The multidisciplinary team's perception on the structure of mental health services: phenomenological study

Abstract

OBJECTIVE

To understand the multidisciplinary team`s perception in relation to the mental health services` organizational structure in the city of Cascavel-Paraná.

METHODS

It is exploratory, descriptive, qualitative study with Alfred Schütz's Social Phenomenology approach. The information was collected through a semi structured interview with professionals of those services, between May and July 2016 and analyzed from the social phenomenology`s assumptions.

RESULTS

From the analysis, the following categories were identified: the mental health care network`s organizational structure; care actions in the context of the mental health services` organizational structure and; expectations regarding the mental health care network.

CONCLUSIONS

The multidisciplinary team has knowledge about the structural and organizational format of mental health services and has expectations of improvements regarding the future of mental health care in the city.

Keywords:
Mental health; Mental health services; Mental health assistance

Resumo

OBJETIVO

Compreender a percepção da equipe multidisciplinar em relação à estrutura organizacional dos serviços de saúde mental no município de Cascavel-Paraná.

MÉTODOS

Trata-se de estudo exploratório, descritivo, qualitativo com a abordagem da Fenomenologia Social de Alfred Schütz. As informações foram coletadas por meio de entrevista semiestruturada com profissionais dos referidos serviços, entre os meses de maio a julho de 2016 e analisadas a partir dos pressupostos da fenomenologia social.

RESULTADOS

A partir da análise foram identificadas as seguintes categorias: a estrutura organizacional da rede de atenção à saúde mental; ações de cuidado no contexto da estrutura organizacional dos serviços de saúde mental e; expectativas em relação à rede de atenção à saúde mental.

CONCLUSÕES

A equipe multidisciplinar tem conhecimento sobre o formato estrutural e organizacional dos serviços de saúde mental e, tem expectativas de melhorias em relação ao futuro da atenção à saúde mental no município.

Palavras-chave:
Saúde mental; Serviços de saúde mental; Assistência em saúde mental

Resumen

OBJETIVO

Comprender la percepción del equipo multidisciplinario sobre la estructura organizacional de los servicios de salud mental en el municipio de Cascavel-Paraná.

MÉTODOS

Estudio exploratorio, descriptivo y cualitativo, con un abordaje de la Fenomenología Social de Alfred Schütz. Se recolectaron las informaciones a través de una entrevista semiestructurada con profesionales de dichos servicios, entre los meses de mayo y julio de 2016, y estas se analizaron a partir de los supuestos de la fenomenología social.

RESULTADOS

A partir del análisis se han identificado las siguientes categorías: estructura organizativa de la red de atención a la salud mental; acciones de cuidado en el contexto de la estructura organizacional de los servicios de salud mental; y expectativas en relación a la red de atención a la salud mental.

CONCLUSIONES

El equipo multidisciplinario tiene conocimiento sobre el formato estructural y organizacional de los servicios de salud mental, y tiene expectativas de mejoras en relación al futuro de la atención a la salud mental en el municipio.

Palabras clave:
Salud mental; Servicios de salud mental; Atención a la salud mental

Introduction

In Brazil, the process of psychiatric reform began in the 1970s, inspired by the assumptions of Italian democratic psychiatry¹, and culminated in the enactment of Law 10.216/2001 which redirected the model of mental health care.

In this way, substitutive services were created, such as the psychosocial care centers, the therapeutic residential service, the psychiatric beds, the multiprofessional mental health outpatient clinic, among others, constituting a Psychosocial Care Network (RAPS), regulated by Administrative Rule no. 3088/2011², which aims to direct the user to treatment and social reintegration.

To this end, RAPS organizes itself structurally in basic care in services such as basic health and family health unit, family health support center, street clinic, support to the services of the residential component of transitory character, centers of coexistence and culture; in emergency and emergency care in a stabilization room, a 24-hour emergency care unit and hospital emergency care units and basic health units, residential care of a transitory nature, residential care services and; hospital care in a ward specialized in general hospital, referral hospital service to care for people with mental suffering or disorder and with needs arising from the use of crack, alcohol and other drugs. In addition to the strategy of deinstitutionalization with residential therapeutic services and program back home and; psychosocial rehabilitation strategies with initiatives for the generation of work and income and joint ventures and social cooperatives².

In this sense, after almost 20 years of the promulgation of the law of Brazilian psychiatric reform and 10 years of the regulation that regulates the RAPS, in addition to the scarcity of studies on the theme³, it is justified to investigate how the multiprofessional team that acts in the psychosocial care network perceives the organizational structure of the services, that is, its components, points of attention and service flows² and; what awaits for the future of customer service.

