actions in mental health through creative, aesthetic strategies of expression and participation.Many of these experiences use art and play as collective creative practices in community work, reflecting a close relationship between art and health.Many of these activities emphasize the creation of spaces for community participation, deploying autonomous or network actions in the local context.Such experiences have not been thoroughly studied nor researched in their basic characteristics, thus becoming an area thematically vacant and at times receiving little attention from mainstream clinical discourse.
Such developments give rise to some of the questions leading our present research: How could participatory practices combining art and health at the community level be described?What are the participatory processes involved?How are these practices described by intervening stakeholders?Is it possible to understand these experiences from the perspective of Comprehensive Primary Healthcare focused on mental health?What are the possibilities and implications of such cohesions?
The overall objective of this research was to look into the existing and potential correspondence between the strategy of promoting mental health and participatory community health practices using art, creativity and play in public spaces.
The need to know and indeed experience participatory processes included in community-based practices related to the field of mental health promotion becomes evident.The inclusion of participatory practices in community mental health would be a first step for reform processes in Argentina and the region as a whole.On the other hand, it is crucial to know the processes which, from the perspective of those intervening, contribute to improving different aspects of daily life and wellbeing.To that end, an institution network from the city of Buenos Aires was selected to study participatory practices combining art, creativity and play in public spaces.This paper is principled on a line of work that perceives health and mental health from a comprehensive perspective and not a normative one (Czeresnia & Freitas, 2009).Special emphasis is placed on the socio-historical dimension of the health-illness care processes (Waitzkin, Iriart, Estarada & Lamadrir, 2001), underscoring rights by addressing complex psychosocial issues (Ayres et al;2006).Directed to the community as a whole, the actions for promoting community mental health are those which create collective processes for the transformation of community bonds toward solidarity ties and growing community involvement (Bang, 2014).Sustaining these actions throughout time enables the constitution of the community itself as an active subject for transforming reality, creating the right conditions for independent and joint decision making around the health-illness care process itself.This study thus focuses on the field of practices combining art, play and social transformation, taking as background those developments stressing the participatory dimension of community art (Bishop, 2012;Dubatti & Pansera, 2006).In this sense, the Lima Statement on Art, Health and Development states: Art is a privileged language for the expression and mobilization of desire and emotion, and therefore turns into a powerful tool for promoting and restoring health, enabling individuals and communities to reprocess situations which are critical, painful or problematic, and to promote better and happier scenarios for their lives (PAHO/WHO, 2009)

Methodology
The work plan for the current findings had been in development since April 2009 as part of a research project approved and funded by the School of Psychology of the University of Buenos Aires.In line with qualitative health research (Minayo, 2006), the present study has a descriptive and exploratory nature.The design strategy is cored in the unique case study (Yin, 1994), taking as a unit of observation and analysis the activities of community mental health promotion conducted by an institution network in the city of Buenos Aires.
From an ethnographic perspective (Hammersley & Atkinston, 2007), the fieldwork focuses on the support of the actions taken by this institution network for a period exceeding three years.Participant observation was mainly used as a data collection technique for all activities (Guber, 2001) and interviews (Marshall & Rossman, 1989).Following a naturalist perspective (Erlandson, Harris, Skipper & Alle, 1993), most of the interview material was collected via conversational interview format, which refers to different ways of conversation maintained by the researcher, as both participant and observer.In addition, twenty semi-structured and in-depth interviews were made to institutional referents, key informants and active participants from each activity, selected according to theoretical sampling.Twenty people selected at random were interviewed throughout the street events, following a brief, structured interview.The interviews examined the characterization of the practices and object of study.
The systematization process of the collected material was performed by following two techniques for content analysis: thematic analysis and relationship analysis (Minayo, 2006).The thematic recurrence principle (Stake, 1994) in the interview material helped to delimit large thematic cores, sorted following the processes used for creating categories and conceptual cohesion by subject (Valles, 2000).All the material was ordered following a local and inclusive integration criteria (Weiss, 1994), which allowed for identification of results and conclusions.The following served as criterion validity: the triangulation of methods in the field work and information analysis, the criterion of ethnographic credibility (Geertz, 1990) and informed consent (AAA, 2009).

