GROUP COORDINATION IN A MENTAL HEALTH CARE INTERVENTION: COMMUNITY MENTAL HEALTH GROUP ¹

ABSTRACT.

The Community Mental Health Group (CMHG) is a mental health care promotion program, open to the community and inspired by the goals of Psychiatric Reform. The group has been developed over more than 23 years, through its practice, systematic observation and research. This study aimed to understand the role of the group coordinator within this group modality. The corpus of the research was constituted from six audio-recorded group sessions and transcribed in full. An original analysis was outlined in which all the coordinator's interventions were described, analysed and contextualized concerning the moment and development of the group session. Common axes have been identified, which characterize the interventions: ‘The framework in the Community Mental Health Group’, ‘The look at the human gesture in the contributions’, and ‘Coordinator's personal participation’. It was observed that the CMGH's coordination is related to the proposal of the activity and its theoretical, philosophical and empirical foundation, inspired by Classical Phenomenology. The framework, interventions and coordinator's participation appeared to foster the creation of an intersubjective care space, from a horizontal perspective, based on the task of recognizing significant daily experiences in the human being's maturing path. In this sense, this research highlights the relevance of the in-depth study of group practices’ aspects, such as group coordination, as a way of better describing and understanding them.

Keywords:
Mental health; groups; therapist role

RESUMO.

O Grupo Comunitário de Saúde Mental (GCSM) configura um programa de cuidado e de promoção de saúde mental, aberto à comunidade e alinhado aos princípios da Reforma Psiquiátrica, desenvolvido ao longo de mais de 23 anos, mediante a prática, a observação sistemática e a investigação científica. O objetivo deste estudo foi compreender o papel do coordenador nesta modalidade. O corpus da pesquisa foi constituído a partir de seis sessões grupais áudio gravadas e transcritas na íntegra. Foi delineado um percurso original de análise, em que todas as intervenções do coordenador foram descritas, analisadas e contextualizadas em relação ao momento e desenvolvimento da sessão grupal. Foram identificados eixos comuns às intervenções, que as caracterizam: ‘O enquadre no Grupo Comunitário de Saúde Mental’; ‘O olhar para o gesto humano nas contribuições’; e ‘A participação pessoal do coordenador’. A partir destes, observou-se que a forma de coordenar o GCSM guarda relação com a proposta da atividade e sua fundamentação teórica, filosófica e empírica, inspirada pela fenomenologia clássica. O enquadre, as intervenções e o posicionamento do coordenador favoreceram a constituição de um espaço de cuidado intersubjetivo, em perspectiva de horizontalidade, a partir da tarefa de reconhecer experiências cotidianas significativas ao percurso de amadurecimento da pessoa humana. Nesse sentido, este esta pesquisa aponta para a relevância do estudo aprofundado de aspectos das práticas grupais, como a coordenação, como forma de melhor descrevê-las e compreendê-las.

Palavras-chave:
Saúde mental; grupos; papel do terapeuta

RESUMEN.

El Grupo Comunitario de Salud Mental (GCSM) es un programa de promoción de salud mental, vuelto a la comunidad y alineado a principios de la Reforma Psiquiátrica, desarrollado a lo largo de más de 23 años, por intermedio de la práctica, la observación sistemática y la investigación científica. El objetivo de este estudio fue comprender el papel del coordinador de grupo en esta modalidad. El corpus de la investigación fue conformado a partir de seis sesiones grupales audio grabadas y transcritas. Se ha delineado una ruta original de análisis, en el que todas las intervenciones del coordinador fueron descritas, analizadas y contextualizadas en relación al momento y desarrollo de la sesión grupal. Se identificaron ejes comunes a las intervenciones, que las caracterizan: ‘El encuadre en el Grupo Comunitario de Salud Mental’; ‘La mirada hacia el gesto humano en las contribuciones’; ‘La participación personal del coordinador’. Se observó que la forma de coordinar el GCSM se relaciona con la propuesta de la actividad y su fundamentación teórica, filosófica y empírica, inspirada en la fenomenología clásica. El encuadre, las intervenciones y el posicionamiento del coordinador estimularon la constitución de un espacio de cuidado intersubjetivo, en perspectiva de horizontalidad, a partir de la tarea de reconocer experiencias cotidianas significativas al recorrido de maduración de la persona humana. En este sentido, esta investigación apunta a la relevancia del estudio de aspectos de las prácticas grupales, como la coordinación, como forma de describirlas y comprenderlas.

Palabras clave:
Salud mental; grupos; rol del terapeuta

Introduction

The psychosocial model of mental health care began to be outlined in the 1980s, with the emergence of the first experiences of care for people in psychological distress in the community; later, it becomes legitimized and stimulated by public policies aimed at this area (Brasil, 2005; Trapé & Campos, 2017). In this model, it is recommended the deinstitutionalization of the person in distress, the integrality of care, the co-responsibility and the protagonism of the various people involved in mental health, proposing care oriented for the community and daily life (Brasil, 2005). Davidson (2017) points out to the need for a community repositioning in the face of psychological suffering so that it can welcome it since rehabilitation takes place in the process of resuming life in this context.

