REVOLVING DOOR IN THE CARE FOR CHILDREN AND ADOLESCENTS DRUG USERS: CHALLENGES AND MANAGEMENT

Abstract

The study aimed to describe characteristics related to the revolving door phenomenon in a Child and Adolescent Shelter Unit and to analyze the way in which the service manages this phenomenon. A qualitative case study was carried out with the analysis of: semi-structured interviews; participant observation recorded in a field notebook; documents and a focus group. From the analysis, three themes were constructed: Broken bonds: “If the family does not take care of itself, we can’t” (generational issues, family bonds, adherence to treatment); Underfunding: “They work miracles with the resources they have” (state underfunding, prejudice and private investment); Public policies: “This is not my problem” (segmentation of care, lack of community support and information/preparation of the institutions). These points constitute barriers in the treatment of children and adolescents that use drugs and highlight the revolving door phenomenon.

Keywords:
Case study; Drugs (use); Treatment; Children and adolescents; Public policies

Resumo

O estudo teve como objetivo descrever características relacionadas ao fenômeno da porta giratória em uma Unidade de Acolhimento infantojuvenil e analisar o modo como o serviço maneja este fenômeno. Foi realizado estudo de caso qualitativo com análise de: entrevistas semiestruturadas; observação participante com registro em caderno de campo; documentos e grupo focal. A partir da análise, foram construídos três temas: Vínculos rompidos: “Se a família não se cuidar a gente não consegue” (questões geracionais, vínculo familiar, adesão ao tratamento); Subfinanciamento: “Eles fazem milagre com os recursos que têm” (subfinanciamento estatal, preconceito e investimento privado); Políticas públicas: “Esse problema não é meu” (segmentação do cuidado, falta de apoio comunitário e informação/preparo das instituições). Esses pontos constituem entraves no tratamento de crianças e adolescentes usuários de drogas e remetem ao fenômeno da porta giratória.

Palavras-chave:
Estudo de caso; Drogas (uso); Tratamento; Crianças e adolescentes; Políticas públicas

Resumen

El objetivo del estudio fue describir características relacionadas con el fenómeno de la puerta giratoria en una Unidad de Acogida de Niños y Adolescentes y analizar la forma en que el servicio maneja este fenómeno. Se realizó un estudio de caso cualitativo con el análisis de: entrevistas semiestructuradas; observación participante registrada en cuaderno de campo; documentos y grupos focales. A partir del análisis se construyeron tres temas: Vínculos rotos: "Si la familia no se cuida, no podemos hacerlo" (cuestiones generacionales, vínculo familiar, adherencia al tratamiento); Falta de financiación: “Hacen milagros con los recursos que tienen” (falta de financiación estatal, prejuicios e inversión privada); Políticas públicas: "Este no es mi problema" (segmentación de la atención, falta de apoyo comunitario e información/preparación de las instituciones). Estos puntos constituyen barreras en el tratamiento de los niños, niñas e adolescentes consumidores de drogas y se refieren al fenómeno de la puerta giratoria.

Palabras clave:
Estudio de caso; Drogas (uso); Terapia; Niños y adolescentes; Políticas públicas

Introduction

Regional healthcare for specific publics, such as children and adolescents and drug users, continues to be a challenge for the Brazilian psychiatric reform process, due to healthcare gaps, underfunding in the public sector, dependence on the private sector, and lack of State regulation, among other factors (Macedo, Abreu, Fontenele, & Dimenstein, 2017).

A care option for the child and adolescent population, highlighted by the legislation, are the Children and Youth Reception Units (Unidade de Acolhimento infantojuvenil - UAi). These were instituted through Ordinances No. 3.088/2011 and No. 121/2012 of the Ministry of Health, and are supported by Federal Laws No. 10.216/2001 (which provides for the protection and rights of people with mental disorders) and No. 8.069/1990 (which establishes the Child and Adolescent Statute). The program concerns the expansion of the capacity for care and attention made available to users of mental health services (Ministério da Justiça, 2013). This initiative originates from with the Psychiatric Reform movement, proposing services that focus on community and territorialized care to replace the hegemonic model of the psychiatric hospital (Mielke, Kantorski, Jardim, Olschowsky, & Machado, 2009). In the field of drugs, this proposal is an alternative to institutions that are based on individualistic, moralistic and prohibitionist discourses, focused on isolation, abstinence and the war on drugs (Araujo, 2018).

