Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
The Psychosocial Care Center in the everyday lives of its users*
El Centro de Atención Psicosocial en el cotidiano de sus pacientes
Cíntia NasiI; Jacó Fernando SchneiderII
MS in Nursing. Doctoral Student, Federal University of Rio Grande do Sul, Nursing
Graduate Program. Porto Alegre, RS, Brazil. firstname.lastname@example.org
IIRN. PhD in Nursing. Professor, Federal University of Rio Grande do Sul, Nursing School, Nursing Graduate Program. Porto Alegre, RS, Brazil. email@example.com
The objective of this study was to understand the everyday lives of users of a Psychosocial Care Center (CAPS, Centro de Atenção Psicossocial). This is a qualitative study, with Alfred Schutz's phenomenological sociology as the theoretical framework. The studied field was a CAPS located in Porto Alegre, and the interviewed subjects were 13 users. Data collection was performed between April and June 2008, through interviews performed using a guiding question. The comprehensive analysis of the subjects' testimonials resulted in five concrete categories, and this article reports on the category named: Users consider the CAPS to be a dimension of their everyday life. Through this research it was possible to understand the conceptions that users have about their everyday life, showing that they are re(acquiring) social living in the various social environments. In conclusion, besides providing care, the CAPS are promoting the psychosocial rehabilitation of their users.
DESCRIPTORS: Mental health; Rehabilitation; Mental Health Services; Psychiatric nursing; Deinstitutionalization.
El estudio objetivó comprender el cotidiano de pacientes de un Centro de Atención Psicosocial (CAPS). Estudio cualitativo que utilizó como referencial teórico-metodológico la sociología fenomenológica de Alfred Schutz. El campo de estudio fue un CAPS en Porto Alegre, y los sujetos entrevistados consistieron en 13 usuarios. La recolección de datos se realizó entre abril y junio de 2008, mediante entrevista con pregunta orientadora. En el análisis comprensivo de los testimonios, emergieron cinco categorías concretas. Este artículo se explaya en la categoría denominada: Los usuarios consideran al CAPS como una dimensión de su cotidiano. Con esta investigación pueden comprenderse las concepciones que los pacientes tienen acerca de su cotidianeidad, demostrando que están (re)adquiriendo la convivencia social en diversos espacios de la sociedad. Se considera que los CAPS están promoviendo, además de atención, la rehabilitación psicosocial de sus pacientes.
DESCRIPTORES: Salud mental; Rehabilitación; Servicios de Salud Mental; Enfermería psiquiátrica; Desinstitucionalización.
This study addresses the routines of Psychosocial Care Center (CAPS)(a) patients. The modality of this service represents the reorientation of the mental health care service from the asylum model that focused on mental disease, where the mental facility is the main means of treatment, to a psychosocial model that focuses on the individual in suffering and who is included in a given social group, whose care is based on substitutive services, organized into a mental health care network.
This change in the care model was initiated with the Brazilian psychiatric reform in the 1970s, which is characterized by a process that questions the traditional psychiatric model, centered on asylums and almost exclusively marked by the role of one health worker, the psychiatrist. Such a movement seeks to re-direct the care model so that individuals are deinstitutionalized, which implies not only the creation of services to replace the asylum model but also the adoption of new ways to see and deal with madness.
Psychiatric reform seeks to adopt the notion of psychosocial care, which encompasses a broader view of mental health care, with the inclusion of different fields of knowledge considering patients as essential social actors(1). In this context, psychosocial care includes a set of theoretical/practical, political/ideological and ethical actions guided by the objective to replace the asylum model and the psychiatric paradigm itself, welcoming innovations in the field(2).
The CAPS is one of these innovations that seeks to replace the asylum model with a theoretical and technical perspective other than that of traditional psychiatrics. Its assumptions highlight care delivered to individuals in psychiatric suffering, as well as psychosocial rehabilitation, seeking to promote citizenship and the level of autonomy and social interaction as much as possible.