Trapé and Campos (2017) stress that the models of care are a synthesis of what is proposed by public policy guidelines and what is composed in the daily life of services, actions and relationships established among people involved in the field of mental health. Thus, in this context, it is necessary to include and strengthen practices that focus care on the intersubjective relationship, covering the individual's uniqueness and potential, beyond the disease, understanding the community dimension as constitutive of the human being (Silva & Cardoso, 2016; Silva, Iglesias, Dalbello-Araujo, & Badaró-Moreira, 2017).

From a psychosocial perspective, group practices, in their multiplicity and diversity, gain prominence, since they represent strategies with significant potential for the promotion of care (Nogueira, Munari, Fortuna, & Santos, 2016; Silva et al., 2017). The group device, as a possibility of help and care for its participants, is the product of a historical path marked by diverse theoretical, practical and philosophical contributions from different authors (Sheidlinger, 2004).

Currently, there is a group work field marked by a diversity of settings, participants, objectives, theoretical and epistemological approaches, which characterize the distinct and innumerable groups (Shay, 2017). Despite this diversity, there is a field of scientific production marked by the predominance of quantitative methods with experimental designs, whose focus was the results produced by a certain group in terms of pre and post-test (Cantarella, Borella, Marigo, & De Beni, 2017; McFarlane, Burrell, Duggan, &Tandon, 2017; Zlotnick, Tzilos, Miller, Seifer, & Stout, 2016).

However, Alves (2013) is attentive to the importance of studying the various elements that makeup group practices to understand it fully. Rocha (2015) also highlights the relevance of the rigorous methodological and epistemological description of the groups, so that they can be meaningful to the participants and those who propose it, as well as to contribute to the development of effective care tools in the mental health field, necessary for the consolidation of the psychosocial model.

Specifically about the coordinator's role, that is, the way he follows and facilitates group work, Lieberman, Yalom and Miles (1973), in a classic text from the area, assign him the functions of organizing the group session, of care and genuine attention to the group, of encouraging the participants’ affective involvement, in order to promote resources to broaden their understanding on themselves and the other - despite the theoretical-methodological perspective adopted in the conduct of the group. Rasera, Oliveira and Jesus (2014) found, in a review of current international ethical guidelines on group practices, that the coordinator is still predominantly understood along the lines of traditional, clinical, long-term group psychotherapy and carried in private contexts. In these documents, the coordinator was identified exclusively as a group ‘psychotherapist’ or ‘therapist’, despite a large number of both group modalities and coordination forms that happen in the daily life of the health services.

In the context of proposals for new group care modalities in tune with the mode of psychosocial care, the Community Mental Health Group (CMHG), focus of this study, was developed at the Hospital-Dia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HD-HC-FMRP / USP)- (Day Hospital of the Clinic Hospital from Medicine Faculty of Ribeirão Preto at São Paulo University), from 1997, in dialogue with the principles arising from the Brazilian Psychiatric Reform (Crovador, Cardoso, & Ishara, 2013). Over more than 23 years, the design of the modality took place from the fruitful dialogue among the group's clinical practice; observation and recording, systematically performed; and its scientific investigation (Pinheiro, 2017; Rocha, 2015, among others). The group's work had as epistemological, anthropological, theoretical and methodological inspiration the authors of classical phenomenologies, such as Edmund Husserl (1859-1938) and Edith Stein (1891-1942), and from the Operative Group, as Enrique Pichón-Rivière (1907-1977) (Ishara & Cardoso, 2013), linked to empirical knowledge coming from the practice of the modality in the service. Currently, the CMHG takes place in several places, with electronic means of dissemination and a training course aimed at training the modality coordinators.

The CMHG's general objective is to promote an open and accessible mental health care and promotion program for the community, complementing and diversifying existing therapies in this area. From the perspective of the participant, the group aims to promote continuous attitudes of attention, reflection and elaboration of daily experiences, insofar as such experiences are understood as potential resources for the mental health care and the maturing of the human being (Ishara & Cardoso, 2013). In the group, attention to mental health is affirmed as belonging to the human and everyday sphere (Crovador, Cardoso, & Ishara, 2013).

In this sense, all groups are open to all interested people, thus composing themselves in a heterogeneous way. It is understood that all participants can provide and receive care through reflection and the sharing of significant daily experiences, regardless of the social roles they occupy (Ishara & Cardoso, 2013; Pinheiro, 2017; Rocha, 2015). In this direction, the CMHG sets up a practice that implements the principle of horizontal care, one of the guiding principle of health and mental health policies and guidelines.

Group sessions are held in a conversation circle format and mediated by a coordinator, lasting approximately one hour and thirty minutes. Each group session is unique, containing its own the beginning and ending. The continuity among group sessions takes place in terms of proposal and structure. Each group session is divided among the Soirée, Experiences Reports and Elaboration of the Group Work. The Soirée is made up of participants' communications about experiences based on their contact with cultural elements. The second moment, ‘Experiences Reports’, develops with the communication of significant experiences of the participant's daily life in terms of personal maturation and mental health care. In the final moment, ‘Elaboration of the Group Work’, the participants and coordinator seek to elaborate the experience of having participated in that group session, communicating the repercussions, reflections and considerations on their participation in the session (Ishara & Cardoso, 2013).

