Attitudes and pleasure / suffering in mental health work

Objective: to investigate the existence of a relationship between attitudinal profi les and the pleasure/suffering dynamic in workers of Mental Health Services. Method: a quantitative, descriptive-analytical, correlational and cross-sectional study conducted in 2014. We used three instruments: characterization questionnaire, Opinions on Mental Illness Scale and Pleasure and Suffering Indicators at Work Scale, answered by 80 workers of the Network for Psychosocial Care of Alfenas, state of Minas Gerais, Brazil. Results: Authoritarianism proved to be the predominant profi le. As for the pleasure/suffering at work, Gratifi cation was considered adequate, and indicators such as Freedom, Wear and Insecurity were considered moderate critical. There were positive correlations between the most favorable attitudes and pleasure indicators at work. The values of both scales showed a relationship with socio-demographic and professional variables. Conclusion: the less favorable attitudes are prevalent and, in spite of suffering being present, these professionals feel gratifi ed about their work.


INTRODUCTION
The Psychiatric Reform is the result of several changes in the way services are organized, in the way we approach people with mental disorders, in the way we care and in the knowledge of the Psychiatry field (1) .Since then, psychiatry integrated into various levels of complexity, not limited to psychiatric hospitals (1) .However, designing the Psychiatric Reform merely as a society free of psychiatric hospitals does not guarantee a break with the old model, since this same society would strongly remain institutionalized, dependent on adopted discursive practices (2) .Thus, it becomes necessary for professionals to adopt new attitudes, distancing more and more from the mental hospital culture, and focused on the rehabilitation of psychiatric patients (2) .
Regarding attitude, it becomes necessary to conceptualize this term.Numerous definitions were proposed, but even considering the most varied interpretations, there are areas that hold an essential agreement.Thus, attitude can be described as a "predisposition" to respond in a consistent, positive or negative way, to a specific object (3) .
According to the Psychodynamics of Work, the way the employee experiences the labor practice is conditional upon the relationship established with the job and may be perceived as a cause of unwanted suffering, a painful and humiliating toil (4) .Thus, labor relationships deprive employees of their subjectivity, excluding the sense of self, and resulting in suffering (5) .However, they can be considered pleasurable, as something that gives life meaning, elevating the status, defining personal identity and boosting human growth, and extoling the work and the worker (4) .
Understanding that attitude is what moves a person and what can determine their behavior when faced with an object, and that pleasure and suffering can boost, positively and negatively, the person to their work, this study was born from the unrest about the existence of a relationship between these two sides, with both of them as part of the subjectivity of the worker as a subject.
The literature was reviewed in 2012, and we were faced with a shortage of studies on these workers, which makes it relevant to get to know them better.It is also important to investigate these two aspects of the subjectivity of the subject, seeking to enable new intervention strategies.

OBJECTIVE
This study aimed to investigate the existence of a relationship between attitudes when one is face to face with mental illness and the mental pleasure/suffering dynamic of workers of the Mental Health Care Service.The specific objectives of this study included cataloguing attitudes towards mental illness and the existence of pleasure/suffering at work of people who work in this area, checking for a correlation between the factors of attitude and opinions scales about mental illness and pleasure/suffering indicators at work, and evaluating possible association/correlation between gender, age, education, type of service, profession/role in the service and working time in mental health through, using factors from these scales.

METHOD
Ethical aspects this project was approved by the Ethics Committee of the Federal University of Alfenas -UNIFAL/MG.We requested the workers who agreed to participate in this study to fill out and sign an Informed Consent Form.

Design, place of study and period
This is a quantitative, descriptive, analytical and cross-sectional study, developed in a medium-sized city in southern Minas Gerais.
We conducted the investigation in services that treat people with mental disorders, with a Psychosocial Care Center II (CAPS II), a Community Center, seven Therapeutic Residency Services II, a clinic that provides medical and psychological care, two Reference Centers for Social Assistance (CRAS), a Specialized Reference Center for Social Assistance and twelve Family Health Strategies (FHS).

Population
We chose to work with professionals from various fields and categories that provide Mental Health Care, part of the Municipal Network of Psychosocial Assistance.At the end, we had reached a total of 80 workers; in this network, 5 individuals were on sick leave or on vacation and 18 refused to participate in the survey, making it impossible to work with the complete universe.

