Guidelines to the families of mental health service users from the multi-professional team’s perspective

Objective: to apprehend the guidelines provided by the interdisciplinary team to the user’s family member at a Centro de Atenção Psicossocial Álcool e Drogas (Psychosocial Care Center for Alcohol and Drugs). Methods: descriptive-exploratory study, with a qualitative approach, carried out in a Psychosocial Care Center for alcohol and drugs in the southern region of Brazil, using the Psychiatric Reform as a conceptual basis. Data collection took place from June to August of 2019 through semi-structured interviews with a multidisciplinary team. The data were organized and operationalized in the IRAMUTEQ® software, and submitted to content analysis, thematic modality. Results: two classes emerged: “Guidelines referring to moments of crisis and the family members’ arrival to the service” and “Difficult factors and strategies to enhance the guidance to family members”. Final considerations: The guidelines focus on pathology and the service itself. Participants highlighted embracement, the group for families, qualified listening, and cooperation with primary care as ways to enhance the service to families. Descriptors: Family; Mental Health; Mental Health Substance-Related Disorders; Patient Care Team. RESUMO


INTRODUCTION
Since the years 1980s, a broad social movement has promoted advances in the construction of a model of psychosocial and community care, alternative to the psychiatric institutions prevalent until nowadays. Currently, mental health care consists of a network of services that pursues the articulation between Atenção Primária à Saúde (Primary Health Care) (APS), specialized community-based services Centros de Atenção Psicossocial (Psychosocial Care Centers (CAPS), hospital services (psychiatric beds in general hospitals and beds in psychiatric hospitals) and deinstitutionalization strategies, social support, work and income (1) . In this context, the deinstitutionalization movement was benefited from the incorporation of the CAPS and of the Law No. 10,216/2001, which redirected the mental health care model to community care, with the enhancement of social integration and people's autonomy (2) .
The CAPS are currently one of the most significant elements of Psychiatric Reform, as they encourage the individual's reintegration into the community. It aims to provide care for people with mental disorders, organize the network of mental health services, encourage the construction of exclusive therapeutic projects, support mental health in Primary Care and hospital units, among other activities (3) . The CAPS are classified as I, II, III, for children and users addicted to alcohol and other drugs, according to their size (human resources, physical dimension and enrolled clients) and the type of customer served (adults, children and teenagers) (1) . In these services, users are followed by an interdisciplinary team composed of a psychiatrist, nurse, psychologist, social worker, nursing technician, occupational therapist, among other professionals, to treat symptoms, stimulating social integration and family ties (4) .
In the search for the development of practices that benefit the integration of people in psychological distress, with free circulation through the various health facilities, community and territory, the role of the family in the treatment of one of its members is highlighted. So, the family, which was once understood as a triggering factor of the individual's health condition, starts to play an important role in supporting its member, besides being characterized as a real intervention space. For this reason, it began to receive greater attention from mental health services, and even became part of the global process of attending to mental illness (5) .
Thus, the impact of drug addiction causes a break in the routine in the lives of family members, feelings of vulnerability, helplessness, and frustration. Substance addiction not only exposes family dynamics but also impacts on the relationships established between its members (6)(7) . Due to the complexity of the alcohol and drugs clinic, the training of workers that serve this public needs to be continuously linked to the daily services, since the management necessary to offer adequate care to drug addicts and family members goes beyond the traditional/academic learning and encompasses knowledge that is acquired in practice, empirically (8) .
So, despite being well established in the literature, the relevance of the family to the treatment of people with mental disorders, especially those addicted to alcohol and drugs, studies on the guidelines with a focus on the proposed actions by the Psychiatric Reform, as far as it is concerned, are still incipient. However, it is considered relevant to recognize who the professionals that work in Psychosocial Care Centers are and how they act, as they have the opportunity to get to know the particularities of the assisted families and work on their strength and potential for transformation, attempting their balance and well-being (9) .
For believing that actions aimed at the family of people addicted to alcohol and other drugs should benefit and enhance the consideration to their psychic needs, also for being guided by the family understanding as a unique and participatory partner in the care process, and that for this very reason, also needs care, it is questioned: what guidelines are provided by the interdisciplinary team to the family members of the users of the Psychosocial Care Center for Alcohol and Drugs (CAPS ad)?

OBJECTIVE
To apprehend the guidelines provided by the interdisciplinary team to the user's family member at a CAPS ad.