The UAi offer shelter to children and adolescents from 10 to 18 years of age with needs arising from the use of drugs, guaranteeing housing, social and family life, and education, based on the right to family and community life. It also aims to expand their possibilities for social inclusion for the promotion of mental health and the construction of new life projects directed toward their autonomy and emancipation. The UAi is important within the individual therapeutic project (ITP) developed for the adolescent in conjunction with the family and Psychosocial Care Center (CAPS), in order to avoid unnecessary hospitalizations and favor the strengthening of care actions for the adolescent. (Ministério da Saúde, 2014).

Despite national advances in the structuring of the Psychosocial Care Network (Rede de Atenção Psicossocial - RAPS) brought about by programs such as “Crack, it is possible to win” (Ministério da Justiça, 2013) and the role of the UAi in this context, there are still weaknesses that involve the articulation of services, systematization of case flow, lack of reliable and up-to-date data, need for professional qualification, ideological bias in understanding the dynamics of drug use and treatment, and insufficient number of services in relation to the increased demand (Passos, Reinaldo, Barboza, Braga, & Ladeira, 2016).

Pimenta, Augusto, Guimarães and Cardoso (2017) reported the challenges of the work experience in a UAi highlighting that, like the intersectoral network for this public, it is a service that is still under construction and seeking qualification to meet the growing demand of adolescent drug users. The authors indicate problems in the RAPS related to the difficulty of understanding the functions of the UAi teams, as well as the lack of back-up for assistance to this public. The disarticulation of services can promote fragmented care, without focusing on social reintegration and the community, and disregard the uniqueness of the users. This configuration contributes to the phenomenon known as “revolving door”, in relation to the institutionalization processes of this population.

The revolving door phenomenon - so called in the field of psychiatry - refers to the frequent rehospitalization of psychiatric patients. In the (post) (de)institutionalization context, it is important to identify subgroups of patients affected by this phenomenon (Golay, Morandi, Conus, & Bonsack, 2019). Regarding treatment aimed at drug users, this phenomenon is present when the flow of crises remains recurrent and is related to the logic that the user must adapt to the services available, revealing a network that is insensitive to the individual needs of each user (Ministério da Saúde, 2015). Despite the need to understand this phenomenon and the challenges posed to overcoming it, there is a scarcity of national studies involving the implications of this phenomenon in the RAPS and a lack of consensus on definition criteria in Brazil and abroad (Zanardo, Moro, Ferreira, & Rocha, 2018).

Considering this scenario, research is needed that can analyze different aspects related to the revolving door phenomenon so that the implications of this phenomenon for the organization of flows between RAPS teams can be better comprehended in order to improve the care provided to children and adolescents that use drugs. Accordingly, this study aimed to describe characteristics related to the revolving door phenomenon in a UAi from the perspective of the professionals and to analyze the way in which the service attempts to manage this phenomenon. It is expected that the results of this study can contribute to the field of Social Psychology in the context of understanding the work processes in the RAPS and its capacity to produce active, resolutive, longitudinal and territorial care faced with the revolving door phenomenon and, consequently, its role as a network that shapes objective and subjective conditions for the experiences of the adolescents.

Method

Design

This study is characterized as a qualitative case study. This strategy is generally used when the researchers have little control over the events they study, elaborating questions such as “how” and “why” to investigate a certain contemporary social phenomenon that occurs in real life. Due to the complexities related to the intended study subject, multiple instruments are used to investigate the case (Yin, 2015).

Location

The study was carried out in a UAi located in the central region of a medium-sized municipality (600,000 inhabitants) in São Paulo state. The UAi was founded in 2014 and receives adolescents referred by the Child Psychosocial Care Center - Alcohol and Drugs (Centro de Atenção Psicossocial Infantil - Álcool e Drogas - CAPSiAD). It operates 24 hours a day, seven days a week, with 10 places for transitional voluntary shelter for children and adolescents that are drug users, aged 8 to 17 years at the time of entering. The UAi was initially set up in a single space, which had previously been an asylum and nursing home. With time and the perception that it had become extremely institutionalized, the UAi was divided into two distinct physical spaces that complement each other with regard to the care offered to the children and adolescents. With this institutional management by the municipality studied, the shelter was moved to a smaller house, with characteristics closer to a home. In this place, the sheltered children eat their meals, sleep, bathe and play with greater intimacy with each other. Bureaucratic activities, artistic workshops, individual and group consultations and pedagogical and therapeutic groups were transferred to the second space with opening hours from 8am to 5pm, from Monday to Friday. In this place there are 50 spaces to care for children and adolescents that are sheltered, at risk or that have already been sheltered, with care and groups also provided for family members. The same team serves the two spaces, composed of 15 professionals, including a coordinator, two psychologists, two social educators, a cleaner, a cook, and eight monitors.