Objective

The objective of this study was to understand the role of the group coordinator in a mental health promotion and care modality open to the community, the Community Mental Health Group - CMHG.

Method

Corpus construction

Routinely, CMHG sessions are audio-recorded and make up the service's historical collection. This work corpus consisted of six CMHG sessions, selected randomly from this collection, by lot, and transcribed in full by the researcher. Sessions held in 2014 and 2015 were selected as a way of covering coordination in two different years, seeking common elements to them. As an inclusion criterion, it was adopted that the groups: 1) have been held at HD-HC-FMRP / USP, an institution where this group started, and, 2) have been coordinated exclusively by the creator and coordinator of the modality since its inception. The sessions studied are not consecutive, given that, in the activity, each group is unique and independent of the previous or next. In this sense, the participants vary from session to session. The CMHG at HD-HC-FMRP / USP brings together about 30 to 40 adult participants, among users and ex-users of the service, family members, professionals and students, who are invited to integrate the activity in a horizontal perspective, as a person carrying daily experiences, and not based on their functional roles. Thus, the corpus consisted of 9 hours of audio recording and 106 pages of sessions' transcriptions.

Corpus analysis

Initially, the transcriptions for each session were read thoroughly, to apprehend general meanings. From this, the need to understand the interventions of the coordinator inserted and in relation to the group context that gave rise to them was identified. Therefore, a methodological path that did not abstract interventions from their generative context was necessary, but that encompassed them in relation to the chronological development of the session and the group process. In the analysis, the six groups that make up the corpus were analyzed individually, and procedurally, that is, considering the context, the process and the chronological development of each of the sessions. To this end, clippings were demarcated in the transcription, whose criterion was the presence of the coordinator intervention or participation. It was decided to include all clippings that contained this criterion as a way of giving broad visibility to the CMHG coordination and group phenomenon.

After delimited and selected, the clippings were numbered and analyzed one by one, concerning the context and group process, with emphasis on the description and understanding of the coordinator's interventions. Then, the clippings and their respective analyzes made up the elaboration of a narrative text for each of the studied sessions (06 texts), so that the reader, when reading each of the texts, obtains a descriptive, analytical and comprehensive panorama of the group phenomenon and the coordination of each of them.

From the texts, the coordinator's interventions were synthesized and organized into six tables, referring to each of the sessions studied, as a way of understanding the set of sessions, aiming to identify and to outline common characteristics of the group's coordination. In this direction, characteristics common to the interventions were identified throughout the sessions and among the groups studied. These characteristics were organized into three main axes, which describe the role of the coordinator in the CMHG. The axes will be presented as a result of a more comprehensive analysis process, which includes the procedural analysis mentioned above. Each axis will be described, analyzed and discussed, and clippings from the interventions that illustrate and favor their understanding will be used.

Ethical care

The Research Ethics Committee of the Faculty of Philosophy, Sciences and Letters of Ribeirão Preto, São Paulo University (USP) (under CAAE n. 38571214.0.0000.5407), approved this study. All ethical precautions were adopted, including the adoption of fictitious names, aiming to preserve the participants' identity.

Analysis and discussion

The analysis was composed of three axes that characterize the CMHG group coordination, namely: a) ‘The framework in the Community Mental Health Group’ - subdivided into a.1.) ‘The framework of the group session’ and a.2.) ‘The framework as an outline of the CMHG proposal’; b) ‘The look at the human gesture in the contributions’; and c) ‘Coordinator's personal participation’. Below, these axes are presented, exemplified and discussed.

a) The frame in the Community Mental Health Group

This axis covers the framing interventions performed by the coordinator during the studied sessions. It is subdivided into the items: a.1) ‘The framework of the group session’, which gathers the interventions in which the coordinator seeks to ensure the organization, structure and functioning of the group session and; a.2) ‘The framework as an outline of the CMHG proposal’, which, in turn, encompasses interventions in which the coordinator seeks to favor the contextualization, understanding and appropriation of the participants to the proposal and task of the Community Group Mental Health. It is a didactic separation, since, in the scope of practice, these two vertices can permeate the same intervention.

a1. The framework of the group session

The functions related to the framework of the group session were shown to be fundamental attributions of the coordinator in the CMHG, such as the spatio-temporal organization of work; promotion of structure for the activity; the maintenance of a coherent and consistent sequence between the steps that make up the CMHG and the fluency among them. In this sense, in all the studied sessions, the coordinator introduced the CMHG, pointed out the transitions among stages, signaling them and indicating their respective tasks and concluded the activity. The clippings, below, give visibility to the framing interventions of the session: “My name is [name of the coordinator], and we do this work on Tuesday mornings ... it is called the Community Mental Health Group”; “In this part now, which we call Soirée, we then continue to share the things we learn from books, magazines, movies [...] and, in short, culture in general”; and, “We could go on with the Soirée if someone has another contribution, but also now, whoever wants to share experiences [...]”.