II. Results
The results were sorted into different sections: first, the experience under study is described and analyzed, incorporating the voice of the participants.Then, the connections between such experience and the conceptual approach of promotion in mental health are established, and finally the participative processes involved are addressed.

Describing the experience
The experience studied takes place in a densely populated neighborhood at the geographic center of the city of Buenos Aires, where a major business-tourism-real estate hub coexists with a large number of migrants precariously settled in tenements, family hotels and squatted houses.In 2008, 12.5% of the housing in this area was deficient (INDEC, 2010).This neighborhood accounts for the highest percentage of migrants in the city (14.3%), mostly from bordering countries and Peru.They are representative of the lowest socioeconomic status, with a significant sub-employment percentage (44.6%).Among the occupants of substandard housing, overcrowding reaches 56.2%, with critical overcrowding at 12.8 (Bou Perez, Mir Candial, Iglesias, Pastor & Alfano, 2011).This population coexists, as social counterpoint, with another: families of the middle-to-high socioeconomic level in the scale (85.7% of the population) (INDEC, 2010).Such coexistence is not openly violent; nevertheless, previous research has shown a high degree of discrimination and segregation toward immigrants, derogatory of their traits and cultural expressions (Carman, 2004).
In the year 2006, a few institutions from the neighborhood created a territory-based institution network.Since then, this network has been working for a better quality of life drawing on growing community participation, contributing to restoring the social fabric and recovering the public space for the regeneration of ties and community integration.There are ten to fifteen organizations participating actively in joint activities: state institutions and civil society organizations.The two health institutions participating are: a Community Action Health Center placed at the first level of care of the programmatic area in a General Hospital, and an Outpatient Mental Health Center under the Mental Health Department of the Government of the City of Buenos Aires.All the institutions constituting the network work centrally with families in the poorer sector in the neighborhood, widely deprived of their basic rights and characterized by precarious labor and housing.This network is particular in the sense that their joint actions revolve around the making of collective events in public space, with art, creativity and play at the core.The street is the venue for all such events, changing the daily logic and topography of public space, by opening a space for shared activities previously engineered.
In the period analyzed, all the events observed started with the unfolding of a community recreation space of urban intervention named Cumbre de Juegos Callejeros.This device of play is especially important, integrating and inclusive, gathering adults and children, professionals and the community to share two hours of traditional games in the street.Activities blending the creative, the artistic, play and the social community are unrolled: art workshop exhibits, neighborhood music bands and theater groups, the screening of videos, open dance classes, recreation and play activities oriented to working on different community subjects and concerns.The whole celebration is accompanied by dancing, typical food and different stands exhibiting the community activities of the organizations in the network.The event concludes with a joint work of disassembling and cleaning, where everyone is invited to participate.An incipient way of approaching complex psychosocial concerns have been observed in this practice: discrimination affecting part of the neighborhood, invisibility of some social segments, housing situations, difficult access to neighborhood institutions, general social isolation, fearing the street, among others.There is a potential to generate actions for a better quality of life and social integration in the neighborhood.Revaluing different cultures is essential in a context marked by strong processes of segregation and exclusion.In the understanding that these situations bring a high degree of subjective ailing, it is assumed that they must be addressed in a collective and community fashion.The fact of functioning as a network supposes understanding the complexity of the multiple tranversalities involved in an inter-institutional approach.