Psychosocial rehabilitation is a strategy that implies changing the entire policy of mental health services and involves professionals, users, families of users and the community in general. Rehabilitation is a reconstruction process, an exercise of citizenship and contractual relationships in three scenarios: habitat, social network and work as social value(3).
Reinstating citizenship for these individuals as well as achieving and ensuring the maintenance of people's rights is a challenge in Brazil, though essential in mental health when a change in the paradigm is proposed, when one removes the focus from the disease and broadens the field of interventions to the individual existence and suffering(4).
It is important, especially for people who recently entered the service or even for those who have chronic mental disorders, that CAPS not only offer means for individuals to socially interact but also enable the patients themselves to (re)construct/strengthen their relationships and bonds established in their social milieu, so they do not become dependent on this single type of service. These individuals should become independent, or access varied entities in society. We are all dependent individuals, however, some users excessively depend on a few relationships, which ends up reducing their autonomy. Hence, users can become more autonomous as they become increasingly dependent on the most entities as possible, enlarging their possibilities of establishing new standards and a new order for their lives(5).
Given our academic and professional experience with people in psychological suffering and also given the importance we attribute to the structuring of services that replace the asylum model, especially CAPS, certain concerns arose concerning the elements that constitute the everyday lives of users of this type of service.
This investigation concerning the everyday lives of users of one CAPS is relevant since the health team should, while working with mental health care, enable users to reinvent their lives in their most routine aspects, since individuals experiencing psychological suffering are mainly deprived of an everyday life(6).
Therefore, as nurses working in the psychosocial field, the motivation to conduct this study was to understand what users do when they are not in the service, which social spaces do they circulate in? Another objective was also to understand how the service helps users to keep non service-related relationships. Are these individuals interacting with society or do they remain in a certain social isolation within the service?
The guiding questions include: did changes occur in the users' everyday lives after they entered the service? Did the users begin to engage in new activities in the community and attend new places after they entered the service? Do CAPS facilitate the psychosocial rehabilitation of users?
The relevance of this study is related to the support it can provide to mental health teams to identify the understanding of users concerning their everyday lives after they entered the service, and also to enable the team to reflect on how they work, supporting the potential restructuring in their work necessary in mental health care.
This study sought to understand the everyday lives of users from a Psychosocial Care Center from the perspective of Alfred Schutz' Phenomenological Sociology.
We opted to use Alfred Schutz' phenomenological sociology to understand the everyday routine of users attending a CAPS. Phenomenological sociology listens to the individuals considering their subjectivity in the attempt to reveal the essence of the phenomenon.
The use of the theoretical-methodological framework of Schutz' phenomenological sociology is useful in studies addressing mental health, especially those focusing on the strengthening of the psychiatric reform because the purpose of both mental health care and phenomenological sociology is to give voice to the individuals taking into account their singularities, desires and subjectivities. It is necessary to focus on these individuals in order to understand their experiences in everyday life, which is an inter-subjective world, shared among like individuals.
The framework of world of everyday life, proposed by Schutz, is adopted in this study because we believe that it is in everyday life that individuals' experiences and relationships occur. The world of everyday life is seen as natural, a social world and is the scenario that imposes limits on human actions. The individual not only acts inside the world but also upon it. The world of everyday life is the region of reality one can intervene upon and change while acting in the face of one's own body. Only in this sphere can the individual be understood by her/his fellows and interact with them(7).
This qualitative study with a phenomenological approach is part of a master's thesis. We used Alfred Schutz' phenomenological sociology as our theoretical-philosophical framework to catalogue the participants' experiences concerning a given phenomenon. The phenomenological trajectory seeks to establish a direct contact with the phenomenon, and to understand such a phenomenon one needs individuals to describe their experiences(8).
This study was carried out in a CAPS located in Porto Alegre, RS, Brazil because this service receives students for supervised training and the Federal University of Rio Grande do Sul also performs services directed to the community.