In these clippings, respectively, the coordinator: 1) starts one of the studied sessions; 2) signals the start of the Soirée and its particular task; and, 3) transitions between the Soirée and the Experiences Reports. In this way, he offers, throughout each session, a clear and consistent structure, seeming to facilitate the attention and engagement of the participants, in line with what was proposed by Lieberman et al. (1973). In addition, it is noted that, when doing so, it is placed ‘in the first person’, as part of an exercise that is carried out in community, “[…] we do this work” [sic], corroborating the coordinator's personal participation as a striking characteristic of this group, identified by Rocha (2015). Besides, the transitions among the stages were not made abruptly or definitively, but guaranteeing space for participants to be welcomed if they still have some contribution to share. In terms of group coordination, based on such interventions, the coordinator favors certain balance in the promotion of group limits and structure what, when it is little or excessively presented, can damage the group work (Dies, 1994).

It should also be noted that it is a care modality in which participants are invited to integrate the activity in a horizontal perspective, through the common proposal that is to recognize and communicate significant daily experience. Even so, the coordinator has a different role with those regarding the framework of the session. It is worth mentioning that it is a large group, with the participation of about 30 to 40 people, which can vary from session to session, and not everyone is necessarily familiar with the CMHG. In this context, the favoring of a spatio-temporal organization of the session and the demarcation of the task - which will be discussed below - are shown as care with group functionality, so that the activity can develop in line with the proposal of the modality.

a.2 The framework as an outline of the CMHG proposal

As previously described, this vertex encompasses the framework interventions ‘as an outline of the CMHG proposal’, that is, in its broadest sense - encompassing the interventions in which the coordinator seeks to promote the understanding and appropriation of the task by the participants, which transcends the specific context of each session. Thus, such interventions favor the outline of the CMHG, in the sense that they promote the development of the session in line with the proposal, the characteristics and peculiarities of this modality (Ishara & Cardoso, 2013), which distinguish it from other proposals, such as, group psychotherapy and self-help groups.

In the following section, the coordinator explains and contextualizes one of the aspects of the CMHG proposal.

[...] so, this is our exercise [...] to help each other to be able to encounter people [...] I speak this by calling attention to the fact that this is far from being a natural, obvious thing. [...] We try to do an encounter exercise that is different from being together. Why is it different? Because it is the search that being with the other person will acquire a meaning for us [...] Do you understand? Then, there is a real encounter. An encounter for real [...] And another great challenge of our work is that this exercise is also an exercise in which we can find our own history, being able to appropriate our history [...] Taking care, also, so that our experience does not pass us by [...] So, when we are looking at our experience, it is so that we can live it for real, as an event, as anything that we can say, ‘this is really mine’, this is my pain, my joy, my memory, the book I read, the song I listened to’. However, I say, ‘This is mine, this is mine’, ‘It is a piece of me’ (authors emphasis).

In this clipping, the coordinator means the CMHG work as “[…] our exercise in helping each other to be able to encounter people” [sic] seeking to remove the obviousness of the encounter, by differentiating it from “[…] being together” [sic], since the first involves a meaning. It proposes two meanings of encounters, distinct and complementary, that make up the work: the encounter with the other, unveiling a community perspective, and the encounter with one's own experiences, so that these “[…] do not pass us by” [sic]. In this direction, it is sought that the experiences be lived in the first person, from a protagonist perspective before his life and of attentive and profound interaction with reality and with the other, within a horizon of the reciprocal constitution. In a phenomenological perspective, it is understood that the opening for oneself and the other, as well as the possibility of realizing what is lived and what is lived by an otherness, are constitutive and specifically human, being able to be enlarged and deepened from intersubjective relations that favor both a formation path and an person´s development (Stein, 2000).

Therefore, it is highlighted that the coordinator strives to share some resources so that the participants can interact significantly with the task, being able to understand better and experience it. These resources reflect the anthropological vision inspired by the classic phenomenology that permeates the CMHG, which gives meaning to the proposal itself and to group work, just like the human being as a being who apprehends and gives meaning to reality, who can hold meaningful encounters, which can be constituted by a community perspective, among others (Ishara & Cardoso, 2013; Rocha, 2015). In this sense, in another section, the coordinator says,

[...] when we say that we come here to exchange experiences ... exchanging experiences is different from telling things. We do not come here to tell things, as a group of gossip [...] we come here to seek to do experience based on the things that are happening, it is very different!

With this intervention, the coordinator seems to facilitate the group functioning, pointing to a subtle difference between “[…] telling things” [sic] and “[…] exchanging experiences” [sic], which underlies the CMHG's own work. In this direction, the group seeks more than the report of individual circumstances and problems but rather an attitude of identification, contemplation and sharing of daily experiences that can acquire some value in the development and maturation of the person, from a mental health care perspective. The possibility of not only “[…] telling things” [sic], but of “[…] to seek to do experience based on the things that are happening” [sic], also finds support in the anthropological understanding inspired phenomenologically. Husserl (2012) and Stein (2001) explain that the human possibility of knowledge is not limited to the knowledge of the factual dimension of phenomena, of “[…] things” [sic]. Rather, it advances to apprehend the meaning of these “[…] things” [sic] and his own lived experiences, valuing the subject's place in this process. This opens up the possibility that the most diverse reports may occur, given that the focus is not on “[…] telling things” [sic], but on the perspective of recognizing meanings in what one experiences, a possibility that is anthropologically common to all participants.