Participants

Eight UAi professionals and six CAPSiAD professionals participated in the study. In the selection of the participants, members of the services team were invited, guaranteeing the variability of the functions performed and the proximity with the care of those sheltered. In order to preserve their identities, they will be identified with fictitious names. Table 1 describes the characteristics of the participants.

Table 1
Characterization of Participants

Participant	Institution	Function	Time working	Education
Helena	UAi	Coordinator	6 years	Complete higher education
Maria	UAi	Educator	4 years	Complete higher education
Vitória	UAi	Monitor	2 years	Incomplete elementary education
Fernanda	UAi	Monitor	2 years	Complete High School
Sandra	UAi	Psychologist	4 years	Complete higher education
Sofia	UAi	Educator	6 years	Complete higher education
Simone	UAi	Psychologist	3 years	Complete higher education
Rafael	UAi	Monitor	5 years	Complete higher education
Sueli	CAPSiAD	Manager	6 years	Complete higher education
Serena	CAPSiAD	Psychologist	4 years	Complete higher education
Lorena	CAPSiAD	Pediatrician	5 years	Complete higher education
Manuela	CAPSiAD	Psychologist	2 years	Complete higher education
Alice	CAPSiAD	Nursing Ass.	7 years	Complete higher education
Luiza	CAPSiAD	Psychologist	1 year	Complete higher education

• Source: Author

Instruments

The following data collection techniques were used for the development of the case study: (a) Semi-structured interviews with the UAi professionals, with a script that addressed the professionals’ account of the practices developed in the UAi, among them, the activities performed, advances and impasses faced in the routine, strategies used to provide a humanized welcome, socialization, family integration, social reintegration, articulation with the network, difficulties encountered and possible improvements; (b) Focus group: together with the CAPSiAD professionals to encourage discussion about the care network with a script that included questions regarding changes in the municipality’s RAPS after the implementation of the UAi, the referral flow, articulation of care, potentials and limits of the UAi and possible improvements; (c) Documentary analysis: the implementation projects, descriptive memorandum of activities, work plan and annual activity report for the year 2018 were analyzed; (d) Field notebook: notes were made about situations related to the aims of the study during the 65 hours of participant observation.

Procedures

Data collection was carried out for ten months during the years 2017 and 2018, in the two spaces that comprise the UAi. The researcher followed the routine of the home where the children are sheltered, attending there weekly on different days and times. The researcher also participated in workshops and activities developed by the technical professionals. Meetings held between the CAPSiAD and UAi teams were observed. Interviews with the UAi professionals were conducted during the participant observation. The focus group with the CAPSiAD professionals was held at a pre-scheduled time, on a team meeting day. The interviews and the focus group were audio recorded on a digital recorder, with the consent of the participants. Participation in the study was voluntary and preceded by information and clarification regarding the aims and procedures of the study, with all participants reading and signing the consent form prior to beginning the interviews. The study was approved by the Research Ethics Committee (CAAE No. 72999417.0.0000.5407), considering all ethical aspects for the development of studies with human subjects, in compliance with Resolution 510/2016.

The analysis of data from the case studies consisted of the search for patterns, insights and concepts that appeared promising through the categorization and combination of the data (Yin, 2015). The analytical strategy used considered treating the data without a prior theoretical proposition for the development of descriptions of the case, with the purpose of associating the data with concepts of interest. The analysis of the field notebook contributed to the description of the context of the study, the institutional routine and the social vulnerabilities of the adolescents sheltered. The service documents were analyzed, investigating their conformity with the requirements of Ordinance no. 121/2012, in order to comprehend how the service complies with what is established by the government guidelines, how the institution is financed and its implementation history.