Ethical aspects
The ethical precepts established by Resolution 466/12 of the National Health Council and Resolution 510/2016, were followed, with the approval of the study by the Research Ethics Committee of the signatory institution. All participants were informed about the objectives of the study, data collection procedures, risks and benefits and signed the Informed Consent Form. To preserve anonymity and confidentiality about the information collected, the participants' reports were named with the letter I, of the interviewee, followed by Arabic numbers, according to the sequence of the interviews and the participant's profession.

Theoretical Referential
The principles and concepts proposed by the Psychiatric Reform (2) were used as a conceptual basis for the study, directing data collection and analysis. The context of Psychiatric Reform in Brazil is composed of four dimensions that articulate and feedback: the first refers to the theoretical-conceptual a, which represents the production of knowledge and learning; the second is the technicalassistance dimension, which emerges in the assistance model; the third refers to the legal-political area, which rediscovers and redefines social and civil relations in terms of citizenship, human and social rights, and the fourth dimension is sociocultural, which expresses the transformation of the social place of madness (10) .

Study design
Descriptive-exploratory study with a qualitative approach. This type of study is appropriate when it is intended to analyze and understand dynamic and non-linear reality, to support changes and transformations in social reality (11) .

Setting
The study was carried out in a CAPS ad in a municipality in the interior of the state of Paraná, in the southern region of Brazil. The service carries out various activities such as: individual and of Guidelines to the families of mental health service users from the multi-professional team's perspective Nacamura PAB, Marcon SS, Paiano M, Salci MA, Radovanovic CAT, Rodrigues TFCS, et al. group care, therapeutic workshops and home visits and its opening hours are from Monday to Friday, from 7 am to 9 pm. It serves users or family members who seek the service due to spontaneous demand, or referred by other services of the Psychosocial Care Network (RAPS), such as the Basic Health Units. The interdisciplinary team working in the service consists of 22 professionals (one general practitioner, two psychiatrists, four nurses, five psychologists, two social workers, two social educators, two occupational therapists and four nursing technicians).

Study participants
The eligible participants for the study were the 22 members of the interprofessional team involved in assisting families. The only inclusion criterion was defined as having worked in the service for at least six months (criterion met by 21 professionals). So, four professionals who were on vacation or medical leave during the data collection period were excluded.

Methodological procedures
Data collection took place from June 2019 to August 2019 through a semi-structured interview, which after consent was audio-recorded on a smartphone device. During the interview, a script consisting of two parts was used, the first addressing sociodemographic characteristics (sex, age, professional training, and length of experience). The second part consists of a guiding question: What are the guidelines that you provide to the family members of CAPS ad patients? The script was previously evaluated by researchers in the mental health area of the study institution.
The professionals were invited to participate in the study during work hours. The interviews, whenever possible, were previously scheduled and carried out in a private room and during the work shift, at an appropriate time to the activities. A single interview was conducted with each participant. They lasted an average of 30 minutes and in the end, the main topics reported were validated between the researcher and the interviewee to ensure the quality of the data collected.

Analysis and data organization
The analysis of the interviews was carried out by two researchers, opting for the strategy of content analysis of Thematic Modality (12) , which aims the critical display, primarily through description and inferences that seek to clarify the causes of a problem or its possible consequences. It was followed three phases: 1) In the pre-analysis there were material preparation, hypothesis construction and formulation of indicators that guided the final interpretation; 2) Exploration of the material, data coding was carried out, by grouping it in record units, and; 3) Treatment of the results where there is a guided inference by several attention/communication poles, which were clarified and then new themes and data were discovered, making it necessary to compare statements and actions to check for possible combinations (12) .
To assist data organization and presentation, the software IRA-MUTEQ (an acronym for R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) 0.7 ALFA 2.3.3.1 was used. For the data processing the analysis of Descending Hierarchical Classification (CHD) was used, in which, based on a textual corpus, built from the speeches of the participants, it is divided into text segments or the Elementary Context Units (ECU), which are classified according to their respective words, and divided according to their frequency. The percentage refers to the repetition of the word in the text segments in this class regarding its occurrence in the corpus (13) .
The textual corpus built to answer the objective of this study, presented 90 text sections, with an average of 3.14 lines each. The software indicated the separation of the text into five initial classes. For the creation of the two final classes and their nomination, their main subjects were considered, supported by the words and the interpretation of their thematic convergence with the adopted theoretical framework, which originated two classes. It is noteworthy that the use of this program consists only of a tool that helps the grouping of information through the lexical analysis of words and statistical methods, but for the content analysis, the researcher's interpretation was essential.