It is worth mentioning that the CMHG therapeutic work depends, in large part, on the participants' sharing experiences of their own daily life, and, for that, that they understand and appropriate themselves of resources to identify, elaborate and share them. In this sense, with these interventions, the coordinator seems to equip the participants to interact with the proposal and with the group, favoring group operability. Moreover, it is observed that it is not a matter of providing rational or theoretical explanations, nor of ‘applying’ a technique and a ready theoretical perspective - but of meaning the group's proposal, providing it with outlines that characterize it. In this way, the proposal and the transparent philosophical, theoretical and methodological concepts gain meaning and vivacity from the dialogue with the experiences brought by the participants and coordinator; whereas, conversely, the central proposal for the recognition of experiences, permeated by the theoretical and methodological concepts that inspire the group, give a kind of outline for the signification of reported experiences, then the CMHG proposal update itself during the group encounters for both the participants and the coordinator.

b) The look at the human gesture in the contributions

This axis covers interventions in which the coordinator understands the participants' communications not only in terms of the explicit discursive content but also from a look at the human gesture involved in them. The ‘gesture’ is understood as an action that starts from a singularity and finds the gaze of an ‘other’ available to perceive and signify it; in this encounter path, the action becomes a human, unique and personal gesture (Safra, 2015). In the following clipping, Silvia tells the group that she has noticed some changes in her son, and her speech is followed by an intervention by the coordinator that reveals a look at the human gesture.

Silvia: It's very interesting how he gets to know things [...] Now he decided to buy a motorized scooter [...], and he ended up making friends [...] His friend, João, as he works at a bike shop, he understands about repair, adjustment, I don't know what else ... and as the scooter is old, it gets a flat tire all the time [...], and João sits there and spends Saturday afternoon trying to help to fix it [...], and he [the son] is delighted with this boy's availability, and that made me very happy. He's starting to notice that this exchange is a very important thing to bring people together because he was closed since he started his treatment; he closed himself [...]

Coordinator: Thanks, Silvia [...] I just wanted to draw your attention to a small aspect of this that Silvia was talking about, right [...]. Because [...] Ah! This ability to follow the experience of the other [...] I mean, you know [...] she is telling, among other things, how she can follow the experience of her son's growth [...] Learning to identify as a valuable experience, not only when I grow up [...] we can also be excited when we realize that someone we care for is also growing.

In this clipping, among other aspects that appear in Silvia's speech, the coordinator apprehends and makes explicit the participant's gesture of ‘following the experience of the other’, recognizing, in addition to the discursive content of the speech, her movement before her son. The ‘look at the gesture’ is also a look at the person, for the person's daily lived experiences, mobilizing and following the participant in his ‘doing experience’ from day to day. It is noticeable that the coordinator does not enter Silvia's individual problematic, imbued in her discursive content - such as her relationship with her son, the resumption of his daily life after treatment - nor does he intervenes in a hermeneutic-interpretative way but highlights Silvia's singularity in her human gesture in the face of daily life, which is shown in her contribution.

By signifying such a movement, making it a gesture, the coordinator places it on a possible horizon for other group participants: “[…] we can also be excited when we realize that someone we care for is also growing” [sic]. The gesture of “[…] following the experience of the other” [sic] is not only possible for other participants but also as desirable so that the CMHG can occur. In this perspective, the coordinator expands Silvia's specific contribution to the group as a whole, favoring the functioning of the activity as a community. Looking at the other, recognizing him as a ‘you’ similar to ‘me’, which carries experiences similar to mine in terms of structure, but multiple in content, stories, et so on, makes up a community, as discussed by Ishara and Cardoso (2013), Safra (2015), Silva and Cardoso (2016). So, in this context of anthropological understanding inspired by classical phenomenology, not all groups are configured as communities. According to Stein (1999), the community perspective is constituted from the active availability among the participants, marked by a solidarity opening, which preserves, however, the very uniqueness. Such availability is encouraged by the coordinator in his intervention since it is a possibility structurally shared by all. In this sense, looking at the gesture emphasizes the uniqueness of the participants, also allowing the construction of the community aspect of the activity - a dimension valued in the psychosocial field of mental health care (Davidson, 2017; Silva & Cardoso, 2016).

In another clipping of the group, at the time of Soirée, Virgílio gets up from his chair to share a contribution that consisted of a series of jokes, taking a long time from the activity. Due to the way he does it, the other participants show some difficulty in understanding him. The following clipping is the intervention of the coordinator whose axis is guided by ‘the look at the human gesture’ in the contributions.

Coordinator: [...] I think the most valuable thing for us is to say that we can find a person who is literally standing up to make us laugh, to try to build his own life with the possibility of laughter. Therefore, I think that when we find someone who can stand up to give us a present, this is the different possibility for us to perceive, you know. How many people will we meet in our day who will want to stand before us to transmit something to us? [...] I think that this is a possibility of encounter that we cannot lose sight [...].