The reflective thematic analysis technique was used for analysis of the interviews and focus group, as proposed by Braun and Clarke (2013). This analysis made it possible to organize and describe the information in a detailed way, assisting in its interpretation. The researcher carried out a complete transcription of the individual interviews, as well as the focus group and became familiar with the data by performing repetitive readings. The coding was prepared by organizing the data in three columns, the first containing the interview in its entirety, the second containing a synthesis related to the aims of the study and the third with the groups of meanings identified in the interview. In this process, there was the collaboration of a judge (member of the research laboratory in which the study was conducted), who codified three interviews and participated in meetings with the main researcher, to compare and discuss the codes, in order to analyze the coherence between them aiming to improve the analysis process. Initial themes related to the objectives of the study were then constructed in order to convey the central idea of the codes and organize the related concepts. These initial themes were discussed, revised and expanded by the first and third authors after further immersion in the codes and discussion. From the analysis, three themes were constructed: (a) Broken bonds: “If the family doesn’t take care of itself, we can’t”; (b) Underfunding: “They work miracles with the resources they have”; (c) Public policies: “This is not my problem”.

Results and Discussion

Following the rules of operation of the intersectoral network present in Ordinance no. 121/2012, the municipality’s CAPSiAD became responsible for referring children and adolescents to the UAi, which sheltered them through a decision taken by the CAPSiAD referral team. However, due to urgent issues, such as homelessness, and in order to make referrals possible at any time, the municipality decided that different services (Specialized Reference Center for Social Assistance, Guardianship Council, school, among others) could contact the UAi and make referrals and, in these cases, the CAPSiAD needed to be notified within 48 hours, being co-responsible for the sheltered population.

Precisely because of the situations of social vulnerability of the population studied, an oscillating frequency was found in the network among the services of the municipality. In the UAi, professionals reported cycles of coming and going among the children and adolescents sheltered, and most of their requirements had already been fulfilled by the service studied at some other time. This movement was understood, in this study, by the revolving door phenomenon, which will be better explored and discussed in the following topics:

Broken bonds: “If the family doesn’t take care of itself, we can’t”

One of the factors that contribute to the revolving door phenomenon, according to the professionals, is the lack of family bonds and the difficulty of integrating the family into the treatment. The importance of social and family support to reduce this phenomenon has been highlighted (Zanardo et al., 2018). For Maria, the cycle of coming and going from shelters was strongly influenced by the family context: “He was in this cycle of coming and going and his mother used [drugs] more than he did, so you imagine the situation of this boy. When he leaves the unit, where does he go? What is he going to do? So, he ends up being on the street”. (Maria)

The report highlights the recurrence of stories marked by social inequality experienced through the generations, which deeply marks the generational horizon of these families with a cycle of repetition. Helena commented on the trajectory of exclusion and suffering of the families attended as processes of rights violation, which makes it difficult to integrate them into the activities proposed by the services.

It is not an easy task, because it is a generational question. They are families with a history of having suffered neglect, of having suffered some type of abuse, of not having had access to all the rights to which they are entitled. So they come with very difficult histories. (Helena)

For Arenari and Dutra (2016), the trajectories of exclusion are reproduced by the formation of precarious socialization in the family context, which would result in the absence of fundamental provisions for successful behavior in future social life. This also undermines the appropriation of resources necessary to participate as a person in the entire social life in the spheres of formal education and work. However, the authors state that precarious primary socialization does not have the capacity to determine the fate of individuals, and that the institutions have a fundamental role in the confirmation or not of this trajectory.

It is important to comprehend the context of the families and the social imaginary in relation to the treatment offered to drug users produced by an asylum model aimed at a cure (abstinence) with practices based on isolation that reflect on the family’s withdrawal from the care process, leading to reduced family bonds (Silva & Oliveira, 2018). For Sandra, the families’ understanding of the care is a key point, with there being difficulty in comprehending the voluntary nature of the shelter:

Most are referrals, so there is not much of a spontaneous demand of wanting to go to the shelter. Because they are referred, many understand that it is our obligation to make them stay there, but the question of the harm reduction policy and voluntary nature is already raised in the screening, so they are already aware of the shelter, but some families don’t understand this. (Sandra)

The discourse of frustrated expectations of the professionals in relation to the role of the families also appeared in other forms. According to some interviewees, the families often place the responsibility for care exclusively on the institutions, demonstrating difficulties in comprehending the need to maintain permanent contact with the child. This could interfere in the adolescents’ process of returning to family and community life, which should be modified. Accordingly, it would be necessary to make the family aware that, in addition to the adolescent, they also need care and transformation:

There are families that don’t get involved at all and we are actively searching, visiting the house, trying to gain the family’s trust, because most of them are very suspicious. We are present in the family’s life for the family to understand that we are not here to just take care of the little guy, because if the family does not take care of itself, we can’t either. They understand that in fact our movement is the idea of transforming the family as a whole to receive this adolescent back. (Helena)