Thus, the aim of the study was to understand the perception of the multidisciplinary team regarding the structure of mental health services in the municipality of Cascavel-PR.

Methods

This is a qualitative, descriptive, exploratory study with an approach in the Alfred Schütz Social Phenomenology, carried out in the municipality of Cascavel - PR, Brazil, which originated from the monograph of course conclusion entitled “The multidisciplinary team's perception on the structure of mental health services: phenomenological study”⁴. For this, the following concepts of the theoretical-methodological framework were used: reasons for and reasons for, direct and indirect relation and knowledge stock.

The ‘reasons why’ refer to past experiences as constituting an objective category. Already the ‘reasons for’ mean the state of affairs concerning the future. Direct relationships are those we establish with actors in close contact, face to face. The indirect ones are those that we develop with contemporary individuals who do not occupy the same space with us. And the stock of knowledge consists of the lived experiences that help us to reflect and act in the everyday world⁵.

The research was approved by the Ethics Committee under opinion No. 1.529.966, CAAE: 53220815.3.0000.0107 and respected the ethical aspects of the research according to Resolution 466/2012 of the National Health Council.

A semi - structured interview was conducted by one of the researchers, with 20 professionals from the mental health network of the municipality of Cascavel, from May to July 2016. The interviews were recorded, transcribed and listed as Professional 1, Professional 2 and so on, to preserve the participants' anonymity. We use the following guiding questions: Tell me how the mental health network is organized and structured in the municipality; What implications does this structural and organizational format generate in caring for the individual in psychic suffering? What do you expect in relation to the future of mental health care in the municipality? The interviews were carried out until the moment the research objective was reached. Inclusion criteria were: to be an effective employee of the mental health care network in the municipality of Cascavel-PR for at least one year. There was no participants refusal.

The information was analyzed through the steps suggested by researchers of Alfred Schütz's Social Phenomenology, with the following methodological pathway⁶:

(1) Sequential, detailed and exhaustive reading of the testimonies of the members of the multiprofessional team, trying to identify the units of meaning; (2) Reading of the units of meaning, grouping them according to their convergences, to form the concrete categories of the perception of the members of the multiprofessional team; (3) Construction of categories, identify those expressing the ‘reasons for’ and the ‘reasons why’ of the actions of members of the multiprofessional team; (4) Comprehensive analytical movement based on the philosophical-methodological framework of Alfred Schütz.

Results and Discussion

Twenty professionals participated, including four coordinators, two nurses, four psychologists, four social workers, three nursing technicians, two occupational therapists and a psychiatrist. Being 19 women and a man, with average age of 41.35 years and working time in the mental health network of the municipality of, on average, 7.2 years. Participants were part of the multiprofessional team of the following services: Center for Child Psychosocial Care (CAPSi), Center for Psychosocial Care of Alcohol and Drugs (CAPSad), Center for Psychosocial Care (CAPS III), Detoxification Ward of the University Hospital of the West of Paraná (HUOP) and Integrated Service in Mental Health (SIMPR).

Three categories emerged from the analysis of the participants' speech: ‘The organizational structure of the mental health care network’; ‘Care actions in the context of the organizational structure of mental health services’ and ‘Expectations regarding the mental health care network’.

The first two categories refer to ‘reasons why’ and category ‘expectations in relation to the mental health care network’ refers to ‘reasons for’. The ‘reasons why’ are related to the actions carried out for the organization of the psychosocial care network according to the precepts of psychiatric reform and the care actions directed to the users of mental health services. And the ‘reasons for’ refer to the expectations of the professionals regarding the care to the users.

In the category A organizational structure of the mental health care network, we realize that professionals know the services that make up the network, its operation and the ways of access. They point to the Primary Health Care (PHC) as a condition for users' access and recognize their importance in mental health care, being the place of reception and initial treatment and of mild cases.

The network consists of several services, from Basic Attention, which is one of the services that make up the network, UPAs, CAPS, SIMPR [...]. (Professional 1)

[...] some (services) are open door, that you can come and ask for help, and there are others that do not, you must have the reference to be able to be evaluated in the service. (Professional 2)

In the great majority, the entrance door is via UBS or family health unit, which are referred to, the CAPSad which is an exception to this structure, which we have open door. (Professional 12)

With the reorientation of mental health services, it has become necessary to reorganize care actions to the user based on the provision of treatment modalities that aim at completeness in the perspective of psychosocial care¹.

The professionals revealed to have stock of knowledge⁵ about the mental health network from the professional practice that directs the work and the care to the user.

Regarding the hierarchy of the structure of the mental health network, professionals pointed out that PHC is the gateway, but some services meet spontaneous demand. The same condition was observed in Sobral/CE⁷ in which there is a rupture in the vertical logic of the health system.

