Occupational therapists’ performance in the Psychosocial Care Network in a brazilian northeast state

Abstract

Mental health care in Brazil has been changing throughout history, establishing new practices, forming the Psychosocial Care Network, affirming the protagonism of users in the production of care, their social rights and their citizenship. Among the professionals involved in these changes are occupational therapists. This qualitative research aimed to understand the performance of these professionals in this Psychosocial Care Network in the Paraíba state, Brazil. Thirteen occupational therapists were interviewed using a semi-structured questionnaire, applied remotely. These professionals are mostly women, with professional experience and interest in working in Mental Health, as well as work in Psychosocial Care Centers I. A low number of professionals in state services was evidenced, being only 17 in a Network of 124 services. As for the actions developed, they listed: individualized care, reception/screening, groups, Unique Therapeutic Projects, participation in team meetings, crisis management and workshops. The precariousness of working conditions was perceived, in particular, by the lack of resources to carry out the interventions. Only occasionally they feel supported by the representative entities (class council, union, and state professional association). The service coordinators understand the professional performance, but it is the users who value it the most, followed by family members, teams, and service coordinators. This appreciation and recognition by the main agents involved in the production of community life demonstrates that occupational therapists are an integral and active part in this process of reception, coexistence and inclusion of vulnerable and fragile people facing their condition of mental suffering.

Keywords:
Professional Practice; Mental Health; Occupational Therapy

Resumo

O cuidado em saúde mental no Brasil vem mudando ao longo da história, instituindo novas práticas, formando a Rede de Atenção Psicossocial, afirmando o protagonismo dos usuários na produção do cuidado, seus direitos sociais e sua cidadania. Dentre os profissionais envolvidos nessas mudanças, estão os terapeutas ocupacionais. Esta pesquisa qualitativa teve como objetivo compreender a atuação desses profissionais na RAPS do estado da Paraíba, Brasil. Foram entrevistadas 13 terapeutas ocupacionais utilizando um questionário semiestruturado, aplicado de forma remota. Essas profissionais são, em sua maioria, mulheres, com experiência profissional e interesse pelo trabalho em saúde mental e atuam em Centros de Atenção Psicossocial I. Foi evidenciado um baixo número de profissionais nos serviços do estado, apenas 17 em uma rede de 124 serviços. Quanto às ações desenvolvidas, elencaram: atendimentos individualizados, acolhimento/triagem, grupos, Projetos Terapêuticos Singulares, participação em reuniões de equipe, manejo de crise e a realização de oficinas. A precarização das condições de trabalho foi percebida, em especial, pela insuficiência dos recursos para a realização das intervenções. Somente eventualmente elas se sentem apoiadas pelas entidades representativas (conselho de classe, sindicato e associação profissional estadual). Os coordenadores dos serviços compreendem a atuação profissional, mas são os usuários quem mais a valorizam, seguidos pelos familiares, equipes e coordenadores do serviço. Essa valorização e reconhecimento pelos principais agentes envolvidos na produção da vida comunitária demonstra que as terapeutas ocupacionais são parte integrante e atuante nesse processo de acolhimento, convivência e inclusão das pessoas vulnerabilizadas e fragilizadas diante de sua condição de sofrimento mental.

Palavras-chave:
Prática Profissional; Saúde Mental; Terapia Ocupacional

Introduction

The Brazilian Psychiatric Reform was characterized by the conception and proposition of new values, practices and institutions oriented towards overcoming the asylum model and logic, and towards the affirmation of the defense of human rights and citizenship of people with experience of psychic suffering (Brasil, 2005, 2016). In the last 40 years, this process has brought to society the need to invalidate the psychiatric hospital as a place for the treatment of people with mental disorders, as it is based on an asylum model based on segregation, exclusion, and violation of rights. The Psychiatric Reform process involves the participation of users, family members and professionals who make up the services of the Psychosocial Care Network - RAPS, as well as agents from the sectors of education, justice, social assistance and others in proposing, articulating and carrying out actions of a more humanized (Braga, 2019; Sousa & Jorge, 2019).

Federal Law n. 10.216, of April 6, 2001, also points to the need for care for people with mental disorders to occur freely and be redirected to extra-hospital substitute services in the territory. As for Ordinance n. 3.088/2011 instituted the Psychosocial Care Network - RAPS - and established the criteria for its organization and implementation across the country, integrating mental health at all levels and points of care of the Unified Health System (Brasil, 2001, 2012).

Thus, the mental health policy redirects assistance based on the remission of symptoms and places the subject as the protagonist of their care process, dealing with the reconstruction of family and social bonds and their autonomy in life, which implies the definition of new professional profiles. In this new model of care, RAPS is inserted, composed of Psychosocial Care Centers - CAPS, Therapeutic Residential Services, Coexistence and Culture Centers, Comprehensive care beds in General Hospitals, Return Home Program, Health Income Generation Mental Health and Adult and Child Care Units (Brasil, 2011; Lins, 2015).