A total of 13 patients of the CAPS were randomly chosen to participate in the study and be interviewed. All the interviews were held at CAPS. Of the 13 interviewed users, nine were women and four were men, ages ranged from 26 to 56 years old, eight were single, five were separated and one was married. In relation to the regimen of treatment provided at the CAPS, ten were semi-intensive and three were included in the non-intensive treatment.
Data collection occurred through phenomenological interviews whose guiding question was: Would you tell me what you do in your everyday life? Interviews were recorded on cassette tape and later fully transcribed. Interviews were conducted between April and June 2008. The interviews were carried out within the phenomenological framework: individuals were listened to without being judged according to an understanding approach. It is worth noting that we already had established a close relationship and bonds with the interviewees given our professional and academic activities carried out with them, which favored the relationship between researcher and studied individuals at the time of the interviews.
Data collection ceased when a considerable amount of repetitive information was collected in the interviews with the studied individuals. In order to keep confidentiality, the interviewees are identified by the letter E followed by the number that corresponds to the order of the interviews (from E1 to E13). The names of the professionals at the service mentioned by the participants were replaced by the term therapist.
In order to unveil the participants' experiences concerning their everyday life, information that emerged in the interviews was analyzed from the perspective of the phenomenological framework according to the following steps(9): a) reading of reports; b) identification of the guiding question within the report and search for statements that presented meanings; c) reflecting on the meaningful statements to describe what was expressed; d) search for convergent units of meanings through phenomenological analysis, gathering meaningful statements to construct thematic units; e) non-specific and intermediate understanding of reports based on thematic units; f) comprehensive interpretation in order to reveal the understanding acquired concerning the users' everyday life.
After gathering the convergences that emerged from the interviews, five concrete categories expressing what users experience in their everyday life were constructed: experiencing psychological suffering; performing diverse activities; considering the CAPS a dimension of their everyday lives; highlighting work as having intrinsic relevance; and establishing social relationships. The information that emerged in the participants' reports was discussed according to framework developed by Alfred Schutz, in addition to literature in the mental health field to enrich it. In this study, we opted to focus on the concrete category in which the participants consider the CAPS to be a dimension of their everyday lives.
Ethical aspects concerning research involving human subjects were complied with. Confidentiality and anonymity of the participants were ensured through free and informed consent forms. The project was approved by the Ethics Research Committee at the City Health Department of Porto Alegre (Protocol No. 001.006314.08.2).
Taking into account that the participants consider their CAPS to be a dimension of their everyday lives, this routine is seen as a world of everyday life, which according to Alfred Schutz, is the area of reality in which one can intervene and change while acting upon it, in consideration of one's body. Only in this sphere can the individual be understood by and interact with her/his fellows. The world of everyday life is an essential and eminent reality for the individual(7).
Social relationships and dimensions of social organization permeate the social world in which the individuals' everyday life occurs. When talking about their daily lives, the participants point to the CAPS as a meaningful dimension in their lives, reporting that the service is very good and a place in which they obtain help and feel safe in relation to the treatment, as seen in the following excerpts:
[...]so I feel well when I come here (E3).
[...]I'm feeling very well here [...]I'm very happy here (E12).
In addition to the participants' reports that they feel well at the service, they acknowledge that the care provided in this modality of service contributes to reducing hospitalizations, as is identified in E1's report:
I don't know what would become of me if it weren't this service. This is really good for me [...] It is good for me, I don't need to go to the hospital, so this is a good thing for me [...] (E1).
Care provided in the services according to the psychosocial models such as a CAPS means that users do not need hospitalization, since hospitalization within this model is the last option among therapeutic resources, giving priority to outpatient services found in the users' community. Users also talk about the importance of the service's workers, considering them essential to their treatment and with whom they establish bonds and relationships of trust.