Study protocol
Data were collected in the first half of 2014, via three instruments, which included: • Questionnaire on sociodemographic and professional characteristics, developed by the researchers for characterization data collection from the study participants, and containing nine structured or semi-structured questions.• To evaluate the attitudes of health professionals in mental illness, we used the Opinions about Mental Illness Scale (OMI) (6) , translated and validated for the Brazilian culture with the title Opiniões sobre a Doença Mental (ODM) (3) .
• Lastly, to approach pleasure and suffering at work, we opted for the adapted form of Pleasure/Suffering Indicators at Work Scale (EIPST), developed and validated in Brazil (7) and later adapted (8) .

Results and statistical analysis
The data obtained from the application of these instruments were entered into a database using a MS-Excel spreadsheet, version 2010, with double entry, and then exported to the Statistical Package for Social Sciences (SPSS) softwareversion 17.0 for the relevant analysis.
We determined to use pre-established formulas for counting the points obtained from the implementation of the ODMs, associating scores for every professional with the seven factors of the scale (3) .Regarding the EIPST, for the pleasure factors, the analysis had to consider a positive connotation, we had the following scores: above 4, a more positive assessment, considered satisfactory; between 3.9 and 2.1, as moderate critical; below 2.0, evaluation conceived as rare and severe (8) .For the suffering factors, considering the items as negative, we had the following classification: above 4, a more negative assessment, considered severe; between 3.9 and 2.1, as moderate critical; below 2.0, the less negative evaluation, conceived as satisfactory (7) .Data from the EIPST were analyzed according to descriptive statistics.
The Shapiro-Wilk test, which verifies normality, showed no normality for any of the data; thus, we used non-parametric measures for correlation and association.To verify the correlation between the factors of the two scales and between these and numeric variables (age, education level, family income, working time in Mental Health Care Services), we used the Spearman coefficient.To associate the sex variable and the factors of the scales, we used the Mann-Whitney test, since it is dichotomous.To investigate the association between the marital status, type of service and categorization of the profession variables and the factors of the Opinion about Mental Illness Scale and the Pleasure/Suffering Indicators at Work Scale, we used the Kruskal-Wallis test, adopting a significance level of 5%, i.e., p <0.05.
To test for multiple comparisons, we used the Student-Neuman-Keuls test (SNK) consisting of setting a test value t for more than two treatments in the BioEstat 5.0 software.
The results obtained were summarized using information tables for better data exposure.