The practices developed in the network of substitute services require the creation of multidisciplinary teams, whose central objective is to promote the social inclusion of users through multidisciplinary actions that involve education, work, sport, culture, and leisure, developing joint and intersectoral strategies to face the problems (Brasil, 2004).

However, in December 2017, Ordinance n. 3.588 (Brasil, 2017), which advocates care in psychiatric hospitals, was approved, completely diverging from the principles that underpin the current Psychosocial Rehabilitation policy. This resolution ensures the maintenance of beds in psychiatric hospitals and establishes increases in the amounts paid for hospitalization in these institutions, placing them in the RAPS, together with the therapeutic communities. Also in that year, there was a 49% increase in complaints about mistreatment, religious impositions and forced labor, simulated as labor therapy, in some institutions of these modalities. Therefore, this proposal is configured as a major setback, as it opposes the movement of Psychiatric Reform and the Anti-Asylum Struggle, which envisages the defense of users' human rights and care in freedom, by rescuing an obsolete and segregating paradigm, limiting the user diagnosis, drug prescription and violations of various types (Associação Brasileira de Saúde Mental, 2018; Guimarães & Rosa, 2019; Lussi et al., 2019).

It is in this field of disputes that occupational therapists are called upon to join the multiple forms of resistance from workers, users, family members and social movements, to defend the maintenance of the principles of the Psychiatric Reform and the model of mental health care resulting from it, for through practices that reach the daily lives of subjects and promote their social protagonism (Ribeiro & Machado, 2008; Lussi et al., 2019).

It is believed that knowing the practices of occupational therapists in RAPS services makes it possible to identify if and how these principles are present in their work, as well as the repercussion of their actions for the assistance produced in the services and their possible repercussions for RAPS. Historically, occupational therapy has contributed to the expansion of affective and material exchanges between people in psychological distress, with professionals and other users of different services, and with society in general. By organizing, coordinating, and monitoring actions in the RAPS devices and in spaces that circulate around the city, professionals have enabled care in freedom and promoted opportunities for recognition and exercise of citizenship for these people. The development of users' autonomy and protagonism in the face of their daily needs, their unique treatment project and the production of a life with meaning, as well as their social inclusion, have been objectives of the work of occupational therapy. In this direction, it is observed that the principles that found a logic of territorial care are close to the values that support the actions of occupational therapy, reaffirming the potential of the profession to act in psychosocial care services (Morato & Lussi, 2018).

This text aims to present part of the results of the research entitled “Performance of occupational therapy in the Psychosocial Care Network of Paraíba”, referring to socio-professional data; actions developed in the services; management; availability of resources; professional recognition by users, family members, other professionals and managers; and the role of representative entities in supporting the actions of professionals.

Methods

The presented research has a qualitative, exploratory and descriptive approach, since it proposed to understand the work of occupational therapists in RAPS in the state of Paraíba. The term understand is one of the main verbs for qualitative research, as understanding requires taking into account the uniqueness of the individual; the results of this research started from the conceptions, attributions of meanings and opinions of the participating occupational therapists regarding the experiences in their professional practice contexts. Due to its applied nature, it sought to generate knowledge that would contribute to the advancement of these workers' practice, by outlining and characterizing the mental health care processes developed by them (Minayo, 1994; Gerhardt & Silveira, 2009). We chose to use the female gender to refer to the research participants, as most of them are women.

The state of Paraíba is made up of 233 municipalities comprising 16 regions (Instituto Brasileiro de Geografia e Estatística, 2010). Of these municipalities, 78 have some mental health equipment, including: Psychosocial Care Centers in their various modalities (CAPS I, CAPS II, CAPS III, CAPS AD, CAPS AD III, CAPSi), Adult and Child Care Units, Therapeutic Residences, Return Home program¹ , Clinic in the Street and Mental Health Beds in General Hospital, totaling 125 services throughout the state.

Based on the Paraíba RAPS Monitoring Report, referring to the second half of 2018, a mapping form was prepared in which those responsible for each of the Network services were listed and contacted by telephone and/or e-mail, raising the number of 11 occupational therapists working in the interior of Paraíba in the year 2020. At the same time, the mapping of occupational therapists from RAPS in the metropolitan region of João Pessoa-PB was carried out, through the network of professional and personal contacts of the research proponents, and another 6 professionals were also identified in the respective year of 2020. In this way, the number of 17 occupational therapists in RAPS throughout the state of Paraíba, who were invited to participate in the research, was raised.

Of the 11 professionals from the countryside, 10 responded to the researcher's initial telephone contact and 7 participated in the study. In the metropolitan region, the 6 occupational therapists contacted agreed to collaborate with the research, which thus totaled 13 participants.

