The Psychosocial Care Center on the users point of view

Abstracts

O presente estudo tem por objetivo descrever o funcionamento de um centro de atenção psicossocial e apreender como os usuários atendidos por esse serviço percebem o processo terapêutico oferecido. Foram realizadas entrevistas semi-estruturadas, com onze usuários de um Centro de Atenção Psicossocial (CAPS), localizado no interior paulista. Os dados foram submetidos à Análise Temática, segundo Minayo. Os temas emergidos, a partir da análise dos dados, possibilitaram a configuração de três temas. No primeiro deles, o usuário percebe o tratamento, sob um enfoque organicista do cuidado, relatado por meio da valorização do profissional médico, na abordagem medicamentosa e o controle dos sintomas. O segundo tema traz a percepção do espaço do CAPS, enquanto cenário propiciador de trocas sociais. E o terceiro tema diz respeito ao processo terapêutico estar voltado à vida cotidiana dos usuários. Com base nesses dados, pôde-se refletir sobre os rumos dos novos dispositivos em saúde mental, os CAPS.

saúde mental; serviços comunitários de saúde mental; desinstitucionalização

El presente estudio tiene por objetivo describir el funcionamiento de un centro de atención psicosocial y aprender como los usuarios atendidos por este servicio perciben el proceso terapéutico ofrecido. Fueron realizadas entrevistas semi-estructuradas, con once usuarios de un Centro de Atención Psicosocial, ubicado en el interior paulista. Los datos fueron sometidos a Análisis Temática, según Minayo. Los temas emergidos a partir del análisis de los datos, posibilitaron la configuración de tres temas. En el primero de ellos, el usuario percibe el tratamiento sobre un enfoque organicista del cuidado, relatado por medio de la valorización del profesional médico, en el abordaje medicamentoso y el control de los síntomas. El segundo tema trae la percepción del espacio del "CAPS", mientras el panorama propiciador de cambios sociales. Y el tercer tema se refiere al proceso terapéutico estar dirigido a la vida cotidiana de los usuarios. Con base en estos datos, podemos ponderar sobre los rumbos de los nuevos dispositivos en salud mental, los "CAPS".

salud mental; servicios comunitarios de salud mental; desinstitucionalización

ORIGINAL ARTICLE

The Psychosocial Care Center on the users point of view¹

Sandra Regina Rosolen Soares^I; Toyoko Saeki^II

^IRN, Master's student, e-mail: [e-mail]

^IIRN, Advisor, Assistant Professor, e-mail: [e-mail]. University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil

ABSTRACT

The present study has as its aim to describe the daily work of a psychosocial care center and to aprehend how the users cared by such service experience the offered therapeutic process. Semi-structured interviews were carried out with eleven users of the Psychosocial Care Center, located in the countryside of São Paulo state. The data were submitted to Theme Analysis, based on Minayo. The themes which came from the data analysis, allowed the configuration of three topics. In the first one, the user experiences the treatment on an organicist focus of the care, assessed by the medical professional value, in the medicine-based approach and the symptom control. The second topic brings the perception of the space in CAPS as a helping scenario of social exchanges. And the third topic is about the therapeutic process as being towards the daily life of the users. Based in these data, we could reflect on the directions of the new facilities in mental health, the CAPS.

Descriptors: mental health; community mental health services; deinstitutionalization

INTRODUCTION

After the military coup in 1964, the official Brazilian mental health policy was based on investments to increase the number of psychiatric beds, multiplying the privately hired network at a time when the entire world was moving towards dehospitalization. Thus, commitment practically consolidated itself as the only mental health care alternative in the country. This health resources was mainly administered by private initiative, without any kind of social control⁽¹⁾.

At the end of the 1970's, society was looking for technically and politically more adequate alternatives to treat mental patients, guided by the principle of deinstitutionalization^*, in which organized segments in civil society incorporated the movement that started in Italy and became known as the Network of Alternatives to Psychiatry, seeking ways to confront the model established in that country. In 1979, the Italian psychiatrist Franco Basaglia visited Brazil and the I National Meeting of Mental Health Workers was held in São Paulo. These were two landmarks in the discussion of Mental Health Policies in Brazil.

This scenario gave rise to the Psychiatric Reform Movement^**. Based on the country's redemocratization process, this movement criticized psychiatric knowledge and institutions, as well as the asylum infrastructure.

In response, the State incorporated this criticism and organized the I National Mental Health Conference, in June 1987, as a consequence of the 8^th National Health Conference. In the same year, the II National Meeting of Mental Health Workers was held in Bauru (SP), which ratified changes in the ethical-theoretical principles of psychiatric care and created the Anti-asylum Fight Movement, under the motto For a society without asylums.