RESULTS
As for the population characteristics, Mental Health professionals in the city participating in this study were predominantly women (80%), aged between 41-50 years (36%), married (51.3%),Catholics (65 %) and with a family income ranging around 4-5 minimum wages (38.7%).Professional variables showed that the predominant category was the toplevel workers (42.5%), followed by the fundamental level (38.8%), especially crowded in the Therapeutic Residences Services II (36.3%), with working time of 1 to 5 years (51.3%).
Considering the studied population as a whole, we observed that Authoritarianism has the higher mean in the attitude types (6.650), followed by Social Restriction (6.580).The corresponding attitude to the Etiology of Mental Hygiene had a lower mean among the rest.
We also verified Attitudes against the broad categories of professionals, since they can be modified depending on the level of education.
Authoritarianism was prevalent in the high school level (7.000) and higher education professionals (6.000).At the technical level group, Authoritarianism and Benevolence had similar values; however, the highest mean value corresponds to the Etiology of Mental Stress (8.000).The elementary school level professionals had a higher mean for the Social Restriction factor (7.420).
The results obtained from the pleasure and suffering indicators at the work scale are presented in Table 3.
As for the pleasure indicators, Gratification was the only averaging more than a 4, considered satisfactory (7) , and Freedom had an average considered moderate critical (7) .Suffering factors both showed means characteristic of moderate critical levels (7) .
The following values can be observed for the professional categories shown in Table 4.
We can see that the levels of pleasure and suffering of these professionals are more favorable among those whose functions require lower education; mid-level professionals all showed moderate critical indicators (7) : 3.865 for Gratification; 3.679 for Freedom; 2.452 for Wear, and 2.552 for Insecurity.
Since those of technical level showed satisfactory values (7) for the pleasure indicators, 4.208 for Gratification and 4.048 for Freedom; and moderate critical for suffering indicators: 2.714 for Wear and 3.958 for Insecurity.The superior level professionals showed satisfactory values (7) for Gratification (4.312) and moderate critical (7) for the rest.Table 5 shows the data obtained from the crossing of values provided from both scales.
We observed positive correlations between: Benevolence factors and the Gratification indicator (0.284); Ideology of Mental Hygiene with the Freedom indicator (0.374); and Etiology of Mental Stress with the Gratification indicator (0.227).These factors suggest that professionals that have better pleasure indicators are more likely to have favorable attitudes.
Regarding the correlations/associations with the variables studied, we found that the factors connected to authoritarian, restrictive and discriminatory attitudes showed very significant correlations with the schooling variable.Authoritarianism had a weak magnitude correlation (-0.334),Social Restriction of moderate magnitude (-0.435) and of Mental Stress showed strong magnitude ratio (-0.582) to the variable mentioned.Thus, we inferred that professionals that are more educated are less prone to negative attitudes.However, when looking at the descriptive measures, authoritarian attitudes seem to be prevailing.Social Restriction and Etiology of Mental Stress factors showed significant correlation, although weak magnitude, regarding the Working Time in Mental Health variable (-0.344 and -0.276, respectively).The same variable correlated with the Ideology of Mental Hygiene factor (0.232).Thus, we can predict that the longer working time in mental health, the lower the trends of authoritarian and discriminatory attitudes and the greater are the trends of displaying attitudes more consistent with the Psychosocial Model.
Family income correlated with the weak magnitude of Etiology of Mental Stress (-0.347), allowing us to infer that the higher the family income, the lower the tendency of this professional to display discriminatory behavior.
The Ideology of Mental Hygiene and Minority View factors were significantly associated with the service type variable (0.043 and 0.034).We noticed that the professionals of the Therapeutic Residency Services II are more likely to have an Ideology of Mental Hygiene attitude, while the professionals from the Community Center have a higher propensity to Minority View attitudes.
Regarding the professional category, the attitudes of authoritarianism (0.028), Social Restriction (0.019), Etiology of Mental Effort (0.000) and Minority View (0.002) showed significant associations.We identified that the fundamental level professionals are more likely to have a more authoritarian and restrictive attitude, and technical level professionals tend to present higher means in the Etiology of Mental Stress and Minority View factors.
Regarding pleasure and suffering at work, the Gratification indicator showed an inverse correlation of great significance and moderate magnitude on the education level variable (-0.430).The Freedom indicator showed a direct correlation with low magnitude, with the age variable (0.296) and an inverse correlation of low magnitude, with the education level variable (-0.300).The Insecurity indicator showed an inverse correlation of low magnitude with the age variable (-0.389), and a direct correlation of low magnitude with the education level factor (0.235).The Wear indicator showed a direct correlation of low magnitude, with the education level variable (0.355).This means that the higher the education level of these professionals, the lower the tendency to feel gratified and free, besides being more prone to wear and insecurity.And, still, the higher the age, the greater the trends of freedom and lower the insecurity indicator.
All Pleasure and Suffering indicators at Work were significantly associated with the type of service variable (p <0.05).The Gratification indicator was higher for professionals in outpatient care, while the Freedom indicator showed better levels for those of the Community Center.Regarding the suffering indicators, the Reference Center for Social Assistance (CREAS) had the highest rate in the Insecurity indicator and the professionals of the Family Health Units (USF), the higher values for Wear.
All Pleasure and Suffering indicators at Work were significantly associated with the professional category variable (p <0.05).The elementary level professionals showed higher values for both Gratification and Freedom indicators.The suffering of indicators, on the other hand, showed that high school level professionals had higher levels of Insecurity and the technical level professionals showed the highest level of Wear.
The other variables showed no associations with the factors or indicators of the two scales.