The street events from the perspective of the participants
The interview material merges into five common and recurring subjects which allow for setting a common denominator to characterize these experiences: 1.In all the narratives the street events are associated with the idea of feasts overflowing joy, happiness and creativity, where affection circulates and bonds are built.Naturally, on account of the joy shared, these events are optimal spaces for neighbors and institutions to meet and get to know one another.In this sense, one participant stated: "the people are out in the streets sharing food, dancing, enjoying, and in addition to making all this… behind is the possibility of looking at things from another perspective.Creativity is another way of being in the street, to recreate, to share, to assume other roles… ".Another participant added: "what is different in these events is that the people can go and share with others".And another neighbor said: "the important thing is to create bonds, because when you're alone everything is more difficult… to make links with others who can do what we cannot".
2. One of the central objectives manifested by the interviewed is that of community participation: "that the people from the neighborhood come", "the important thing is the community participation", "to assemble the event between all" are objectives by themselves and this feels transformer.Referents and institutional workers as well as community members feel as subjects of participation in a collective event.It is understood that it is through participation that the space of encountering and sharing is built.In many narratives participation is associated with the possibility of leadership: "It is the spirit of every street party that the neighborhood becomes protagonist".The effects are multiple and include the possibility of generating a change in the social imaginary about young people.In the words of a neighbor participant: "The important thing is that the neighbor sees how a group of young people participate, they are criticized and actually what always happens is that there are no projects for them.When there are projects where they can participate there is a wonderful magic… ".
3. The value of going out into the street and occupying public space by relating to others spontaneously is also evidenced by the interviewed.A neighbor said: "this so fast and alienated city prevents you from seeing whom you have next to you, and these events help us a lot to get to know each other, leaving the selfishness to understand and tolerate".The street is positively valued as a strategic site of participation and the human encounter between neighbors: "The idea is to meet each other, to get out of the place of fear and prejudice against the street…" This cann be understood as a space of freedom and where there is the liberty of circulation.Another participant stated: "…imagine that this is a place where you suffer and to transform it into a place where you enjoy with others has a lot of power, then life can be different…".
4. The street celebration is perceived as an important chance to make visible the existence of a population that is otherwise sidelined and eclipsed.An institutional referent said: "there is many marginalization in this neighborhood, here the shopping and almost private neighborhoods coexist with people from other countries with violated rights, and the street events generate the possibility of an encounter with those other people that ordinary people do not want to see, so they can also feel that the public space and the street belong to them".The neighborhood institutions and organizations working with this population also become visible and less marginal.
5. The idea of health tied to the possibility of enjoying and sharing a creative and pleasant activity in street events surfaces in the narratives collected.A neighbor commented: "I bring my children because I see that they play happy and I think that they have more health, therefore I say to my sister to come up with her children too".A worker of the health center said "this help not to lose the ability to laugh, the ability to play, the wonder, and this contributes to their physical and mental health, and ours… ".

Articulations from the perspective of promoting community mental health
Event characterization drawing on the double register of participant observation and interviews provides some axes to this experience.The narrations and practices emphasize a series of elements within the framework of promotion in mental health from a perspective of Comprehensive Primary Health Care: creating a space for community gathering to promote bonding, intersectoral articulation, community participation, sustaining spaces of joy shared collectively, the possibility of inter-institutional networking and the reconfiguration of neighborhood and community networks.
These events contribute a space of mutual knowledge and shared activity, necessary for generating processes where conflicts are enunciated and problems to be thought out are unveiled (Stolkiner, 2001).In a community that begins to get organized to operate on transforming situations causing distress, developing these celebrations collectively represents an opportunity.Street events are an invitation to put one's imagination to work together with others, creating a possibility for change and collective confidence in that possibility.This mental health promotion practice is developed in a maverick, less normalized space, outside the traditional institutional devices, and embedded in the everyday life of the community.These events provide a space where bonding, solidarity and horizontal relationships are crucial, recovering and revaluing the subjective dimension of human interaction.