From that point onwards, the Anti-asylum Fight Movement, constituted by different social actors - users, relatives, workers and intellectuals - appointed the need for a broader political action strategy, establishing a dialogue with the population about madness and its aspects, with a view to reconstructing the relations between mad people and society.

Influenced by the Italian transformation model, the Anti-asylum Fight Movement indicated deinstitutionalization as a fundamental premise in service reorganization and mental health practices. Thus, the guiding issue was not the modernization of institutions, but the creation of new spaces, with other approaches.

In the legislative area, the mobilization of civil society, allied with the political society, led to the discussion of Law Project No 3.657/89 in the Brazilian National Congress, proposed by federal congressman Paulo Delgado and related to the progressive extinction of asylums and their replacement by other care resources (Day Hospitals, Psychosocial Care Groups and Centers - NAPS and CAPS, Protected Homes). This project, sanctioned and issued as Law No 10.216 in April 2001 on the basis of a progressive understanding of care, was a tool used by the organized society to reform psychiatric legislation and consolidated the discussion process about mental health and psychiatric institutions.

In 1992, the II National Mental Health Conference took place. Participants included users, workers and outsourced professionals. Discussions included issues like care municipalization and citizenship of mental patients and ratified criticism against the hospital-centered model from the ethical, technical and political perspectives.

Law No 10.216/01, from April 2001, lists the rights of mental patients, strengthening these subjects' social inclusion and regulating a new psychiatric care policy in Brazil.

In December 2001, the III National Mental Health Conference occurred. In its final report, this conference reaffirmed the conquests achieved as a result of earlier conferences, Law No 10.216/01 and Health Ministry decrees that regulate mental health care in Brazil. This consolidated the community service strategy (CAPS) as priority equipment in mental health care organization.

Furthermore, in order to regulate and reorganize new practices, decree No 336/GM was issued in February 2002. This document distinguished between the CAPS, ranking them in terms of complexity and range. Thus, the CAPS were defined as strategic services to replace psychiatric hospitals.

Hence, open services emerged as a counterpoint to closed institutions and are aimed at "breaking with the commitment tendency of the asylum ideology; keeping users at the institution for the shortest time possible; stimulating users' permanence in the family and social nucleus; and making viable a life project that is compatible with each individual's potentialities"⁽⁴⁾.

However, during this deinstitutionalization movement, in view of the importance of its events and innovations, new problems arose. One of these put forward that the fact that a service is external or open does not guarantee its non-asylum characteristic, and that the service structure, professionals' actions in care for mental patients should be investigated, with a view to diagnosing remnants of asylums⁽⁵⁾.

In this perspective, the CAPS Prof. Luiz da Rocha Cerqueira in São Paulo City and the Psychosocial Care Group in Santos stand out as forerunners in this mental health care modality.

Nowadays, a comprehensive network of therapeutic offers is functioning, aimed at replacing the hospital-centered model, such as: psychosocial care centers, psychiatric beds in general hospitals, social centers, work cooperatives, therapeutic residences, among others. In general, these new services are characterized by the use of a broad and complex set of therapeutic technologies and psychosocial practices, aimed at maintaining patients in the community.

The ethical commitment to guarantee quality care to patients with mental disorders, based on premises like singularity, right to health and to a dignified life, has driven innovative projects, breaking with the reclusion model. These projects include the Psychosocial Care Centers (CAPS). These experiences under construction are spread out across the country nowadays and should constitute innovative services, guaranteeing a "production space for new social practices to cope with madness, mental suffering, diverse experience; to construct new concepts, new forms of living, of inventing life and health"⁽⁶⁾.

This historical context also contains the Psychosocial Care Center (CAPS) "Espaço Vivo" in Botucatu, which has been active since 2000. One of the goals of this service is to implement the psychiatric reform principles, founding its practices on respect for singularities and on the defense of life. The institutional axis guiding its interventions focuses on the premises of Psychosocial Rehabilitation, not as a set of techniques, but as an "ethical requirement"⁽⁷⁾.

Thus, this study aims to apprehend how users attended at the CAPS "Espaço Vivo" perceive the therapeutic process that is offered.

METHODOLOGY

This study was carried out by means of the case study method, because it can provide a more detailed and focused view on the study context and because the objective of this research approach is to analyze a unit in depth⁽⁸⁾.

This study aimed to approach mental patients' experience with their understanding of the treatment offered at a mental health care service, in this case the CAPS "Espaço Vivo", with a view to obtaining in-depth knowledge about the study object, without ignoring that this approach is incomplete and that its conclusions are temporary.