According to Belotti, Fraga and Belotti (2017), family members’ non-involvement in the care can be associated with different factors: seeking quick treatments and solutions, understanding of hospitalization and abstinence as the only treatment alternative reflecting the biomedical hegemonic discourse; and lack of family information on the psychosocial care model. Family integration in the UAi is provided by the individual and group care of the family carried out by a psychologist, home visits by technical professionals to the families’ place of residence, authorized trips for the adolescents to stay with the families on weekends and holidays, family visits on Saturdays when the adolescents cannot leave the shelter for some reason and telephone contact between the adolescents and family members on Thursdays: “When we realize that the family is resistant, we insist a lot on authorized outings, on visits to be able to reconstruct this bond between the adolescent and the family members because they cannot live with us forever. (Simone)

The professionals reported that they promote the integration of the family into the service through different strategies, in addition to routine activities, such as: donation of vegetables and food hampers for the family, in order to bring them to the service; home care; help with transport; and the treatment of other members. According to Maria, these are necessities to really reach the family: “To structure this bond, for example, there is a mother that comes here who has three of her children being attended here. We take her and pick her up from her medical consultations. . . She is also a user, we accompany her at CAPSad.”

In addition, the professionals noted that the caregivers often had no one to leave other children with and brought them to the family meeting. Therefore, in order to guarantee participation, the service created a specific group, called the “prevention group” for children and adolescents who are members of the family. During the observation, it was noticed that themes about school and socialization were dealt with, with flexibility for the requests that came up during activities, such as drawing, painting and games.

Studies show that the effective shelter is based on the expansion of bonds and for that, the development of new mechanisms of action continually seeking creative strategies that address issues that go beyond the disease and that consider the unique requirements and real needs of each family (Lisbôa, Brêda, & Albuquerque, 2016). Information for the family members about the care proposal of the substitute services, the network and the functioning of the psychosocial care model emerged in this context of the importance of support for the user (Silva & Oliveira, 2018).

The issue of drug use is a complex issue that must consider the dispute between different models of care (social welfare, the judiciary, health, public and private investments). In this context, it is worth reflecting on how families are invited to participate in the care processes. The provision of care is often associated with a punitive logic of state surveillance over the family situation. The UAi staff reported the difficulty in reconciling actions aimed at protecting adolescents from the family problems with other actions that aimed to reconstruct the family bond. This can damage the family’s relationship with the services, with them tending to avoid the services because they do not consider that they would be partners in the care.

Underfunding: “They work miracles with the resources they have”.

The statement of the CAPSiAD professional Lorena, was used to name this theme: “They work miracles with the resources they have, I think they should have more support” . This summarizes the aspects of financing that contribute to the revolving door phenomenon, such as state underfunding, seeking private investment and the prejudice of companies in relation to the subject. Ordinance no. 121/2012 establishes a financial incentive for the implantation of the Unit to the value of R$70,000, transferred to state, municipal or district health funds and a monthly allowance of R$30,000 to the UAi. However, this monthly budget only guarantees approximately 85% of the UAi funding investigated, as Helena commented:

The UAi, let’s assume about 85% is maintained by the federal government, so they pass this amount on to us. Then part of the money comes from a Foundation, we submitted a project to them and we were awarded funding. It is also maintained by the entrepreneur who founded the institution and by the events that we organize such as pizzas, bazaars, bingo...

According to Macedo et al. (2017), there were 69 adult and child care units in Brazil in 2017, considering that the forecast was that 574 units would be opened by 2014, this corresponds to 12% of what was announced. The changes that can be observed in the current Brazilian context related to the construction of public policies on alcohol and drugs demonstrate the predominance of the hegemonic discourse (moral and biomedical) when emphasizing the financing of coerced residential treatment to the detriment of harm reduction strategies as a care paradigm (Araujo, 2018).

From the documentary analysis, it was identified that the institution seeks investment from private companies with the presentation of projects tailored toward the proposals of each financing notice. However, these generally cover a small number of employees, with an execution period of one year. The two UAi spaces are partly financed by private institutions, partly public and partly by actions developed by the institution itself.

From this perspective, the weakening of the role of the State and public strategies aimed at this theme can be perceived, something that is present in the socio-historical context of planning, financing and executing public policies aimed at treating the population with problems arising from the use of drugs in Brazil. In this area, private, philanthropic and non-governmental initiatives prevail (Costa, Ronzani, & Colugnati, 2017). According to the professional Sofia: If we had more of this income, not just public money, but also private, because unfortunately it is much easier to receive private income than public.