The research was approved by the Research Ethics Committee (CEP) of the Medical Sciences Center (CCM) of the Universidade Federal da Paraíba, under opinion n. 4.066.899 and CAAE 31997920.5.0000.8069. After the first contact with the occupational therapists and the indication of interest in contributing, the research instrument was sent via e-mail, with the Informed Consent Form being the first item of the questionnaire to be completed. Focusing on the privacy and secrecy of information, in order to avoid identifying the participants, the acronym OT was used, plus the numbers 1 to 13 to indicate the professionals’ speech.

The data collection period was from August to October 2020, in the interior of the state, and from October 2020 to March 2021, in the metropolitan region of João Pessoa. The questionnaire was prepared by the research proponents, using the Google forms tool, and contained semi-structured questions about: socio-professional data; actions developed in the services; management; availability of resources; professional recognition by users, family members, other professionals and managers; role of representative entities; theoretical basis adopted to support the developed practices; specificity of occupational therapy in professional practice; team work; potentialities and difficulties found by occupational therapists to work in RAPS. As mentioned in the previous topic, this text is dedicated to the presentation of the results referring to the first six items mentioned.

With regard to the participants from the countryside, based on a preliminary analysis of the questionnaire responses, it was identified the need to deepen the questions they narrated. Then, interviews were conducted with two occupational therapists, selected for having longer employment with RAPS services, based on a script prepared built with the responses already sent. The interviews were carried out by voice call, via a messaging application, and recorded using a recording device installed in another cell phone; subsequently, the reports were transcribed and analyzed.

The analysis considered the complete study sample, corresponding to the 13 participants. The answers from the objective questions of the semi-structured questionnaire were described and organized in tables. The data from the answers to the open questions underwent content analysis, having been, at first, systematized according to the categories pre-established by the instrument, guided by the research objectives, and presented descriptively. Then, these results were interpreted and discussed in dialogue with the literature on the themes addressed in the research, enabling the production of new knowledge, reflections, and interpretations about them (Gibbs, 2009).

Results

After socio-professional characterization of the research participants, their main results regarding the understanding and appreciation of the profession, availability of resources, representative entities of the profession and actions developed by occupational therapists in RAPS will be presented. The data displayed in the tables and figures provide an overview of the performance of the participating occupational therapists in the state of Paraíba, with some comparisons being made in the text between the findings in the metropolitan region and the interior, in order to point out the differences that were significant.

Socio-professional characterization of the research participants

Of the 13 occupational therapists participating in different mental health facilities in Paraíba, 12 are women, between 25 and 47 years old, 61.5% (8) are brown, 23% (3) white and 8% (1) of people declared themselves black, as shown in Table 1.

Table 1
Characterization of occupational therapists.

Characterization of occupational therapists	% (n)
Age group	46% (6) between 25 and 30 years
	54% (7) between 32 and 47 years
Gender identity	84% (11) Cis woman
	8% % (1) Woman
	8%% (1) Cis male
Racial/ethnic identification	61.5% (8) Brown
	23% (3) White
	8% (1) Black
Raps service where works	46% (6) CAPS I
	8% (1) CAPS II
	8% (1) CAPS III
	15%% (2) CAPS ij
	23% (3) CAPS AD
Workload	61.5% (8) 30 weekly hours
	31% (4) 20 weekly hours
	8% (1) 08 weekly hours
Employment Relationship	23% (3) Contest
	77% (10) Temporary contract
Working time in the service	46% (6) 3 to 11 months
	46% (6) 1 to 6 years
	8% (1) 15 years
Time working in the field of mental health	15% (2) less than a year
	31% (4) 1 to 4 years
	46% (6) 5 to 9 years
	8% (1) 15 years
Interest in the area of mental health, before working in the current service	85% (11) Yes
	15% (2) No
Experience in the field of mental health before working in the current service	77% (10) Yes
	23% (3) No

• Source: Elaborated by the authors.

Most occupational therapists work in CAPS in modality I. One of the respondents works in two RAPS services in Paraíba, however, she answered the questionnaire considering her work in a single service. The workload of occupational therapists, for the most part, is 20 to 30 hours a week.

Regarding the employment relationship, three are public servants and the others are in temporary work situations, characterized by the absence of documented contracts and verbal agreements. Regarding the length of time working in the service, professionals working for a minimum of three months and others with a maximum of 15 years were verified. Most professionals (85%) had an interest and experience in mental health.

Of the participants, 12 graduated from universities in the Northeast, most of them from public universities; 69% (9) have a graduate degree, distributed in the following areas: Child Development Disorder and autism; Behavior Analysis applied to Autism and postgraduate studies in Mental Health and Cognitive Therapies; three have Residency in Mental Health and one in Family Health; one holds a master's degree in Education, Work and Innovation in Medicine and the other holds a master's degree in Teaching in Health Sciences with research focused on RAPS.

The training time of occupational therapists, at the time this study was carried out, ranged between 4 and 18 years, as shown in Table 2. As for training activities to work in the services, 77% (10) mentioned that they carry out self-directed studies on the field of mental health and 38% (5) also study through courses offered by service management.

Table 2
Academic education.