RESULTS
The 13 professionals participating in the study (two social workers, two nurses, two social educators, a clinical physician, two psychologists, a psychiatrist and three nursing technicians), had from 35 to 53 years old, with training time from 7 to 34 years and experience in the CAPS ad from seven months to 17 years.
The textual corpus had 90 text sections, 63 were analyzed, which corresponded to 70% of the total. From the contents organization and the convergence with the adopted theoretical framework, it was originated two defined classes: Class 1: "Guidelines referring to moments of crises and the family members' arrival to the service" and Class 2: "Difficult factors and strategies to enhance the guidance to family members", which are arranged in the class dendogram ( Figure 1).

30/63 ECU (48%)
Guidelines regarding moments of crisis and the arrival of family members to the service  It was observed the role of professionals, in the sense of providing subsidies not only about mental disorder, but also about the treatment provided in the CAPS ad, to avoid unnecessary hospitalizations, which, in most cases, is still seen as the main coping strategy by family members.

Class 2. Difficult factors and strategies to enhance the guidance to family members
Professionals referred to the aspects, in this class, that they consider that reduce interactions with the family and, consequently, the guidelines they offer to them, while indicating strategies that could improve this service. Among the factors that limit the guidance provided, they highlighted the absence of the family from the service, the non-monitoring and/or continuity of treatment and the lack of understanding of ambulatory treatment. Among the strategies to be affected with the families, the participants referred to humanized hosting, group care for family members and the articulation with the APS, to promote the monitoring of the family in the recovery of the addicted individual.