The coordinator intervenes by apprehending the gesture that makes up the contribution: “I think the most valuable thing for us is to say that we can find a person who is standing up to make us laugh, to try to build our own life with the possibility of laughter” [sic]. The ‘look at the human gesture in the contributions’ allows, on the one hand, welcoming the participant and his desire to contribute to the group, genuinely valuing him; on the other hand, it helps to signify and favor the welcoming and understanding of this participant by others in the group. The resource of ‘the look at the gesture’, in the CMHG, favors the acceptance of multiple, varied and unusual contributions since it makes explicit the gesture and the meaning they carry concerning the person who contributes, in which the singularity is valued, as well as the active gesture of contribution with the group, strengthening the community possibility of the activity. Safra (2015) points out the fundamental need for the person to be recognized in his originality through his gestures. To do so, it is necessary the availability of the other who apprehends the uniqueness and creativity of his acting in the world, not reducing him to a reactive being but perceiving him as somebody who has a spontaneous and original gesture in the world, having the perspective of being open to the surprise, who is the other (Safra, 2015; Stein, 2000).

Still in terms of identifying and valuing the participants' gestures, the coordinator, in several clippings, seeks to explore more information about the contributions, such as the name of the author, the artist, the painter, the music, the film, the place where the event of certain experience occurred; among others. In addition, from an investigative perspective, he seeks to know the meaning of a particular contribution for the participants, stimulating the deepening of its appropriation and elaboration. The coordinator's reports that aim to better understand the contribution and the participant's perspective seem to preserve them, as they were lived, signified and expressed by the participants, emphasizing the gesture and the uniqueness of the contributor.

As already mentioned, when the coordinator and the group can recognize the gesture that allows a certain communication or participation, the perspective of contribution with the group is emphasized. As worked throughout this study, the development of the group depends on the contribution of people, the availability to perform an exercise of attention, elaboration and sharing of experiences, which, as exposed by Rocha (2015), demands an attitude of openness and availability for the activity. Given this expanded understanding about participating and contributing to the group, the coordinator shows gratitude for the communications in many clippings, thanking the participant explicitly. This is not a formal thank you, but an acknowledgment of the gesture involved during the participation.

c) Coordinator's personal participation

This axis covers the participation of the coordinator that carries personal content and lived experiences; it also covers aspects of such participations that show the uniqueness and originality of the person who coordinates. Consistently with the phenomenological design of the CMHG and with the invitation that proposes to all members, the coordinator also participates as a ‘person’ who integrates a jointly developed work, to occupy a distinct ‘place’ from that historically constituted, about the group therapist, inspired by the group psychotherapy model (Rasera et al., 2014). In the following clipping, the coordinator, when starting one of the sessions, brings an account of his own work routine.

[...] On Friday, I was talking to Eugênia and Eugênia was talking about some people who are being treated here at the hospital and that she realized that they were improving, that they were getting better [...] there was a moment when she said, ‘I am still excited about these things!’ [...] the theme of the Community Group this year is: The formation of the human being. I mean, how we are being formed. Therefore, we are interested in all these things, because they form us, that is when you hear something and say, ‘Wow! I want to be a professional who comes close to 93 years old [laughs] and is still thrilled with the improvement of his patients’. Therefore, that’s why I told you this story, because these are things that we see and hear that like so many others that we heard today that are forming us as a person (authors emphasis).

In his communication, the coordinator makes an approximation between his own experience, in his daily work at the hospital, the CMHG context and proposal, based on the possibility of “[…] being formed” [sic] by the events, so that the report itself can help the participants to take ownership of the task and the possibility of recognizing meanings that say about themselves, about their own desires, in the midst of what is experienced in daily life, from a certain availability of attention and elaboration before the experiences. With his report, he communicates to the participants, experientially - and not discursively or explanatorily - the possibility of ‘doing experiences from everyday events’, a complex task and motto of the CMHG. Above all, the incorporation of the CMHG proposal by the coordinator appears in the clipping, to the point of experiencing it daily, and not only at the moment when he is coordinating the group session. The coordinator recognizes himself, through this report, in a developmental path of himself, understood in broad terms, which, for Stein (1999), is continuous and unfinished, as well as a possibility for everyone.

This axis, as already mentioned, covers original and unique characteristics in the way that each coordinator facilitates the group event. In audio recordings and transcriptions, it was observed, for example, the use of an aesthetic and imagery language, loaded with metaphors, a specific tone of voice and speech cadence, among others, which are specific of the target coordinator from this study. According to the phenomenological anthropology that supports the activity, each participant, including the coordinator, has something singular and unique, which finds, in the group, space for spontaneous and genuine expression (Ishara & Cardoso, 2013; Safra, 2015). It should be highlighted that such a way of being in the group does not deprive him of group coordination specific tasks. On the other hand, he is not a ‘neutral’ therapist who ‘applies’ a technique, but someone who genuinely experiences the proposal in his daily routine, appropriates it and prints a certain uniqueness to the way of being in the group.