Academic education and training	% (n)
Institution/State of graduation	69% (9) in Paraíba
	8% (1) in Pernambuco
	8% (1) in Rio Grande do Norte
	8% (1) in Ceará
	8% (1) in São Paulo
Year of completion of graduation	31% (4) 2002 a 2012
	69% (9) 2014 a 2020
Post-graduate	69% (9) has a postgraduate degree
	31% (4) does not have a postgraduate degree
Forms of training for performance	77% (10) Self-directed studies in the field of mental health
	38% (5) Courses offered by Service Management
	15% (2) Spontaneous demand
	8% (1) Specialization
	8% (1) Update and search on the health portal
	8% (1) PICS
	8% (1) courses and scientific events not offered by the Service Managements

• Source: Elaborated by the authors

Regarding the theoretical productions carried out by occupational therapists, considering the scientific publications about professional practice, and others regarding the production of content to publicize the profession, the study pointed out that these practices are occasionally carried out or were never carried out by the interviewees.

Understanding and valuing the profession

With regard to professional recognition, Figures 1 and 2 show the opinions of occupational therapists about the understanding and appreciation of the profession by users, family members, professionals and coordinators of the services in which they work, and also by municipal and state managers.

The results show that, in the opinion of the interviewees, most users, work colleagues, family members and municipal and state managers partially understand the work of occupational therapy. Comparatively, municipal and state managers and family members are the ones who have less understanding in this regard, unlike service managers/coordinators, the only category in which more respondents marked “yes” than “partially”. However, when comparing the responses of occupational therapists from the metropolitan region with those from the interior of the state, it is noted that a much larger number of the first group (66.7%) considers that their work is understood by the coordination of the service, as opposed to the 28.6% of the colleagues from the interior with the same opinion.

With regard to the appreciation of occupational therapy, for the participants, users are the ones who most recognize the importance of occupational therapy in the services, closely followed by the coordinators and teams where they work, with more expressive numbers also among the participants of the Metropolitan region. More than half of them consider that they are also valued by the users' families, and the greatest devaluation occurs among municipal and state managers. No occupational therapist in the metropolitan region consider themselves to be fully valued by managers; among those in the interior, 42.8% and 28.2% mentioned this appreciation by state and municipal managers, respectively. No participant pointed out that service users and teams devalued their work.

Figure 1
Understanding the performance of occupational therapy.

Figure 2
Valuing the performance of occupational therapy.

Availability of resources for professional performance

The resources made available in the services to carry out professional activities were considered insufficient by most occupational therapists: eight of them (61.5%) stated that eventually the available resources are sufficient, and two others (15.4%), both from interior of the state, point to the serious reality that they never were. Only two participants (15.4%) assess that resources are often sufficient, and one (7.7%) that such sufficiency always occurs.

Among the resources whose scarcity has made it difficult to carry out activities are materials and tools, indicated by 92.3% of the 13 participants, followed by physical space (46.1%), transportation (38.5%) and furniture (38. 5%). One participant selected the “other” option and added the lack of human resources in the team. Comparing the two groups of participants, only two who work in the interior (15.4% of the total) selected the physical space as a problem for the performance of the services, in contrast to the four occupational therapists in the metropolitan region (30.8% of the total) who did. Furniture, on the other hand, was considered by only one participant from this region (7.7% of the total) as an obstacle to the development of activities, as opposed to the 30.8% of professionals from the interior who pointed it out.

The issue of resources and materials always matters, I don't know if it's because people don't understand, or because they don't want to invest, I think it's both. [...] even today, to carry out a service, I bring materials from home, I reduced it a lot, I bring one or another nowadays, because I have to work with what I have, and I noticed that it is useless to bring them, they do not value them, I spend my things right, so it's better we leave it without, to see if people start to complain and start to arrive. [...] we make a list, years go by, but when it arrives it is a material of poor quality, very childish. [...] it is more penalized with the adult group, [...] there is this difficulty in putting the therapeutic project up to date. (...) it's suffering, it gets tiring, [...] I'll put together my list, I explain why, but not everything is enough and we know that sometimes it's a matter of not understanding, because if you understood, I invested, because money is available [laughs] (OT2).

Representative entities

The Figures 3, 4 and 5 show the participants' opinions about the support they receive from entities representing the profession. They are: Regional Council of Physiotherapy and Occupational Therapy of Region 1 (CREFITO-1), Union of Physiotherapy and Occupational Therapy of Paraíba (SINFITO-PB) and Association of Occupational Therapists of Paraíba (ABRATO-PB). In this category, we sought to investigate how much the participants perceived themselves supported and assisted in their professional needs by the representative entities.

Figure 3
Support from CREFITO 1.

Figure 4
Support from SINFITO-PB.

Figure 5
Support from ABRATO-PB.