The professionals know the composition of their team and other network services, from an indirect relation, evidencing the formation of a team composed of social worker, nurse, psychologist, occupational therapist, psychiatrist, general practitioner, nursing technician, coordinator. In addition, some services also have workshops and pedagogues due to the differentiated activities developed in these places.

[...] usually include: psychologists, social worker, physician, general practitioner, psychiatrist, some have craftsmen, have nursing, have mental health nurses, have nursing technicians, pedagogue [...]. (Professional 7)

[...] the multidisciplinary team is great, so we know the function of each professional to be within the area. (Professional 8)

[...] nutritionists, clerks in the service that has a therapeutic workshop. (Professional 18)

We understand that from the knowledge of the professionals in relation to the services team can establish direct and indirect social relationships that enable the intersubjectivity between them and the interrelationship of network devices enabling care.

Schütz⁵ indicates that social interaction involves at least two people who have a relationship with each other. Thus, living in the world of everyday life usually means engaging with other people in complex networks of social relationships.

The new concept of mental health aims to prioritize the individual holistically, and the service acts in an intersectoral way to better assist the subject. Such a strategy makes it possible to articulate professionals from different sectors and knowledge to provide integral care and to improve organizational health models^8-9).

In this context, we perceive the importance of social interaction for users of mental health services, since practices broaden the users' lives, that is, the social interaction in services helps people to experience and interpret the world of singular way, broadening its perspectives¹⁰.

We note the significant participation of community services in the service to the user such as schools, churches, associations, self-help groups, labor and culture secretariats, among others, make a difference in the individual's recovery process, contributing positively to their improvement and social reintegration.

The school, yes, when they go inside, even the school gives a lot of information [...]. (Professional 4)

There are CRAS, who give support in the neighborhoods, including CRAS CEU, that we have some adolescents who follow up on their activities there, there is the youth center, CEMIC [...]. (Professional 15)

Residents' associations, academies, the elderly group, we end up talking to these groups [...]. (Professional 19)

We have a very large partnership with the secretariats of culture, sport through the services they offer education, social assistance, some non-governmental [...]. (Professional 20)

We realize that mental health care has prioritized the precepts of psychiatric reform. In this sense, mental health services provide users with active social life and interacting with other people favors and enhances social interaction.

For social reintegration to become possible, intersectoral actions are needed to overcome the fragmentation of care based on the articulation of different sectors of society and dialogue between institutions, governments and individuals to formulate public policies with the aim of improving the condition health status of the population^11-12. For this, it is necessary to overcome the idealization of this process and transcend the good intentions of the sectors involved to the detriment of the specification of the actions^13).

In the category Care actions in the context of the organizational structure of mental health services, we realize that the organizational structure of the services and the composition of the teams impact the achievement of integral care for users and their families. Mental illness is not an individual process, but family and collective, in the same way the treatment requires of the teams an extended and articulated look with the various components of the network, through mental health matrices, to establish the project as a central strategy in patient care.

[...] attending to the patient and welcoming the family, because during mental illness or problems of dependence it is very common and very natural for the family to fall ill together [...]. (Professional 1)

[...] we call for family reunion, we schedule individual care [...]. (Professional 7)

We can treat the user and can treat the family, we should have more moments with the family, but the team is reduced, so ends up being few moments [...]. (Professional 8)

The integration between APS and the specialized services that characterize the network makes it possible to treat the individual in a holistic manner with quality¹⁴. Such follow-up is based on direct and indirect relations⁵ of the professionals of the teams that establish themselves according to the organization of the components and flows that show the organizational structure of RAPS².

With the beginning of the treatment also begins a process of organizing one's life, increasing self-esteem and social participation. Some professionals pointed out difficulties in the organizational structure, when the user presents comorbidities, as well as when he/she needs medical and dental consultations in PHC. A weakness indicated in the organizational structure was the limitation felt by the user in the post-high, there is a shortage of vocational courses and job opportunities.

I think that there must be more training, aimed at the professionals mainly of the basic network, of UBS, that I feel like this [...]. (Professional 7)

There are many challenges to solidify mental health policies, especially in the PHC network that needs to incorporate community-based and territorial precepts. In this aspect, matrices have a central role, it contemplates the structuring of the network of care from the analysis of the territorial context, including the community resources, it guarantees exchanges of knowledge between the specialist and the generalist about their various actions around the individual¹⁵.

Networking and matrices are important for mental health actions in the territory since they aim at co-responsibility between professionals and health services. To do so, we need investment in human resources, training and infrastructure¹⁴.