However, in favoring knowledge about a delimited reality, the case study permits, based on its results, the formulation of hypotheses for further research⁽⁸⁾.

Eleven male and female users participated in this study. Their selection was based on the following criteria: 1. insertion in the CAPS "Espaço Vivo" and attending the service in the semi-intensive regime at the time of data collection; 2. ability to communicate and understand the research and 3. agreement to participate, by users and their responsibles, in accordance with Resolution 199/96.

This research was approved by the Ethics Committee at the Faculty of Medicine - UNESP.

Semistructured interviews were elaborated on the basis of a script with the main questions. We made an appointment with the users and the researcher realized the interviews individually, at the service. Users' names were omitted and replaced by the names of the main characters in a theatre piece performed by the CAPS.

After data collection, the obtained material was submitted to Thematic Analysis, which "consists in discovering the units of meaning that make up a communication, whose presence or frequency means something to the analytic objective that is aimed for"⁽⁹⁾.

RESULTS AND DISCUSSION

The results were grouped in three large themes that emerged from the research subjects' testimonies: The Organic Influence in care delivered by the service; The CAPS as a scenario that favors the network of social relations; and finally, Therapeutic Work directed at users' daily life.

The first theme contains categories like the valuation of medical professionals, the emphasis on medication therapy and the importance of the therapeutic approach to users' symptoms.

These questions allude to the discussion about the evolution of psychiatry. This knowledge's trajectory was marked by conceptual influences, based on an organic view of their etiology, on sign and symptom management and on the prognosis of mental diseases, which marked its action.

These concepts were introduced in psychiatric practice from the 20^th century onwards as, during the previous century, the details of the human body were practically unknown. The advancement of scientific medicine made it possible to understand physiologic processes, thus attracting attention to increasingly smaller parts of the human machine⁽¹⁰⁾.

At the end of the 1950's, different psychotropic drugs were introduced in psychiatric therapy, including tricyclic antidepressive medication and benzodiazepines, which were the "indirect responsible for the integration of psychiatry into internal medicine"⁽¹¹⁾.

These concepts, marked by traditional practices, still influence professional actions in new mental health equipment like the CAPS⁽¹²⁾.

And mental illness, from an organic focus, proceeds from the conception that "it is something that occurs 'within' the space of the body. Individuals' subjectivity is discarded, operating a reduction that transforms them into damaged objects"⁽¹³⁾.

The report below exemplifies the organic nature of mental suffering, in accordance with literature findings: So, medication treatment is like that, it's logical that we have mental problems, but these are caused by different motives, which is the person's own brain, there's a fluid missing in the brain. I can't explain it very well, but these drugs fight this deficiency you have, this disease [...] The medication helps the person to replace that deficiency that person has, at the level of the brain, you know, like, organic (Nero).

The above interview demonstrates how a user elaborates his illness. This report reveals the influence of the organic view presented here as a brain deficiency. In this case, this dysfunction is appointed as a cause of mental problems.

Consequently, the medication approach is the most indicated option in this situation, expecting that it will solve the problems and equate the deficiency. That is, according to him, the mental illness is perceived as deficiency, disability and loss. And, thus, professionals and institutions are responsible for providing means to fight these sequelae.

Hence, the report translates the image that being ill is essentially a loss: it means losing abilities, it means losing affective bonds; it means losing. This demonstrates that the disease implies a state of disability, established by the event of losing and by the non-valuation of relations and interrelations between the individual and society.

It is remarkable that, even today, this discourse is rooted in and permeates users' statements, although they are inserted in new services, in innovative institutional devices and, theoretically, constituted by new practices.

Thus, the mental disease, settling in the damaged brain, expects that the treatment offered will be guided by this organic focus. According to this perspective, patients associate the treatment with the professional they consider most adequate for the expected therapeutic actions, seeking solutions for the mental illness.

In this case, physicians were professionally most valued to handle the treatment and the medication approach and, from this focus, to handle the treatment offered by the CAPS.

From the organic approach, these professionals are valued because, only the doctor knows what's important for the person's health, and only he can do anything about it, because all health knowledge is rational, scientific, based on the objective observation of clinical data"⁽¹⁴⁾.

Another user illustrates this situation, reporting that: [...] And there's also the psychiatrist we talk to at the CAPS and our head moves back in place, you know (Mário).

In this statement, the emphasis on the organic nature of care also stands out, which is very present in users' discourse. However, this issue needs to be problematized better, as this type of treatment should be part of the therapeutic process offered by mental health equipments. However, for users in this research, the approach described here is more important, referring to a more traditional view of psychiatry.