Founded on a valorization of popular knowledge and social involvement, this experience chooses the strengthening of collective capacity as a path to coping with the multiple factors conditioning health and life.It is thus the basis of a comprehensive rather than normative idea for promoting health and mental health (Czeresnia & Freitas, 2009).Street events constitute health caregiving acts, since they are the means through which these subjects and their groups show their capabilities for action, creativity and problem solving; therefore, it is a potential mechanism for reasserting their own knowledge.The healthy power of this practice lies, to a great extent, in the creation of a space that allows for a collective way of making a difference on "the way to live life" (Merhy, 2000).

Participatory processes
According to this scenario, the activity conducted and the participation dynamics, three major participatory processes have been identified, representing different complementary forms of community participation as part of this experience.Although these actions are articulated through network meetings, each process presents its own features and potentials: 1.An initial process is that of organizing each event, achieved after numerous meetings involving planning, execution and evaluation.This is an open and participatory process, conformed by multiple community stakeholders: institutional referents, popular artists from the neighborhood, population assisted by the network institutions and many other neighbors.This process seeks to work jointly with those whose voice is not heard, with the most discriminated and silenced in their neighborhood, posing a great collective challenge.The main characteristics of this participative process are: effective circulation of relevant information, creation of spaces for community encounter and exchange of ideas on shared issues and concerns, progressive horizontalization of communication, the possibility of participants having an influence on decision making, on their role in the activities carried out, and on developing spaces for discussion and training on the subject of community participation.The result is a programming of activities constructed collectively, drawing on crossover proposals and groups of heterogeneous origin; this enables the conformation of a weave or network of multicultural links and actions, expressed as experiential and act.
2. The subsequent process is that of giving origin to the artistic and play activities presented at each event.This takes place inside the organizations, where community groups including the assisted population are conformed.Each process begins with the acquisition of artistic tools, continues with the collective construction of a play and ends with a presentation before the community.This path is sustained by consensus, joint decision making, participation and commitment.The resulting play-artistic productions share the central feature of being creative creations.The creative process usually works drawing on emerging subjects and concerns arising from daily situations.Such process enables the weaving of collective identities, bonds of mutual cooperation and creative capabilities, building possibilities for the resolution of situations by resorting to imagination, fiction and creativity as a play-fictional rehearsal for solving conflictive situations.
3. Professionals from health and mental health institutions participating actively in the network actions stress the relevance of a third participative process occurring from within their institutions of origin: it is the progressive participation of other health professionals in the network activities based on the attendance to the street events that come up in community articulation.This phenomenon has given rise to gradual institutional openness oriented to the inclusion of these mental health promotion practices.In these institutions, the participation of professionals in the street events has contributed to develop a closer relationship between population and health effectors, a connection usually perceived as distant by the community.This process is widely valued by the parties involved, since it works on the accessibility barriers in services and quality of care.An example of this is given by the celebrations at the door of the Health Center, where play is used to address different subjects in community health, and as a symbolic way of bringing the health center closer to the neighborhood.

III. Discussion
The development of this work allows us to relate the practices studied with the strategy of Comprehensive Primary Health Care in the context of mental health.Such practices are rooted in an intersectoral approach, working in networks and community participation in health with a comprehensive vision, evidencing strong transformative potential.Congruent with the actions of community mental health promotion, participative events of collective creation favor a channel for the transformation of community ties toward solidarity ties.Effective channels of community participation are created, oriented toward the constitution of the community itself as an active subject of transformation of their own reality.These actions generate the right conditions for the community to make joint decisions on the health-illness-care process itself.
These practices appear as alternative critical responses to isolation, relational loneliness, discrimination and other complex psychosocial concerns related to subjective suffering.The processes herein detailed facilitate relational spaces as enablers of new visions, as an outlet of shared desires and needs, as transformers of social representations and imaginaries.Community participation is therefore constituted as a factor of mental health.Participative processes draw on the need to situate the body into the task at hand and prompt it to act along with others, thus generating a transformation oriented to the possibility of collective organization and action.This could be a first step in a transformation leading to a community which can think of, and for itself as a social actor.