With this, the family health team adds to the care of the individual, as part of its therapeutic project, allowing the reception of the individual and his/her family¹⁶.

Study conducted in CAPSad¹⁰ corroborates with this finding, evidencing that in mental health services actions are directed to the adhesion of the user, as well as of his/her family to the proposed therapeutics. This is done by raising awareness about the need for care, building health practices with individuals.

Thus, the service that assists the individual establishes with it a direct relationship; the APS, which carries out the referral in some cases, has an indirect relationship with this subject, since the monitoring is done by the specialized service⁵.

And in the category Expectations regarding the mental health care network which refers to the ‘grounds for’, we noticed that the municipality has been making changes and evolving positively, however, there are some gaps that need to be improved to guarantee an integral and quality service to the users of the network, such as: capacity building for the multidisciplinary team; increase of workers in the teams throughout the network; better structural conditions for care; moments for collective evaluation of the cases served in the network services; investment in prevention regarding the use of psychoactive substances.

I hope that we will be able to meet all the expectations and requirements, the very proposal of the psychiatric reform, that we can move forward [...]. (Professional 20)

I hope so, that there may be an expansion of services, which will bureaucratize, we have already managed to advance [...]. (Professional 9)

I hope you have more attention [...] I think this is a long way off, it is the professional's appreciation for you to qualify, to take courses that help [...]. (Professional 10)

I think we need more resources, human resources, material resources, would help a lot, I think we are very deficient in these areas. (Professional 17)

Study conducted in Santa Maria/RS¹⁶, Brazil also demonstrated challenges to be overcome for mental health care, such as the need to equip the teams for care in the community.

Research conducted in Ethiopia with 94 PHC professionals who participated in mental health training demonstrated that such training can be an effective intervention that contributes to integrated care in health services¹⁷.

In this sense, it is clear the need for attention to such professionals and concern as training becomes paramount for care, since lifelong education can provide some progress in psychosocial care^18-19.

Thus, after recognizing the problems, it is necessary to consider the motivation of the projected act, that is, it is expected the recognition of the motive that leads to the accomplishment of the future action, constituting the ‘reasons for’, as being the expectations that the participants have in relation to mental health services⁵.

The professionals also pointed out some strategies that can help the user to attend to the growing demand for mental health services, such as: the reference file and reference used in all services, and the matrix support that, despite the difficulties faced in this tends to contribute to the link between APS and the specialized service.

Regarding expectations, professionals emphasize the need for greater interconnection of services, obtaining psychiatric beds for serious cases, and greater professional appreciation, as well as for expanding the services team.

We also noticed in the reports, the lack of places that offer employment opportunities and professional courses that can help in the social reintegration of the user after the discharge of the service.

A study carried out in Campina Grande, Brazil, Brazil, showed improvements and progress in psychosocial care based on the articulation with other sectors of society, such as education, culture, economics and social networking. These help to enhance the formation of affective bonds between users, families and workers of the CAPS and the service network, subsidizing mental health and producing a “new” subjectivity related to processes²⁰.

Thus, we understand that professionals have a stock of knowledge about the organizational structure that allows them to act in the network of psychosocial attention based on the direct and indirect social relations they establish with each other and with users and family members in the care, developing intersubjectivity⁵. In addition, they understand that the municipality has the necessary services for care, but that there are gaps to achieve fullness.

It is important to emphasize the importance of the management of substitutive services in mental health, since we perceive the need to involve the various sectors to provide the user with humanized, integral and resolutive care, promoting social inclusion and quality of life for this target public.

Final Considerations

The study reached the objective that was proposed, since we understand that the professionals know the hierarchy, the composition of the team, the flow of the user in the network of psychosocial attention and the services that are inserted in it. And so, they understand the implications that the structural and organizational format generates in the care, and the accompaniment done to the user and his family. In addition, it has expectations regarding the future of the mental health care network in the municipality.

We emphasize that this study has as a limitation the fact of having focused the organizational structure of the network of only one municipality and investigated only the professionals of the substitutive services. However, it is worth mentioning that from the described methodology it is possible to replicate it in places presenting the RAPS with similar characteristics to elucidate the connections between the professionals for the effective execution of the network and as such care contributes to the social reintegration and family of users.

This research does not pretend to exhaust the possibilities of analysis on the subject within the scope of the multidisciplinary team perception about the network of mental health care, but to clarify the interdisciplinary understanding of this team about the services. And, in this way, provide important information to elaborate strategies of intervention in the network, to improve more and more the service to the user of these services.

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Publication Dates

• Publication in this collection
  18 Feb 2019
• Date of issue
  2019

History

• Received
  06 June 2018
• Accepted
  28 Sept 2018