The second category - 'The CAPS as a scenario that favors the network of social relations' - was structured on the basis of how users have perceived and used the CAPS space and how this site has adapted itself to therapeutic actions, in the user/service and user/professional relations as well as in bonding.

Open mental health services, in this case the CAPS, originated from innovative projects that attempted to break with the asylum model in daily practice. Among these projects, emerged at the end of 1980, the CAPS Prof. Luiz da Rocha Cerqueira in São Paulo, the NAPS in Santos - SP and the CAPS "Nossa Casa" in São Lourenço do Sul - RS stand out.

Thus, the work developed in institutions like the CAPS presupposes more competence, availability and creativity in the team than what happens in the traditional psychiatric model, in which therapeutic actions are predetermined and crystallized. And, the psychosocial care service must be a "production space for new social practices to cope with madness, mental suffering, diverse experience; to construct new concepts, new forms of living, of inventing life and health"⁽⁶⁾.

The CAPS "Espaço Vivo" also constitutes a scenario for contradictions, conflicts, uncertainties and negotiations between users and the team. Reflections and debates about doing and know-how are present on a daily basis.

The report below, by Camargo, shows the still current discussion about psychiatry, its role in social organization and, mainly, about psychiatric care institutions. This CAPS user's discourse may also be shared by many other users, relatives and workers, who are actors in an ongoing process. In this perspective, according to Camargo: The CAPS is a dehospitalization proposal, you know. Outside society, nobody survives, because the human being, he needs other people to survive. So the CAPS, it would be nice if we had a CAPS III here as well, if the places were canceled, if the psychiatric hospital were closed, you know. Because the psychiatric hospital was useful in other times, in government regimes with another mentality, but in this democratic mentality, another CAPS would be needed to attend to the demand, you know (Camargo).

Moreover, according to the report, the CAPS appears as a counterpoint to the hospital, as a service working towards dehospitalization. In fact, the CAPS emerged as intermediary services or, better, as institutions whose complexity intermediated between psychiatric hospitals and the community, delivering care to patients when they were discharged from hospitals, with a view to their passage to community life or avoiding commitment. The CAPS project accepts, even if temporarily, the psychiatric hospital.

With respect to professionals' actions, the interviewees perceive an attitude of listening and welcoming of suffering in the workers. This role is valued as an instrument in the therapeutic process. The interviews offered several reports in this respect: That I needed to give vent to my tensions sometimes and I couldn't, you know. Although I released pressure a lot with other people, but it wasn't the same thing as a professional, you know (Adelaide); Your support to me when I needed it most, it was good at that time. I'm much better now (Loucura); It helped in the care they give me, everything they give me [...] Ah, the care, I felt alone [...] I needed to be with some people, because I wasn't with my sister anymore (Michele).

Users report that they feel support, care and listening and use the meetings with the professionals as opportunities to release pressure, to get relief.

Michele accredits her improvement to the continuous support by the service while her social network was not strengthened. At that time, she felt alone and used the CAPS as a space for meeting and having contact with other people.

In their discourse, the interviewees do not define in what activities or 'places' these 'encounters' happen, where the exchanges and networks are established. Thus, the spaces may have been permeable and may have offered support to users' needs.

These testimonies show that patients have used the service as a first approach and that the established relation continues at the level of care and support. However, this approach has occurred gradually. Throughout the research, we found reports demonstrating that the therapeutic process has moved forward to attend users' needs.

In summary, the CAPS constitutes an opportunity to act in the world again. For these users, withdrawn from production processes and facing decreased or even absent social bonds, participating in the service and entering a network of solidarity and support allows them to recover social bonds in a situation where these bonds are even more necessary.

The last category - 'Therapeutic Work directed at users' daily life' - addressed users' difficulties and facilities to deal with challenges in daily life and how the service's therapeutic practices have adapted themselves in this sense. Thus, "Dealing with daily reality is always an intervention that requires dealing with the concreteness of man, this movement of multiple relations. Daily reality is not a routine, it is not the simple mechanical repetition of actions that lead to doing for the sake of doing. Daily reality is the place where we attempt to carry out our practical transforming activity, it is the social; it is the context we live in"⁽¹⁵⁾ (our italics).

The daily context gives rise to conflict situations, fears, difficulties, abilities and concrete situations of life in care. And it is through these situations that the wires of the therapeutic process are woven. Thus, user and service work together in the search for actual needs and desires in the meaning of treatment.

The discourse of users at CAPS "Espaço Vivo" discloses situations and events they lived and coped with, for which they received support from the service. Through the interviews, reports emerged that point towards therapeutic practices that have helped users to face difficulties in daily life.