There was also difficulty noted by the team in obtaining private investments; according to Helena, companies are apprehensive and prejudiced to be associated with the work of the institution: “To say that you work with adolescent drug users, nobody or almost nobody wants to link their company with the cause. It is very difficult precisely because normally they are not seen as they deserve to be”. Faced with the threat of closure of the institution due to lack of resources, the professionals spend a lot of time carrying out actions to increase resources, such as selling food (feijoada and pizzas), holding a bazaar with donated clothes and objects, and seeking partnerships and donations. The time spent attempting to obtain funds hinders the professionals’ dedication to the care of adolescents:

Our biggest difficulty is the financial issue that takes up a lot of time and attention from the whole team, both in seeking donations, as well as in sales and the collection of money. Often we end up getting a little lost in this work and forgetting a little about the boys’ needs. (Simone)

Another limitation of the service linked to financing is the shortage of professionals. At the time of data collection, there was no social worker or occupational therapist on the team. In addition, several workshops had been suspended due to lack of resources. The CAPSiAD professionals commented on the health contracting movement and its influence on financing, salaries and professional guarantees:

The fact of being an NGO is already problematic in terms of politics. So, it is very likely that the professionals there earn less, work more hours, do not have job stability. So you make feijoada and make pizza, because I believe that you can’t just get by with the public money. So it should be a municipal service, but the services are being contracted out. (Manuela)

The institution being an NGO also appears as a problematic issue due to the absence of strict selection criteria. The professionals are usually hired by referral without having experience with the work carried out. Therefore, they end up reiterating a movement of constant need for on the job learning regarding how to act in this area, leading to the frequent concern of the team regarding professional training.

It is also valid to question the impact of public underfunding on the practices offered, including the service’s ideological bias. The scarce public resource leads to the need to seek other forms of financing. Therefore, the institution now has a public financier and another private financier, who may have divergent comprehensions regarding the phenomenon, proposing different care actions, which impact on the professional training.

Public policies: “This is not my problem”

The lack of support from the community is often mentioned, both regarding the services of the network, which avoid receiving adolescents referred by the unit, and the people in the neighborhood and society as a whole: “If we had this participation from society, I think we could help a lot more and the funny thing is that we would help society itself” (Sofia). A study by Acioli, Barreira, Lima, Lima and Assis (2018) addresses the rejection by the neighborhood and the school as fundamental problems that compromise the inclusion of these children in various places. According to Maria, aspects related to the prejudice and victimization of the adolescents in a school environment hinder their inclusion and also contribute to school dropout:

Within the school they are viewed with a lot of prejudice, just by saying they are at a UAi. Other boys are unable to go to school because they are in risk situations, with problems in the neighborhood where they were. The school ends up being a risky place for them and most of those that we manage to include do not stay.

The school should be an environment of belonging for the students, considering that it is a fundamental context for development with recognized importance in the construction of skills, values and identity, and the formation of their education and citizenship, therefore there is a need to implement intersectoral actions for enabling the inclusion and permanence in school, particularly for young drug users (Galhardi & Matsukura, 2018).

These results were also described by Pimenta et al. (2017), who mention the difficulties found in the UAi related to the inclusion and permanence of adolescents in school and the resistance/neglect of the urgency and emergency network, causing isolation of the specialties, with specific, brief and disjointed responses. Fernanda commented on difficulties related to the care network:

We have difficulty with the psychiatry part, because at the CAPS there is no psychiatrist to assist the boys and also when we are going to take them there they have to be a priority because they are very agitated. They can’t sit around waiting.

There were also challenges highlighted by the UAi professionals, related to inter-sector actions, such as the absence of a psychiatrist at the CAPSiAD during the period of data collection, and difficulty in accessing and monitoring medical consultations, which takes time for the team to articulate the care with these services. The movement of approximation between the services of different levels of complexity of the RAPS and from different areas is still incipient, therefore, it would be essential to invest in the continuous education of professionals so that the diverse requirements of drug users can be fulfilled, promoting productive encounters within the network and avoiding fragmented care in a single service (Ribeiro, Gomes, Eslabão, & Silva, 2018). The professionals also highlighted the lack of a psychiatrist as one of the main problems in the articulation of the care network. This indicates that despite all the social determinants, the professionals still tended to comprehend the behavioral and emotional issue of young people as a phenomenon in the field of Psychiatry.