DISCUSSION
By understanding the family as a unique and involved partner in the process of caring for its family member which also needs care, the study confirms that the psychosocial care needed by this public confirms the proposal for psychiatric reform. Despite informing actions that would contribute to the family integration in the context of care and needs to be attended in its many aspects, the guidelines provided, concentrated on information about the pathology and dynamics of the service itself. Actions aimed at the families of people addicted to alcohol and other drugs must be expanded to benefit and enhance relationships in this area (2,5) .
The family care should aim to minimize the impact resulting from the task of caring, being necessary to rethink about care strategies and support to families, as well as to lead to an understanding of alcohol and drug addiction as a mental disorder and the dimensions of the treatment (14) . The dominant guidelines that should be offered to families followed by the CAPS ad, should be to clarify that addiction is a complex mental disorder with multiple factors involved, which can last for years, being marked, often, by frequent relapses (15) . Moreover, the professionals interviewed do not struggle in carrying out this guidance, since it is very clear to them, the importance of approach to addiction and treatment of alcohol and other drugs.
However, treatment models need to include several strategies for approaching the problem experienced by families, considering biological, psychological, emotional, spiritual and social elements (9,15) . Thus, guidance to family members should be focused on understanding addiction, instrumentalizing them to deal with the adversities arising from a daily life degenerated by legal and illegal substances. However, besides handling situations in which addiction is aggravated, it should be promoted self-care and prevention of family members' illness facing emotional overload and exhaustion. So, the family can become an information unit, fundamental in understanding and interpreting the situations experienced (16)(17).
Furthermore, aspects of living with the family during crisis or relapse situations need to be approached by professionals, as they are part of the addiction therapy, given the intrinsic profile and personality of people addicted to alcohol and drugs. It is understood that the treatment consists of an adaptation and socialization process, in which changes are necessary to support new habits, such as the reorganization of life, both in the family and in the social dimension (16) .
The Psychiatric Reform impacted the society, especially in treatment aiding and in the process of demystifying mental disorders, however, deinstitutionalization has raised questions 7 of Guidelines to the families of mental health service users from the multi-professional team's perspective Nacamura PAB, Marcon SS, Paiano M, Salci MA, Radovanovic CAT, Rodrigues TFCS, et al. about the family's responsibility for the care. It is known that the family environment is the space in which the reality of care for the person addicted to alcohol and drugs takes place, as they are responsible for embracing, meeting their needs and ensuring their safety (18)(19) . The participation of the family in the treatment means involving them in the activities offered by the mental health care services, so that they follow the care strategies aimed at their members according to the proposals of psychosocial care within the scope of the Unified Health System(SUS) (20) . Added to the fact that the family is constituted as the individual's primary network, it should also be part of the care plan and a collaborator in the development of therapeutic projects. Health professionals must consider families in their singularities, filling the information gaps in critical situations, in emerging family conflicts, and in the frustrated assumption of cure along with the unknowledge of the disease itself (21) . For the addition of families in the participation of the treatment, it is necessary to establish new mechanisms for them to get closer, to understand the needs, it is necessary to meet what is real in people's lives. It is mainly in these outside spaces that it is possible to know each other and seek possible solutions to the suffering experienced, meeting their needs (22) .
During the interviews, it is observed that health professionals report possibilities to enhance the care of families. However, they remain focused on traditional guidelines, failing to actively listen to family members. The hosting of families, should be guided by the National Humanization Policy, as a way of sustaining the relationship between teams/services and users/populations. It should be built collectively, through qualified listening, ensuring that everyone is served with priorities from the evaluation of vulnerability, severity and risk (23) .
When the health service, in its work process is focused on the individual, including the family as part of this process, bonds are strengthened, both for the integration among individuals and for the complete development of the human being. Thus, users and family members must walk through a care network with welldefined articulations, favoring comprehensive care, considering that each level of health care meets a certain complexity (22) .
Although not carried out at the study site, the participants mention the implementation and maintenance of group therapies for families, to provide spaces for discussion and learning among their members. Participation in groups of therapies becomes essential for incorporating into the care process, both for the family member and oneself (15,(21)(22)24) . Furthermore, the creation of spaces for exchanging experiences with other family members who experience similar situations can help to minimize the difficulties faced in family life (5) .
In this context, the participants also highlighted the partnership with the APS, to strengthen the guidelines provided by the specialized service, to accompany families in keeping care in their territory. According to the Política Nacional de Atenção Básica (National Primary Care Policy) (2) , it is APS's competencies to embrace and stratify risk, direct care, articulate the intra and intersectoral network, register users and create bonds, take responsibility for assigned users, ensure care and resoluteness of care for low and medium risk users, share care with the CAPS of high-risk users, carry out health education activities and develop collective activities (25) .
The reduced participation of professionals in comprehensive care for families leads to a restriction of information, either due to the lack of knowledge of the professionals themselves or due to the lack of contact with them. The interprofessionality of psychosocial care teams is directly justified by the sharing of knowledge, allowing the demystification of hospitalization, and motivating the family to continue the care. However, there is a struggle concerning exchanges of co-responsibility in network care, and in most cases, it occurs in a fragmented way, without the necessary bond and dialogue among professionals, showing the difficulty of services for network job that can guarantee the integrality of the actions to the individual (26) .
Such difficulty opposes the implementation of the RAPS, which seeks to expand the interdisciplinary mental health care of the CAPS to other health care points for people with mental or family suffering or disorder (20) . The distribution of responsibilities (or shared responsibility) requires this interface, since the responsibility for service is not restricted to CAPS. Despite the difficulties and the need to resume dialogue with the network several times, the richness of this strategy lies in composing and reconstructing therapeutic projects that estimate the needs of the user and family to promote network care (27) .
About nursing, their participation in this study was almost imperceptible in the guidelines provided to families. However, it is noteworthy that this category is arranged as essential in all components of the RAPS, as in the caring space it is necessary to consider that the actions related to mental health must be considered in nursing care through embracing processes with the valuing of the addicted individual and his/her family. So, the nurse's attitude in the rehabilitation process highlights in the context of health and illness, which is part of a holistic and humanized approach (28) .
The challenge of nursing professionals to work from different perspectives is highlighted, when facing their fears, anxiety, insecurity, prejudice, and inability to meet and guide families and addicted to alcohol and other drugs. Also, for reconciling activities based on health policies, even if they are not fully consolidated and working in teams and networks, to ensure comprehensive care (4,29) .

Study limitations
A possible study limitation lies in the choice of informants, which are the professionals working in only one of the facilities that make up the RAPS, since it presupposes integrated work. Thus, it is suggested that new studies include among the informants, professionals who work in all the services of the network so that it is possible to understand whether the guidelines provided to the families of these users complement each other and what gaps exist.

Contributions to the areas of nursing, health, or public policies
The results of this study confirm the importance of health professionals, especially nurses, in becoming keys for the approximation and support for families, providing holistic and of Guidelines to the families of mental health service users from the multi-professional team's perspective Nacamura PAB, Marcon SS, Paiano M, Salci MA, Radovanovic CAT, Rodrigues TFCS, et al. integrative mental health care, which understands the importance of the family for the quality of the therapy care.

FINAL CONSIDERATIONS
The study made it possible to learn that the guidelines provided by the interdisciplinary team to the families of alcohol and other drug addicts who are monitored by the CAPS ad focus on mental disorders and the functioning of the service itself. Participants highlighted hosting, qualified listening, and partnership with APS as ways to enhance the service to families. From this perspective, the importance of intersectoriality is understood for the resolution of care, to value, not only the service to the user, but the entire family context.