Comparing the two groups of professionals, occupational therapists from the interior find greater support in CREFITO-1 and SINFITO-PB than their colleagues working in the metropolitan region. For the majority of participants in both groups, support from the three representative entities occurs on an occasional basis; the most frequent support is provided by ABRATO-PB and SINFITO-PB. There were six responses that reported never having received it, with half of them related to CREFITO-1.

Actions developed by professionals in the services

The following actions developed by occupational therapists in the RAPS services were listed in the research form, to be marked by the respondents based on their performance: welcoming/screening, crisis management, unique therapeutic project, user assembly, family group, home visits, intersectoral activities in conjunction with other services and external activities, matrix support, team meetings, workshops, groups, individualized care, consultation, referrals and counter-referrals, training and qualification for the service team, discharge and dismissal; plus the option “Other activities carried out”, in case there were actions not contemplated by the available options.

The actions listed as most developed by occupational therapists working in the RAPS in the state of Paraíba are individualized care (92.3%), followed by reception/screening and groups, each selected by 84.6% of the participants, and by Unique Therapeutic Projects, team meetings and workshops, each marked by 76.9% of the respondents.

The biggest discrepancy verified between the answers of the two groups concerns the management of the crisis, which was indicated by all occupational therapists in the metropolitan region and by only three professionals working in the countryside. Another striking difference was the performance in the user discharge/dismissal processes, listed by only one of the participants from the countryside, as opposed to the five from the other group who reported developing this action.

One of the participants reported, from the option “Other activities developed”, that she had not been carrying out matrix support and groups with family members during the last few months due to the pandemic, and that assemblies with users also need adaptations. Other respondents mentioned developing actions such as: individual monitoring of family members; auriculotherapy; harm reduction actions; bodily practices; participation in Yellow September campaigns; and provision of training for Primary Care teams.

The following reports, about the practices developed in the daily work, illustrate the wide range of possibilities for occupational therapy in RAPS, by bringing actions, objectives and principles common to all professionals who work in it, such as teamwork and in a network, the construction of unique therapeutic projects, matrix support, crisis management, intersectoral work, the exercise of citizenship, the right to coexistence and the protagonism of users. In addition, individual and group consultations carried out in the service and outside it, with users and their families, and occupational therapeutic interventions for expanding repertoires, learning new skills, expanding autonomy and independence (including financial), improving communication and expression, and cognitive stimulation.

Individual and family care; Workshops and Groups focused on cognitive stimulation; for coexistence; for the expansion of expressive and reflective capacity; for the exercise of citizenship (rights); for the recognition or discovery of manual skills; Construction and Monitoring of Unique Therapeutic Projects; Team Meetings; Training/qualification for the team; Home Visits; Articulation with other services (health and social assistance); Crisis management; interconsultation. At all times, the focus on expanding life repertoires crosses my clinical work, as well as teamwork focused on the protagonism of service users and their rights before the SUS. It was not possible to carry out more external, cultural, sports, work, etc. actions, due to the pandemic period (OT4).

I carry out the initial welcoming to the users daily, through group attendance by conversation wheel, and soon after we develop a therapeutic workshop, always involving expressive, communicative and corporal practices. When necessary and/or requested, perform individual care and/or home visits. As I have experience in CAPS III, I am also asked to handle crises for our users. Team meetings take place weekly and the matrix support took place monthly, however, with the pandemic, they were canceled (OT1).

Usually welcoming activities, individual assistance, group with children and group activities with adults, home visits and I participated in team meetings and case discussions with some professionals and, depending on the need, problem solving at the Public Prosecutor's Office (OT3).

One of the main [activities] in my work are workshops and groups, where I usually try to take activities that stimulate users cognitively and manual work that can stimulate their autonomy and independence, even financially, taking activities that can be carried out and used as a source income (OT5).

When asked if they considered themselves capable of acting as managers in the respective services, 61.5% of the participants said yes, and 38.5% said no, with this number being more expressive among participants from the countryside (71.4% of seven professionals), compared to half of the occupational therapists in the metropolitan region who believe they are capable of occupying management positions in the services where they work.

Regarding the possibility of democratic participation by professionals in handling the situations experienced by users and the team in the service's daily life, allowed by the management of the services in which they work, 46.1% of the participants stated that there was always this opportunity, 23.1% reported that the situation in question occurs frequently, another 23.1% consider that this happens occasionally and only one of the participants (7.7%) mentions that democratic participation is never made possible by management.

Discussion

Considering the training of the professionals participating in this study, most graduated from public universities and, later, attended a postgraduate course in various areas. They reported gaps in occupational therapy graduation, pointing out the insufficiency of theoretical-practical training in the field of mental health and its repercussions on professional performance in RAPS services. This indicates the need for greater investments in the training process in the field of mental health, especially in the Higher Education Institutions (HEIs) where they graduated. Aware of these gaps and their impacts, these occupational therapists have been trained to improve their performance in the service, which is consistent with the need for improvement posed by the complexity of the field (Lins, 2015).