DISCUSSION
The attitudes of these workers when faced with mental illness lead us to conclude that Authoritarianism showed the highest mean in this population, as well as association with fundamental level professionals.This factor highlights the prospect that the person in psychological distress needs to be isolated from other patients, remaining under locked doors and surveillance, which expresses the idea of personal and social unrecoverable impairment of the patient, as well as his status as a danger to himself and others (9) .Moreover, it reflects the asylum model, one of the central issues criticized by the psychiatric care reform movement and the process of deinstitutionalization (10) .We believe that authoritarian attitudes lead to authoritarian and mutilating behaviors, which did not sit well with the current principles and ideologies, which mobilize the psychosocial care model to prioritize more egalitarian relationships for the appreciation of the subject and its potential (10) .
The change in behavior occurs when beliefs and the attitudes are changed, which can occur through direct experience with the specific object, in this case the mentally ill, providing opportunities to acquire new information (11) .
Factors related to authoritarian, restrictive and discriminatory attitudes presented inverse correlation with the education level and time of service in Mental Health Care.Thus, we can infer that there is a link, pointing to education and time of service as a way of acquiring new information and therefore influential in the attitudes of professionals (11) .
Study to assess the impact of academic education in nursing, regarding the Authoritarianism factor, concluded that knowledges and experiences obtained during the undergraduate course created incorporation possibilities for new ways to understand and accept mental patients, leading students to adopt new attitudes in different situations (12) .
The Ideology of Mental Hygiene factor had lower means in the population in general and association with the Therapeutic Residences Service II.This factor reflects an opposite orientation view to the one designed by the Authoritarianism factor, showing that the patient offers no greater danger than a normal person, has good work disposition and can perform specialized activities (9) .Time of work also correlated with the Ideology of Mental Hygiene factor.Thus, we can infer that the greater contact with the object can influence the attitudinal profiles; in this study, the influence was positive.Consistent with these results, international survey on attitudes towards mental illness showed that the greater contact with this reality is an important factor for the development of more positive attitudes (13) .
The Ideology of Mental Hygiene also correlated with the family income variable, although it was not possible to establish a relationship between the two, considering that there are no studies about such possible relationships.
This study demonstrated that these feelings -of pleasure and suffering at work -are not isolated, but are interconnected and show themselves positive in two ways.Using this logic, the work can be both source of pleasure and of suffering, which are inherent to the human condition, in other words, cannot be considered void talking about the individual (5) .
We also observed satisfactory means for Gratification, connected to the type of outpatient service and with inverse correlation with the education level.Thus, we can infer that these workers experience pleasure at work and that the higher their level of education, the less they feel recognized for their work.We noted that the gratification involved positive relationship with their tasks and their work to meet professional expectations, bringing satisfaction and pride with the activities performed, as well as recognition of the effort and of their qualification (8) .It would be, therefore, connected to the gratification of these workers: valued by the hierarchical management levels, expressed through fair remuneration, non-precarious employment ties and material working conditions, beyond recognition of their social functions, which targets the users themselves (14) .
These data coincide with those found in another study (15) in which CAPS professionals showed pleasure for the sense of success in the task performed and in the group work.
Still talking about pleasure, the Freedom indicator showed a mean considered moderate critical in the population as a whole and association with the Community Center service.Freedom, as well as the recognition and appreciation, are a manifestation of the life experiences of pleasure at work and are one of the worker's health indicators for allowing the psychic structure, the identity and the subjectivity expression at work, to enable negotiations, establishment of commitment and resonance between the subjective and the concrete reality of work (16) .
To turn a stressful job into a well-balanced one, it is necessary for organization to be flexible, to allow greater freedom for workers to negotiate around their work reality (8) .In this sense, freedom is one of the indicators whose function is to facilitate the transformation of suffering (8) .Thus, the moderate critical level of this indicator may be related to the levels found for the suffering indicators.
The Freedom indicator showed a direct correlation with the age variable and a reverse correlation with the education level variable.The question of freedom is connected to the worker's ability to turn what is prescribed, doing it in a particular and specific manner, and enabling the creation and invention of new way to perform the task and achieve their purposes (15) .Therefore, we can infer that the greater the age of the professional, the greater their ability to reinvent ways to carry out their activities.On the other hand, the higher their education, the lower the possibility of achieving this.
Overall, considering the data obtained in this study, we can infer that the work dynamics in mental health services still result in the experience of suffering by employees, since these indicators presented means considered moderate critical when compared to the population as a whole.
The Insecurity indicator was associated with the Reference Center for Social Assistance (CREAS) service and the professional category of middle level education.It is characterized by the fear of losing their jobs or not meeting expectations; regarding the quality of the work performed, this indicator is closely related to the worker's suffering (8) .
This indicator showed an inverse correlation with the age variable and a direct one with the educational level variable.The insecurity, from the threat of job loss, operates as an inhibitor of requests for higher wages, benefits or rights, keeping workers at the mercy of corporate policies; this means, they choose to consent in order to avoid loss of recognition (17) .
Public administration, in particular, may relate insecurity to periodic changes in city governments and consequent changes in the staff.Regarding age, the study (18) which investigated the status of superior level workers in the state of Minas Gerais, showed that as they get older, suffering at work diminishes, since they cope better with adverse situations.Thus, chronological age is associated with emotional maturity, which allows us to infer that it is a positive factor in the construction of pleasure at work.
The Wear indicator, associated with the Family Health Strategies (ESF) and the middle level professional category indicates that the routine in the work environment presents stressful aspects such as work overload, possibly resulting in fatigue, emotional stress, anxiety, depression and frustration (8) .
This indicator showed a direct correlation with the educational level variable.It is known that all forms of work, from the simplest to the more complex, is performed according to a degree of intensity and requires expenditure of human labor power, body engagement, intelligence mobilization, capacity to reflect, to interpret and react to situations; it is the power of feeling, of thinking and of inventing etc. (5) .Thus, we can infer that the relationship between the educational level and wear occurs due to the complexity of executed intellectual tasks, since the technical and elementary school level professionals exert closer and continuous activities with people with mental disorders, therefore, more exposed to stress, emotional overload and fatigue.
Such associations refer to important concepts of Work Psychodynamics, which indicate that the reference for the study of pleasure and suffering at work (despite being linked to concrete work), takes place also from another perspective, in other words, it is built based on the confrontation with the subjectivity of the worker, their beliefs and desires and also the objective world, the reality of work (16) .It is impossible to study the work psychodynamics without observing the worker in his life context.
The correlation between the Opinions about Mental Illness Scale and the Pleasure and Suffering Indicators at Work Scale, showed that the most positive attitudinal profiles, such as Benevolence and Ideology of Mental Hygiene are directly linked to the experience of pleasure at work.
More favorable attitudes reflect the new health care model, the Psychosocial model, which advocates a shift of medical knowledge for the interdisciplinarity, the notion of disease to health, the walls of psychiatric hospitals for circulation in the city, the mentally ill for individual psychological distress, the unable individual to citizens.This creates satisfaction for the health team, who feel like they are producing health amid the tension created by the act of caring, and also launches a critique of the asylum, encouraging the user to be autonomous (15) .
In contrast, the Etiology of Mental Stress factor, which has discriminatory features, emphasizing the difference and the carrier inferiority of psychiatric disorders compared to normal people (3) was positively correlated with the Gratification indicator.The fact denotes the existence a relationship between a negative attitudinal profile and a pleasure at work indicator, which facilitates the meeting between health worker and user, allowing an intercessor space for a mutual relationship of trust and responsibility (15) .We understand this correlation as being inconsistent with the expected, according to the literature, and suggests further studies in this area.