From a group psychotherapy perspective, in the traditional, clinical, and interpretative-hermeneutic molds - predominant, for example, in the guidelines for conducting groups (Rasera et al. 2014) - preserving the therapist's identity is recommended. On the other hand, Bernard et al. (2008) point out the feasibility of the coordinator's personal participation, as long as it is based on the conviction that such openness will favor the group work and on the non-disclosure of topics that cause discomfort. In this sense, in CMHG, the coordinator's personal contributions are genuine but also guided by the group's objective and the perspective of contributing to its development. It is also necessary to consider that this is not a traditional clinical therapeutic modality, but a community and open modality for sharing daily experiences, to promote and care for mental health -this context allows this type of opening by the coordinator, which could not be adequate in other frameworks.

Final considerations

This study aimed to understand the role of the coordinator in a mental health promotion and care modality open to the community, the Community Mental Health Group - CMHG. It was observed that the way of coordinating the CMHG presents characteristics and peculiarities supported by the classic phenomenological perspective that inspires the modality. As suggested by the analysis carried out, the coordination in the CMHG offers a framework for the group session, from the perspective of a spatio-temporal organization and demarcation of the task, favoring that the participants can understand and appropriate the work proposed by the group. By recognizing the human gesture involved in the contributions, the coordinator values ​​the uniqueness of each member, following the participant in his ‘doing experience’ daily, and favors the community construction of the activity. The personal participation of the coordinator reveals the appropriation that he makes of the group proposal in his own daily life, as well as the impression of a certain singularity in the group's coordination.

Thus, in the CMHG, the coordinator's interventions favored the intersubjective relationships constituted themselves as the heart of the care promoted in the group. Through them, everyday experiences were signified concerning the main group proposal of attention to the human being´s formation in daily life. In this sense, everyday experiences mediated the bond established among the participants, despite the group's heterogeneity - configuring a resource for community practices and the formation of mental health care networks, valued as strategies for consolidating of the psychosocial care mode (Brasil, 2005; Davidson, 2017; Nogueira et al., 2016; Silva et al., 2017; Silva & Cardoso, 2016).

It is observed as a limit of the present work that six transcripts of CMHG sessions were analyzed, which took place in a single institution, the Hospital-Dia, with a single coordinator, who was the creator of the modality. However, it is understood that the constitution of the research corpus allowed an in-depth analysis of the role of the coordinator in the CMHG, in its place of origin and coordinated by the founder of the modality. In this way, it provided the opportunity to outline the characteristics of the coordination of this modality; and indicated the potential for further studies in this field. Thus, new empirical studies are suggested, in different contexts and under the coordination of other coordinators. Furthermore, an in-depth interview with the coordinators is suggested, seeking to apprehend their experience and their conceptions about the modality and their role in it; interviews with group participants that deepen their perception about coordination, among others.

It is considered that this study allowed broadening the understanding of the CMHG coordination and the modality itself, which contributes to the implement of the psychosocial model of mental health care and which can also inspire other group modalities. The study points out to a form of group coordination that can enhance the promotion of care through intersubjective relationships, guided by the horizontality and the encounters among people. It contributes to the practice of groups and the scientific literature, based on the realization of a systematic and qualitative empirical investigation, whose object was the group as it happens in loco, that is, in the daily context of the service, bringing together research and the reality of practices performed in health services.