The university context should provide professionals with a humanistic, critical-reflexive and ethical training process, based on the appropriation and production of knowledge by the student and on the development of skills that fully prepare him for citizenship and professional life (Zimmermann et al., 2019). The National Curriculum Guidelines for the Occupational Therapy Graduation Course (Brasil, 2002) advise that professional training be carried out in an integrated and continuous manner with other instances of the health system, and that occupational therapists in training be able to think critically, analyze society's problems and seek solutions. The training of occupational therapists focused on the Unified Health System, envisioning community care, prepares professionals to deal with the theoretical and technical demands of service demands (Mângia et al., 2010).

The coordination of the services in which the participants worked was the person who most understood the performance of occupational therapists, and the users were the ones who most valued it, closely followed by the director and professional. The fact that 61.5% and 53.8% of the participants believe that the municipal and state administrations, respectively, partially understand their role, and 30.8% claim that they do not understand this, may reflect the managers' lack of knowledge - with the exception of services - on occupational therapy and its possibilities of action in the field of mental health. One of the difficult aspects pointed out by the participants was the lack of knowledge of the management about the profession, pointing out the lack of vacancies in the staff of professionals in the services as one of its consequences.

A survey that analyzed the perception of managers of the Municipal Health Department of João Pessoa (PB, Brazil) about the role of occupational therapists in the health network of the five health districts of the city, showed a reasonable level of understanding regarding their professional role. The terms most cited by managers, highlighting occupational therapy professional, were: “everyday life”, “activities” and “occupation”, and it was also mentioned that the profession focuses on the subject's daily activities and adapts utensils. However, it was found that they confuse practices and attributions of occupational therapy with those of physiotherapy, which also points to their lack of knowledge about the specificity of the profession (Miranda et al., 2019).

Some research participants brought, in their reports, the experience of being confused with recreators and/or workshops, which also demonstrates the insufficient understanding of the management, of the users of the services and their families about the principles and practices that constitute the performance of the occupational therapy in the field of mental health. Lack of knowledge and a mistaken view of the profession require occupational therapists to continually explain their interventions, with the dissemination of their professional practice being one of the possible ways to transform this reality (Gozzi, 2012; Marcolino et al., 2016), which has been done in an incipient way by the research participants.

The perception of not having the capacity to act in the management of RAPS services, pointed out by 38.5% of the participants in general and by 71.4% of those who work in the interior of Paraíba, points to the need for investments in professional training with regard to preparation for management.

Graduated professionals have extensive knowledge of how to relate to the patient/groups (target of the intervention) and how to intervene, but they may not have knowledge of how to manage the service that covers this clientele. To this end, they still need, in their training, to have knowledge of tools that favor performance evaluation to facilitate decision-making, such as cost reduction, resource distribution, human resource training (Cruz et al., 2014, p. 311).

The manager's role includes responsibility for making decisions regarding human and material resources, in order to achieve certain objectives and, for this, it is necessary to develop skills, such as strategic and organizational planning, leadership, supervision and innovation. The National Curriculum Guidelines for physiotherapy, speech therapy and occupational therapy courses recommend that these professionals develop aspects not only focused on the care area, but also directly linked to service management (Brasil, 2001; Cruz et al., 2014).

The statement that for only 15.4% of the participants the resources to carry out activities are often sufficient shows a reality of precarious work, in which the resources identified as scarcer are materials and tools, physical space and transportation. Material in occupational therapy, according to Benetton (1994, p. 32), is “all the instrumental arsenal used in carrying out activities: the raw material, the instruments for its manipulation and all the apparatus that constitutes the therapeutic setting”. For occupational therapists to be able, along with other team members, to act in line with the principles of Psychosocial Rehabilitation, building with users projects that transform their lives and promote their participation and social inclusion, one of the basic premises is the guarantee of conditions appropriate job.

The scarcity of these basic resources can reduce the possibilities of interventions, impact the quality of care for service users and generate dissatisfaction in the work of professionals. Despite the important achievements in overcoming the asylum model and transformations in society's relations with the experiences of illness and psychic suffering, this situation shows that there is still much to be done, in the sense of guaranteeing the working conditions of professionals and the qualification of assistance to RAPS users (Batista, 2016; Batista et al., 2018).

Added to this picture is the fragility of the participants' employment relationships, characterized almost exclusively by undocumented contracts with municipalities. The absence of public tenders and the precariousness of the bonds and working conditions were reported as aspects that hinder their work in the RAPS and can cause these occupational therapists to be dissatisfied with their work, making it difficult for them to stay in the services and compromising the quality of care provided. The profession's representative bodies could play a central role in the fight for better working conditions for these occupational therapists, promoting dissemination and mobilization actions with public bodies to open vacancies; however, they offer occasional support to the challenges posed by the day-to-day activities of the RAPS.

The number of occupational therapists working in RAPS in Paraíba is incipient; the last monitoring report of the network's services shows a lower percentage of occupational therapists, when compared to other higher-level professional categories. The report mentions only 12 occupational therapists working in the 124 RAPS services, as opposed to 119 psychologists, 115 nurses, 83 social workers, 69 psychiatrists and 33 pedagogues (Paraíba, 2020).