Study limitations
This study has some limitations, since the sample is reduced, which suggests results that only apply to the population in question.Thus, it is necessary to perform further studies on this theme, using longitudinal studies with larger populations, for a better observation of the historical transformations of work situations of mental health professionals and their attitudes.
Contributions for the areas of Nursing, health and public policy This research field is endless and unlimited.In this sense, this article is relevant, as well as these two aspects of the subjectivity of the subject, enabling new strategies of intervention and the emergence of new reflections regarding the theme in the mental health area.

CONCLUSION
We conclude that the attitudinal profiles of these professionals were less favorable, with authoritarian, restrictive and discriminatory characteristics.Regarding the construct pleasure/suffering at work, the Gratification indicator presented the highest mean in this population, and is considered satisfactory, followed by the Freedom indicator, which showed a mean critical moderate as well as the suffering indicators such as Insecurity and Wear.As for the correlations tests between the scales, there were positive correlations between some of the factors on the Opinions on Mental Illness Scale and the pleasure indicators on the Pleasure and Suffering Indicators at Work Scale.We observed, therefore, that the most positive attitudinal profiles are directly linked to the experience of pleasure at work.The values of both scales showed associations with socio-demographic and professional variables.
Based on these results, we suggest that professional development programs and training be offered to these professionals, seeking through the deepening of knowledge about mental illness, to make their attitudinal profiles more consistent with the proposals of alternative services in mental health.We emphasize also the importance of work organization, which, by being supportive and a pleasure generator for workers, requires a space filled with recognition, freedom and horizontal relationships.

Table 1 -
Mean values for Attitudes when faced with Mental Illness by Mental Health Services Workers of Alfenas, Minas Gerais, Brazil, 2014

Table 2 -
Means for the values of Attitudes when faced with Mental Illness by the Mental Health Care Services Workers, broken down by professional categories, Alfenas, Minas Gerais, Brazil, 2014

Table 3 -
Pleasure and Suffering at Work indicators of Mental Health Services Workers of Alfenas, Minas Gerais, Brazil, 2014

Table 4 -
Mean values for the Pleasure and Suffering Indicators of Mental Health Service Workers broken down by professional category, Alfenas, Minas Gerais, Brazil, 2014