Another aspect mentioned deals with access to the service, which occurs most often through actions carried out by the Judiciary, which may indicate an inefficiency in the Health sector and/or the existence of complex social situations and impediments (Conceição, Andreoli, Esperidião, & Santos, 2018). According to the professionals, about 95% of the adolescents that attend the service are connected to the judiciary in some way, with this it is possible to verify the high involvement of the judiciary in these services. Simone commented that the judiciary also plays a role in helping to articulate with the network, as they send reports more quickly and communicate with other services:

People keep throwing the bomb at each other: “This is not my problem”. We work with the adolescent, we do all our part and he needs to be discharged, he needs some department to monitor the family to be able to receive this adolescent back and the departments will not commit themselves. Often, we need to go to the judge to determine the measure and to be able to accomplish it.

It is relevant to question the role of the judiciary in articulating the psychosocial care network and its involvement in the care and decisions of this problem. For Serena, a CAPSiAD professional, it is harmful when judiciary professionals interfere in decisions and overlap with health professionals:

Sometimes a document arrives, saying: “I forward for evaluation for hospitalization”. He is not a health professional, he does not know if this is what’s needed, he had to refer him for treatment first and here to assess whether he is going to be hospitalized, what the type of treatment should be. So, not only in health, but the judiciary plays this role of overlapping the technical staff.

For Pimenta et al. (2017), there is a lack of knowledge about the functions performed in the UAi and certain demands of the judiciary contribute to the understanding of the UAi as an end in itself and not a part of a therapeutic project. There is a need for an actively engaged judicial process that promotes the guarantee of rights and dignity. Otherwise, there is a risk of the judicialization of mental health, promoting the institutionalization, stigmatization and medicalization of the behavior (Rocha, Silva, & Asensi, 2018).

Sofia commented that the judiciary often sends adolescents who are considered “difficult” with the promise that the network will work together to develop care, however, over time, the proposed changes and joint strategies are lost and each service ends up segmented in its specificities: “Then comes the whole ‘No, the services are going to work together’ thing, there is that meeting and everyone comes. But when we need and even schedule some meetings only 2 or 3 services go...”

As long as care strategies are not formulated in conjunction with the implementation of flowcharts, there is a tendency for links between the services to be superficial and fragmented. It is necessary that the network recognizes the diversification of the requirements of this population, ensuring care that goes beyond the focus on pathology and drug use, with actions that stimulate the autonomy and citizenship of the subjects (Costa, Ronzani, & Colugnati, 2017). For there to be an active network, the professionals need to be able to connect with people inserted in other services and spaces of the community (Ministério da Saúde, 2015). Helena recalls that the network is made up of people that need to communicate, otherwise the revolving door will continue:

The network does not work between the services, it works between people. I realize that there are a lot of push-push games: It is about health, so it is not about care, it is about the CAPSi, so it is not about the CAPSiAD”. So, the network as a whole does not work, but the social worker who fought over the case makes the network work.

For the construction of an adequate Individual Therapeutic Project (ITP), there is a need for action in several areas, in addition to health, since particular needs are unable to be fulfilled by a single service. The importance of the ITP lies in the ability to guide the processes and paths of intersectoral care in the RAPS (Ministry of Health, 2015). According to Helena, the ideal would be to plan the ITP when the adolescent enters the service, together with the family, however, in practice the service carries out specific actions related to the daily needs and requirements observed: “We kind of put out a fire even to try to guarantee some access. School enrollment is late, let’s go after it, want to do a soccer school, let’s go after it.”

The construction of the ITP should also be carried out with the CAPSiAD team, however, according to Sueli, they do not formulate an official document due to the dynamics of the requirements fulfilled: “The things that happen to them are much faster than we can write on paper. So we have a meeting every Tuesday and agree on something, Wednesday everything changed. There is a phone call, whatsapp message, go there.”

The use of social media emerges as an important tool when considering the speed of the institutional dynamics. This use is in line with the guidelines in the strategic guide for the care of people with needs related to the consumption of alcohol and other drugs, which indicates the use of fast means of communication and discussion forums as efficient strategies for working with the drug user population (Ministério da Saúde, 2015). These guidelines also highlight the potentials related to the bond between the adolescents and the UAi professionals, territorialized care with adolescents and families, and the physical proximity between the UAi and the CAPSiAD, the services that provide case discussions and articulation of joint therapeutic projects between teams.