The precariousness of working conditions, which has been perpetuated in state and municipal administrations for decades, is aggravated by the scenario of dismantling public mental health policies, which puts resources back into the network and directs resources to services that operate from an asylum and propose the displacement of actions from a territorial and community care to an exclusive, restricted treatment that violates human rights (Associação Brasileira de Saúde Mental, 2018).

Despite this, it was verified that the practices developed in the services most cited by the professionals maintain their relationship with the procedures and actions of the RAPS services, based on the principles of the Psychiatric Reform and Psychosocial Rehabilitation, such as: individual care, reception, groups, Unique Therapeutic Project (PTS), team meetings, crisis management and workshops.

All of the participants pointed to welcoming as a care strategy carried out. This practice consists of humanized listening beyond the demand brought by the user and availability to strengthen the bond during the course of the intervention. Services must develop means of welcoming in all phases of the care process and not just in times of crisis or when users enter the services, since it promotes spaces for listening and exchanges, as well as the expression of interests and needs. When it does not happen, it becomes difficult to create a bond, significantly affecting the user's care process (Franco et al., 1999).

The user's access to the service and the team's accountability must occur in the most agile and humane way possible, and in a way that is sensitive to the demand presented and formulated by the user when spontaneously seeking the service or being referred to it. In welcoming practices, therapeutic processes must be established that formulate the first responses to the needs identified together with the user and continue creating life qualification strategies facilitated by the team and led by the user (Mângia & Muramoto, 2006).

Crisis management was also mentioned as a practice developed by approximately 70% of the research participants in their respective services, mainly by occupational therapists in the metropolitan region. Crisis situations correspond to severe acute psychiatric symptomatology; interruption of ties with family members and/or social activities; rejection of interventions, however, with acceptance to maintain contact with the team; and critical situations in the family and/or social context. Strategies such as approximation, presence, and availability of the team to create and strengthen bonds, identifying and intervening in needs, mediating contacts, dealing with conflicts, can lead to a new context of relationships and opportunities. Occupational therapy acts in the production of movements and strategies of support, protection and problem solving that contribute to overcoming situations that have allowed the manifestation of the crisis or the permanence of the user in situations of fragility and vulnerability (Mângia, 2002; Nicácio & Campos, 2004).

By assuming the person and their needs as the object of the therapeutic action and not the disease and the symptoms of the crisis, the therapeutic action becomes more complex and must seek to apprehend and invest no longer in the containment of the symptoms, but in the creation of possibilities for transformation, growth and changes capable of re-dimensioning the person's existential situation, as a whole (Mângia, 2002, pp. 131-132).

It was highlighted, in the participants' reports, the holding of groups and workshops, in which they proposed activities that promoted the autonomy and independence of users, including activities that could generate income for them. A group is much more than a collection of people, as it enhances meetings, and the occupational therapist is a professional with the ability to facilitate group activities and lead them in a way that produces concrete meanings for the individuals who participate in them, based on their needs (Gozzi, 2012; Silva & Araújo, 2013).

Part of the mentioned groups was being carried out in partnership with other service professionals. When actions are developed interprofessionally and collaboratively between different team members, users are the greatest beneficiaries of interventions (Gozzi, 2012).

In therapeutic workshops developed at CAPS, the occupational therapist directs care to individual, collective, contextual, and territorial aspects that involve users (Silva & Araújo, 2013). Within the scope of income generation, it can contribute to the processes of (re)insertion of people who are excluded from the world of work and/or to outline new perceptions of the subjects about themselves, promoting satisfaction and personal fulfillment and implementation of projects of life (Bregalda & Lopes, 2011).

Another action often mentioned by the professionals was the Singular Therapeutic Project (PTS). This practice is defined as a care strategy planned through actions structured and developed by a multidisciplinary team and established from the individual's uniqueness, and can also be directed to a family, a collective or a certain situation experienced by a territory, considering their needs and their social context. Based on this singularity and the demands placed by the individual and identified by the team, short, medium, and long-term goals are established, which must be carried out by the user with the support of professionals, who are divided into responsibility for monitoring and facilitating the achievement of these goals. The construction of a PTS must consider the individual in psychological distress, their family members, and their social networks, in a constant process, integrated and established in actions aimed at developing independence, protagonism and social inclusion (Boccardo et al., 2011).

In this context, professionals from different areas often use common strategies, such as listening, talking, and welcoming. However, an individual can be understood and approached in different ways in the same service, which reinforces the essentiality of dialogue and knowledge sharing between team members, enhanced when the services adopt the construction of the PTS as part of the organization of the work. Some obstacles that can be mentioned related to realize the work are: the lack of spaces to discuss the PTS with the user and their family; the team's resistance in predisposing itself to understanding and assisting the user's demands; the scarcity of records in the medical records; professional training incompatible with the assumptions of the new care policy and staff turnover (Barros, 2010; Filizola et al., 2009).