[...]people here are very nice [...] I don't know what my life would be like if it weren't for my therapist [...] (E2).
[...]the meaning a psychiatrist has to me is very important, the nursing people [...] the social worker, psychologist, psychiatrist [...] when I need it, when I'm not well, they help me a lot [...] (E12).
In addition to these manifestations concerning the importance of the team of professionals working at a CAPS represent for those in psychological suffering, the interviewees also point to the need for the user him/herself to have willpower and help him/herself during treatment.
[...] you have to have much willpower to self-care, it doesn't help coming here to do everything if you don't want it [...] (E3).
[...]The help of the physician is important, but it is important you help yourself as well (E12).
The interviewees report that they participate in diverse therapeutic workshops at CAPS and show they like this participation and consider it important, as the following excerpt reveals:
[...] I come to the workshops, there's one workshop every day [...] I like the one from Mondays best, it's about cooking, we cook, we bring recipes [...] and we develop, there are days there is pizza, other days there is very tasty stuff and I like it very much [...] there's also the beauty workshop that helps us to value ourselves. It is a workshop that gives you self-esteem, a manicure, you have your hair washed [...] the workshops are very nice, I like them (E2).
Users like a diversity of activities provided in the therapeutic workshops, which can contribute to reorganizing their lives.
Some users also report the inter-sector link the service maintains with other government entities, such as the cooperation the service maintains with shelters in the city. Such cooperation appears in the following excerpt:
I'm in a shelter, right now I'm in a shelter [...] but there's a connection with a CAPS where I receive treatment (E11).
Hence, CAPS appears as one of the dimensions of the everyday lives of this mental health service's users. The service is reported as a place that provides good care, preventing users from being hospitalized, assuring them in relation to the treatment provided. The users report satisfaction with the CAPS health team with reports that manifest trust and bonds established with them. Additionally, important elements of CAPS also emerge in the reports, such as the therapeutic workshops and the cooperation existing with other services such as shelters.
CAPS represent a reorientation of the mental health care model from the asylum model, which focuses on mental disease with the psychiatric hospital as the main route of treatment, to the psychosocial model, which focuses on the individual in suffering, considering this individual in a given social group. With treatment based on substitutive services, organized in a mental health care network, CAPS-based treatment has contributed to easing the psychological suffering of its users, generating changes in everyday life and enabling them to resume their lives.
The users in this study see the CAPS as a place that provides outpatient care in the community where treatment is not based on hospitalization. Hence, the role of CAPS in the lives of these individuals is identified as a service that allows users to be cared for in their homes and keep contact with their families and community without segregating them in psychiatric facilities.
The creation of services like CAPS that replace the asylum model was initiated with the deinstitutionalization process, which is a practical work of transformation that disassembles the existing institutional solution, the asylum, in order to then disassemble and reassemble the problem. The way people are cared for is transformed so that suffering is transformed, since the treatment comes to be seen as a complex set of daily strategies used to cope with the problem, taking into account the individuals' suffering existence (10).
Deinstitutionalization is one of the goals recommended by the CAPS, which is based on a process of deconstruction of the asylum model, proposing various elements that enable the construction and creation of new perspectives of life and subjectivity. CAPS have been effective in replacing long-duration hospitalization with a treatment that does not isolate users, rather seeking to re-include users suffering psychologically in the family, in the community, and in productive life through the recovery of their self-esteem and reestablishment of bonds(11).
Users refer to the importance of service professionals, considering them to be individuals essential to their treatment, establishing relationships of trust and bonds. Establishing bonds means becoming sensitized to the suffering of others, of this specific population. It means permitting the establishment of a process of exchange between users and workers that can ground the user's construction of autonomy. It means to feel responsible for users, integrating them with the community and the service and to become a reference point for them(12).
Some users perceive the work of professionals, how they welcome users, listen to them, and provide attention and support(13). The use of the therapist's Self is essential in the relationship with the individual in psychological suffering, in which listening is one of the elements of this relationship. Listening is established in a face-to-face meeting between the therapist and user, that is, both communicate, sharing the same space and time(14).