The two testimonies below present the importance of this theme to support users' improvement, to take control of themselves, to manage their lives: [...] Ranging from the simplest things, cleaning, doing everyday things, to business. Obligation, appointment, time, it helps a lot. Because I was having difficulties like, with times, I had switched day and night, I couldn't manage to do what I do here and, for ten months now, I already manage. It's not from one day to the other. But I already manage to take a burden off my daughter, a very heavy responsibility for her. (Adelaide) and Today I manage to go to the city, buy what I want, I... if there's a bill I go there and pay it [...] Now, at home, if there's a kitchen, I go there and clean the kitchen, I already help my daughter more, you know, clean a house, like... what I'm able to I'm doing. I think this has already helped me a lot. (Dementina)

These statements show that therapeutic work starts with the difficulties established in and related to the performance of daily activities. The reports also reveal that the therapeutic process - which starts with body care aspects - then increases the complexity of interventions, focusing on daily activities, but still in a protected space, the CAPS in this case. Later, these activities are transferred to the respective actual spaces, in each patient's daily context.

The interviewed users perceive the performance of domestic chores as the achievement of higher levels of autonomy, and also as important activities with respect to relatives.

Thus, Adelaide reports that her improvement also brought about a decrease in the "responsibility" she was delegating to her daughter.

Dementina, on the other hand, perceives that her improvement made her share housework with her daughter.

The therapeutic work focused on users' daily activities is also valued as one of the psychosocial rehabilitation tools. The centrality of this question turns the service into an important innovative device in mental health care and "daily practices, in this context, are considered as essential components for users' psychosocial rehabilitation. And, through this rehabilitation, the consequent achievement of citizenship. The differentiation between treating people with their own needs, their subjectivity appears as an important differential in comparison with the centralization in the treatment of the disease"⁽¹⁶⁾.

The analysis of these findings shows that the service has focused daily practices in its work. The therapeutic process is based on responsible care, valuing the subjects' abilities, difficulties and needs. The users perceive the result of the therapeutic contract as an improvement in their quality of life and autonomy. To the extent that these issues are valued and addressed, the service gets closer to the premises of rehabilitation. However, organic approaches like the ones analyzed above are still present. This contradiction may be inherent in the daily construction process of new services, entailing, every day, dilemmas and confrontations in dealing with mental suffering.

FINAL CONSIDERATIONS

This qualitative study aimed to identify and analyze the treatment offered at the Psychosocial Care Center "Espaço Vivo" from the perspective of users attended by the service. Based on the collected data, we could apprehend that the care emphasized from the organic viewpoint appears as the strongest point in the service's therapeutic process. In this perspective, the physician occupies a privileged place in the service, determined by psychiatric knowledge. Thus, the interviewed users perceive the following instruments needed to perform this work: the use of psychotropic drugs to relieve symptoms and the doctor's appointment.

However, the CAPS has also offered approaches characterized in the "therapeutic" range, that is, guided by singularity, listening and welcoming. In the interviewees' statements, the welcoming and listening attitude frequently appears as present in service workers. This characteristic is identified as a current style of work and practice at the service: the human relation, welcoming, respect, affection and support the users are treated with. These premises supporting the institution's actions are in line with the Psychiatric Reform.

Users perceive that talking and being listened to relieves their suffering, and the establishment of this relation is a form of help.

Another important aspect in the user's relations with the service was bonding. The interviewees indicated that the professionals have attempted to "look" at the patients' life context, even when treatment is discontinued. Treatment frequency and continuity are also considered as ways of bonding, strengthening the trust and help relation.

We believe that the realization of daily activities should be inserted as one of first objectives in care contracts and, in a wider sense, in psychosocial rehabilitation projects.

However, once these immediate needs have been overcome, the focus needs to widen to the complexity of subjects in suffering, reaching the concreteness of their lives and relations.

Recebido em: 5.8.2005

Aprovado em: 11.7.2006

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1

Paper extracted from the Master's Thesis

*

Understood as a critical-practical process that reorients institutions, knowledge, strategies towards existence-suffering, or also considered as the construction, invention of a new reality(2)

**

In Brazil, this Movement adopts the concepts of Italian Democratic Psychiatry. The main goal is to humanize care for mental patients, improve the conditions of mental health workers, create a network of extra-hospital services to replace the hospital-asylum network and revise excluding knowledge and practices

⁽³⁾

Publication Dates

• Publication in this collection
  09 Feb 2007
• Date of issue
  Dec 2006

History

• Accepted
  11 July 2006
• Received
  05 Aug 2005