Considering how the revolving door phenomenon is produced and its effects makes it possible to organize other work strategies that guarantee the resolutive and longitudinal care related to this requirement. Accordingly, it is important to think about practices that improve the link between the different services in the network, as well as qualify care for mental health problems (Zanardo et al., 2018). Comprehending the importance of intersectoral public policies that consider the contexts that permeate drug use and guarantee access to services involving community/families/users/training institutions was an advance for the establishment of realistic policies aimed at preventing, promoting and reducing social and individual harm (Passos et al., 2016).

Within this theme, aspects related to the care network that produce the revolving door phenomenon arise, promoting institutionalization and the segmentation of care, such as the disarticulation of the network, lack of preparation of the institutions to cope with the demands from specific populations and lack of knowledge of the network professionals regarding the operation of the unit. These are aspects related to the flows established in the work processes that crystallize defensive positions in relation to the demand (This is not my problem ) and highlight the working conditions of these professionals.

This phenomenon will continue to occur if there is no co-responsibility and continuous interlocution of care to reduce barriers to access, overlapping actions between services and discontinuity of care (Ministério da Saúde, 2015). Inventive strategies and intersectoral strengthening are necessary for the articulation of care to be effective, since this is a challenging theme that is still recent and weakly structured.

Final considerations

Many advances have been achieved with the psychiatric reform process and with the organization of the RAPS in Brazil, however, there is still a need for structuring the network, especially with regard to the care of specific populations such as children and adolescents who use drugs. This is especially relevant considering the current Brazilian scenario of dismantling and setting back public policies in the field of mental health with no investment or implementation of new services such as the UAi.

Regarding the revolving door phenomenon, generational issues and unfamiliarity with the service on the part of family members were reported by the professionals as promoting the lack of family bonds and low adherence to the UAi. From the perspective of the professionals, the family needs to be supported with information to comprehend that the UAi care proposals implicit in the provisional shelter and voluntary nature of the accommodation for the adolescents. They also need to be informed about the functioning of the RAPS, so that they can be prepared to recognize that they are part of the care process provided by the institutions. Another relevant issue refers to public underfunding related to the recent implementation of public policies aimed at this population. Seeking private funds and donations for the service, is hampered by the prejudice of private institutions to develop partnerships associated with this theme. The lack of social support and prejudice from society and institutions were also highlighted, as well as the judicialization of health and the lack of accessibility of the services and institutions such as the school.

The investigation of the revolving door phenomenon in a UAi allowed us to apprehend the set of (dis)articulations between institutions in the implementation of a public policy aimed at a specific age and social segment, which has particularities in the experience as drug users. In this sense, its contribution to the field of Social Psychology consists of making processes of constitution of adolescent subjectivities visible that are not abstract but, on the contrary, concretely situated in the historical plots of care for this population. By highlighting, in the context of a program, the tensions and weaknesses in the State-family and public-private relations, which produce and feed the revolving door phenomenon, the study offers an approach that integrates macro and micro social aspects that conform the conditions of constitution and experience of these adolescents and collaborate to face this phenomenon based on its constituents. Identifying the elements of this process collaborates in the elaboration of ways of inserting Social Psychology into the work dynamics of the RAPS. The institutionalization of adolescents that go through different services, shelters, hospitalizations and deprivation of liberty has a deleterious effect on their lives, generating greater stigmatization, placing them as “difficult” and blaming them for the failure of the care.

Future research is suggested that include family members and adolescents as participants, to observe their flow and trajectory in the care network services and the ways in which these subjects interpret the aspects involved in the revolving door phenomenon. It is also important to analyze the functioning of the UAIs in other parts of the country to investigate aspects related to both the regionalization of care and aspects that appeared in this study that are repeated in the broader structuring of the revolving door phenomenon related to the care of children and adolescents that use drugs.

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• Consent for image use: Does not apply
• Approval, ethics and consent: The study was approved by the institutions: Faculty of Philosophy Sciences and Language and Literature of Ribeirão Preto, Child and Adolescent Shelter Unit, and Child Psychosocial Care Center - Alcohol and Drugs
• Financing: Master’s scholarship from the São Paulo Research Foundation - FAPESP (Process n. 2017/11869-9)

Publication Dates

• Publication in this collection
  25 June 2021
• Date of issue
  2021

History

• Received
  10 Oct 2019
• Reviewed
  25 June 2020
• Accepted
  27 July 2020