The experience studied shows that mental health promotion is articulated through participative forms of the social collective, producing profound subjective effects on the actors involved.This articulation allows sustaining devices and existential mechanism which are open, flexible and inclusive.Collective artistic creation is presented as one of the central participative processes: a group process which serves as a driver of interests and concerns shared through aesthetic channels, putting imagination to work actively.Collective creativity provides a key to unlocking the relationship between art and mental health in the community environment.Developing creative potential in the community strengthens a collective ability to cope with the complexity of constraints conditioning health and life.These creative skills, produced from artistic work, consequently carry the potential to move to other areas of community life, this, as a fundamental capability to contribute solutions to punctual problems.As a consequence, the conclusion is that through processes of collective artistic creation there is inherent and untapped potential for generating healthy effects on the community, increasing mutual understanding, tolerance and dialogue.
On the other hand, the analyzed experience is developed in a conflictive territorial context, where two socioeconomically contrasting populations coexist, with high levels of discrimination and segregation.In this context, the systematic continuity of these events over time generates conditions of possibility for the progressive deconstruction of the social images and stereotypes that sustain such segregating processes.From the perspective of Primary Health Care, this process is a promoter of health.
By virtue of the participatory nature of play and artistic activities, a bridge can be built between institutions and populations.For Health Institutions adhering to the biomedical model of care, such practices have paved the way to horizontal ties, shared practical knowledge and the inclusion of an affective dimension in the healthcare professional-patient relationship.This was made possible through the shared experience of collective creation, which goes beyond the spoken word.On account of the particular play-art characteristics and the related cooperative processes involved, this device also enables conveying a comprehensive health perspective in act, based on care and associated to pleasure, joy and solidarity in community relations.The possibility of exerting influence on the transformation of health and mental health institutional practices has proven to be a powerful and novel contribution to this experience.
Finally, such aesthetic practices facilitate strategic spaces for community participation in health.In this sense, it is possible to conclude that street devices are feasible and powerful tools for community intervention.The street event breaks away with the codes and hierarchies of daily use of the street and other hierarchical venues of the human encounter, presenting a different scenario for interaction.The street is a place of privilege where the invisible turns visible, where the discriminated can be valued; it is a place to create other ways of relating between institutions and the population.

IV. Conclusion
The experience studied is presented as a way of creative resistance to the production of subjectivity hallmarking our epoch, characterized by global standardization of thought, by the overrating of consumption, by the loss of solidarity and an exacerbation of narcissism (Virno, 2004).In such a context, street events of collective creation are producers of an alternative subjectivity that privileges the concept of community, of the relational, of the inclusive and territorial.From the perspective of comprehensive health, the practices that confront individualism and competition -typical of our current market society-to replace them for solidarity and cooperation, are practices that promote community mental health (ALAMES, 2011;Breilh, 2008).
In the experience studied, the participatory processes including collective creativity facilitate the development of community contention networks.This would enable the conformation of a more inclusive community, an aspect necessary for the reform processes in mental health.However, the lack of State support threatens the sustainability of such practices and their possible articulation with processes aimed at transforming the current hardships that affect mental healthcare.In this sense, this studied experience sets a precedent which expresses a way of possible and necessary articulation in the field of practices for promoting community mental health, essential for the success of the reform processes undertaken in our country and in the region.
Our study further shows that, in the field of practices, it is necessary to work broader concepts of health and mental health leading to the construction of social practices that are more spanning and which make effective health promotion possible.At present, many of the conceptual discussions in this field are centered in being able to define mental health promotion as part of a series of categories to sort out areas of intervention (Mrazek & Haggerty, 1994).Such categories focus on the approach of "mental illnesses" defined according to individual psychopathologic diagnoses (Ausburger, 2002).The new mental health paradigm and strategies of mental health promotion must address issues related to the subjective ailing of the community as a whole, not necessarily related with psychopathologic diagnoses.A commitment to defending life must be made, with institutions and subjects potentially capable of contributing to a new scenario of social relations for the conformation of a fairer and equitable society.