Occupational therapy, by acting in the construction of PTS with the other professionals of the teams they are part of, proposes and develops interventions that invest in processes linked to the daily life and life projects of the users. It is realized by mediating process related to new meanings to the relationships with their occupations, with themselves and with the people around them, reducing the effects of social segregation and expanding their possibilities of exercising citizenship (Ferigato & Silva, 2016).

In a survey carried out with occupational therapists working in CAPS in the city of São Paulo, which sought to identify how these professionals understand the specificity of their work, the participants mentioned several common practices, shared with other professions, referring to the interdisciplinary nature of the work of the team, sharing responsibility for users' therapeutic projects and common goals related to their social inclusion. As specificity, they affirmed the property of occupational therapy in observing and organizing activities in the CAPS and in other places of the daily life of the users, from a specific perspective on the activity (Juns & Lancman, 2011).

This research showed that occupational therapists act as important facilitators of the activities developed in the RAPS, in accordance with the proposals of ordinances and public mental health policies and exercise their professional practice from the performance of activities that have meaning for the assisted subject, and/or enable the construction of new meanings that support their existence in the world. Occupational therapy has the potential to transform action, together with people in psychological distress, into ways of favoring their social role, precisely because it has human activity as its main tool of intervention, produced in the daily lives of subjects. In addition, training and work in occupational therapy are in line with the principles and objectives of Psychosocial Rehabilitation, in the sense of social inclusion based on socializing, exchanges, the exercise of contractuality in different life scenarios and circulation through the territory (Almeida & Trevisan, 2011; Morato & Lussi, 2018; Silva & Araújo, 2013).

Conclusion

Investigating the role of occupational therapists in RAPS in Paraíba showed the low number of these professionals in state services during the study period, as well as their concentration only in Psychosocial Care Centers. The performance of this professional in the field is at the origin of the first care efforts for populations in mental suffering and has been accompanying the movements and achievements of the Psychiatric Reform. The performance of occupational therapists has been of fundamental importance in bringing contributions such as those mentioned by the participants: direct intervention in people's practical lives, integration in meaningful activities for them, help to find new meanings and ways of performing occupational roles, re-signification of routines, consideration of occupations in the construction of unique therapeutic projects and promotion of autonomy in self-care activities.

It is necessary to include occupational therapists throughout the RAPS in Paraíba, including Residential Therapeutic Services, Community and Culture Centers, Reception Units, full care beds in General Hospitals and CAPS III, Street Offices and professionals linked to the Back Home, among others.

Considering the limits of a survey whose data were collected virtually during the Covid-19 pandemic, when many services and teams experienced unexpected situations that were difficult to manage, the results possibly revealed only part of the facets of the daily reality faced by professionals. However, aspects related to the precariousness of bonds and working conditions, the scarcity of resources to carry out the interventions, combined with little knowledge and, consequently, the little appreciation of the performance of occupational therapists by managers, possibly reduce the reach and the quality of assistance provided to the population. In this direction, facing the diary challenges, it was also verified that the professionals eventually feel supported in the face of daily challenges by the representative bodies of the profession.

It is important to emphasize that the researchers' definition of what it would mean to be occupational therapy “a profession understood and valued” was not explained in the questionnaire, and that, therefore, the answers were given by the participants according to their understanding of these terms. The specific functions of Representative Entities were not detailed in the questionnaire either, nor was the discussion deepened with the participants about their expectations regarding the support offered by these institutions, which points to limitations of this study and an important agenda for debates on this topic.

The gaps identified by the professionals in their graduate training to work in the field of mental health have mobilized the research participants to improve themselves through continuing education activities, specializations, and master's courses. Their commitment has been recognized and valued by families, users and other team professionals, the main agents involved in the production of community life, demonstrating that occupational therapists are an integral part of this process of welcoming, coexistence and inclusion of vulnerable people and weakened by their condition of mental suffering.

• 1
  Data on the Return Home program and Mental Health Beds in General Hospital were not included in the study, as they are not yet being monitored by the state’s mental health coordination, which makes it difficult to access services and identify professionals that make up teams.
• How to cite: Mata, C. C., Bregalda, M. M., Freitas, R. O. S. N., & Veloso, V. C. F. (2023). Occupational therapists’ performance in the Psychosocial Care Network in a brazilian northeast state. Cadernos Brasileiros de Terapia Ocupacional, 31, e3484. https://doi.org/10.1590/2526-8910.ctoAO267034842

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Edited by

Section editor

Profa. Dra. Ana Paula Serrata Malfitano

Publication Dates

• Publication in this collection
  04 Dec 2023
• Date of issue
  2023

History

• Received
  23 Dec 2022
• Reviewed
  28 Apr 2023
• Reviewed
  29 May 2023
• Reviewed
  05 July 2023
• Accepted
  10 July 2023