The users of CAPS showed the need to engage in their treatment, to have willpower and feel co-responsible for their recovery. Being aware of the need to feel motivated and committed to their treatment is essential for users to avoid becoming passive, merely expecting the intervention of CAPS team. It is essential, especially within the psychosocial model, for users to participate actively in their treatment, be responsible and autonomous.
Another aspect concerning the care provided to CAPS users involves their participation in therapeutic workshops provided by the service, which can be a tool to help them to reorganize their lives. The workshops, as well as work and art, can function as catalysts in the construction of existential territories, in which users can re-conquer their everyday lives(6).
Additionally, the valorization of group activities that encourage and facilitate social interaction is essential to achieve the purposes of psychosocial care, and one should be attentive so that these become both opportunities that enable material construction of goods and subjective construction that enables dialog and social life(15).
The cooperation between CAPS and other sectors in the community, such as the relationship they establish with shelters in the city, are also highlighted. This relationship of CAPS with other services is essential to providing care to individuals experiencing psychological suffering. Enlarging this exchange in the diverse services in the community is necessary to establishing an inter-sector exchange.
Care provided to individuals in psychological suffering needs to be considered beyond the asylum model and extended to the individuals' homes, to the spheres of sports, work, leisure and culture. It shows the need to change the concept of health, indicating the need for a more enlarged care, possibly based on inter-sector cooperation(16).
The cooperation among services in the mental health network with services from other fields is relevant and necessary. Since offering devices related to health is not sufficient, other devices related to culture, leisure, living, justice, social service that enables a greater circulation of individuals in psychological suffering and promoting social re-inclusion and autonomy are needed.
This study examined the everyday life of users attending one CAPS. The purpose was to grasp these individuals' experiences of everyday life. We sought to implement an approach characterized by understanding, not prejudging the individuals according to the phenomenological approach epoché, that is, suspending any kind of judgment.
CAPS are important devices of mental health care configured to be one dimension of the users' everyday lives, though not the only dimension, as was the case in long-duration hospitalizations in psychiatric facilities at the time of the asylum model. Because it is a daily care service, it enables patients to remain in their houses, in contact with family and participating in social life. This modality of service is based on the establishment of bonds among users, professionals and families, which is essential to the construction of individualized and integral care.
The existence of strategies in CAPS, such as therapeutic workshops, turns treatment into a pleasurable event, promoting socialization among the participants and also the development of activities related to beauty and cooking, in addition to treatment. Such workshops, beyond their therapeutic nature, also encourage users to develop such actions not only within the CAPS but also in their homes, which contributes to the exercise of their autonomy in their daily lives.
Another important strategy used by the CAPS is the establishment of inter-sector partnerships with various entities in society, which should be increasingly consolidated as a way to offer integral care to individuals experiencing psychological suffering.
We have verified that care provided in the psychosocial model, especially at CAPS, has enabled users to be (re)inserted into society and participate in diverse social actions, which was not the case when individuals were committed to psychiatric facilities.
We believe this study will encourage health teams and, among these, nursing teams, to reflect on the need to contemplate users of these services in order to learn about their experiences, broadening their perception in order to look at the social reality in which these individuals are found.
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Received: 03/26/2009 *
Extracted from the thesis: "O cotidiano de usuários de um Centro de Atenção
Psicossocial na perspectiva da sociologia fenomenológica", Federal University
of Rio Grande do Sul, Nursing School, Nursing Graduate Program, 2009. (a)
Acronym in Portuguese.
* Extracted from the thesis: "O cotidiano de usuários de um Centro de Atenção Psicossocial na perspectiva da sociologia fenomenológica", Federal University of Rio Grande do Sul, Nursing School, Nursing Graduate Program, 2009.
(a) Acronym in Portuguese.