Referências

• Alves, P. E. R. (2013). O método fenomenológico na condução de grupos terapêuticos. Revista Sociedade Brasileira de Psicologia Hospitalar, 16(1), 150-165. Recuperado de: http://pepsic.bvsalud.org/pdf/rsbph/v16n1/v16n1a09.pdf
  » http://pepsic.bvsalud.org/pdf/rsbph/v16n1/v16n1a09.pdf
• Bernard, H; Burlingame, G; Flores, P; Greene, L; Joyce, A; Kobos, J. C; … Feirman, D. (2008). Clinical Practice Guideline for Group Psychotherapy. International Journal of Group Psychotherapy, 58(4), 455-542.doi: 10.1521/ijgp.2008.58.4.455
  » https://doi.org/10.1521/ijgp.2008.58.4.455
• Brasil (2005). Reforma psiquiátrica e política de saúde mental no Brasil Brasília, DF: Ministério da Saúde.
• Cantarella, A; Borella, E; Marigo, C; & De Beni, R. (2017). Benefits of well‐being training in healthy older adults. Applied Psychology: Health and Well-Being,9(3), 261-284. doi: 10.1111/aphw.12091
  » https://doi.org/10.1111/aphw.12091
• Crovador, L. F; Cardoso, C. L; & Ishara, S. (2013). Encontro Anual dos Grupos Comunitários de Saúde Mental: reflexões a respeito dessa prática no âmbito da Reforma Psiquiátrica. In S. Ishara, C. L. Cardoso & S. Loureiro (Orgs.), Grupo Comunitário de Saúde Mental: conceitos, delineamento metodológico e estudos (p. 95-114). Ribeirão Preto, SP: Nova Enfim Editora
• Davidson, L. (2017). After the Asylum: a basaglian-informed vision of recovery-oriented care. Cadernos Brasileiros de Saúde Mental, 9(21), 125-136. Recuperado de: https://periodicos.ufsc.br/index.php/cbsm/article/view/69540/41662
  » https://periodicos.ufsc.br/index.php/cbsm/article/view/69540/41662
• Dies, R. R. (1994). Therapist variables in group psychotherapy research. In A. Fuhriman & G. M. Burlingame (Orgs.), Handbook of group psychotherapy: an empirical and clinical synthesis (p. 114-154). New York, NY: John Wiley & Sons.
• Husserl, E. (2012). Ideias para uma fenomenologia pura e para uma filosofia fenomenológica (6a ed., M. Suzuki, trad.). Aparecida, SP: Ideias & Letras. Trabalho original publicado em 1913.
• Ishara, S; & Cardoso, C. L. (2013). Delineamento do Grupo Comunitário de Saúde Mental. In S. Ishara, C. L. Cardoso & S. Loureiro (Orgs.), Grupo Comunitário de Saúde Mental: conceitos, delineamento metodológico e estudos (p. 19-40). Ribeirão Preto, SP: Nova Enfim Editora
• Lieberman, M. A; Yalom, I. D; & Miles, M. B. (1973). Encounter groups: first facts New York, NY: Basic Books Inc. Publishers.
• McFarlane, E; Burrell, L; Duggan, A; & Tandon, D. (2017). Outcomes of a randomized trial of a cognitive behavioral enhancement to address maternal distress in home visited mothers. Maternal and Child Health Journal, 21(3), 475-484.doi: 10.1007/s10995-016-2125-7
  » https://doi.org/10.1007/s10995-016-2125-7
• Nogueira A. L. G; Munari, D. B; Fortuna, C. M; &Santos, L. F. (2016). Pistas para potencializar grupos na Atenção Primária à Saúde. Revista Brasileira de Enfermagem, 69(5), 907-914. doi: 10.1590/0034-7167-2015-010
  » https://doi.org/10.1590/0034-7167-2015-010
• Pinheiro, B. C. (2017). Grupo Comunitário de Saúde Mental: formação de recursos humanos (Dissertação de Mestrado). Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto. Recuperada de https://www.teses.usp.br/
  » https://www.teses.usp.br/
• Rasera, E. F; Oliveira, F. M; & Jesus, M. J. B. S. (2014). A prática grupal e o discurso sobre a ética em documentos oficiais. Estudos de Psicologia (Campinas ), 31(3), 405-414. doi: 10.1590/0103-166X2014000300009
  » https://doi.org/10.1590/0103-166X2014000300009
• Rocha, R. M. G. (2015). Análise compreensiva de uma nova modalidade de trabalho em saúde: o Grupo Comunitário de Saúde Mental (Tese de Doutorado). Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto. Recuperada de https://www.teses.usp.br/
  » https://www.teses.usp.br/
• Safra, G. (2015). A face estética do Self: teoria e clínica (7a ed.). São Paulo, SP: Ideias & Letras.
• Scheidlinger, S. (2004). Group psychotherapy and related helping groups today: an overview. American Journal of Psychotherapy, 58(3), 265-280. doi: 10.1176/appi.psychotherapy.2004.58.3.265
  » https://doi.org/10.1176/appi.psychotherapy.2004.58.3.265
• Shay, J. J. (2017). Contemporary models of group therapy: where are we today? International Journal of Group Psychotherapy, 67(1), S7-S12.doi: 10.1080/00207284.2016.1238749
  » https://doi.org/10.1080/00207284.2016.1238749
• Silva, G; Iglesias, A; Dalbello-Araújo, M; & Badaró-Moreira, M. I. (2017). Práticas de cuidado integral às pessoas em sofrimento mental na atenção básica. Psicologia: Ciência e Profissão, 37(2), 404-417. doi: 10.1590/1982-3703001452015
  » https://doi.org/10.1590/1982-3703001452015
• Silva, N. L; & Cardoso, C. L. (2016). Cuidado em saúde mental na estratégia saúde da família: a construção da comunidade. Memorandum, 31, 218-236. Recuperado de: https://periodicos.ufmg.br/index.php/memorandum/article/view/6437
  » https://periodicos.ufmg.br/index.php/memorandum/article/view/6437
• Stein, E. (2001). Introduzione alla filosofia (2a ed., A. M. Pezzella, trad.). Roma, IT: CittàNuova. Trabalho original publicado em 1917-1922.
• Stein, E. (1999). Psicologia e scienze dello spirito: contributi per una fondazione filosofica (2a ed., A. M. Pezzella, trad.). Roma, IT: Città Nuova. Trabalho original publicado em 1922.
• Stein, E. (2000). La struttura della persona umana (M. D’Ambra, trad.). Roma, IT: Città Nuova . Trabalho original publicado em 1933.
• Trapé, T. L; & Campos, R. O. (2017). Modelo de atenção à saúde mental do Brasil: análise do financiamento, governança e mecanismos de avaliação. Revista de Saúde Pública, 51(19), 1-8. doi: 10.1590/s1518-8787.2017051006059
  » https://doi.org/10.1590/s1518-8787.2017051006059
• Zlotnick, C; Tzilos, G; Miller, I; Seifer, R; &Stout, R. (2016). Randomized controlled trial to prevent postpartum depression in mothers on public assistance. Journal of Affective Disorders, 189, 263-268. doi: 10.1016/j.jad.2015.09.059
  » https://doi.org/10.1016/j.jad.2015.09.059

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  Support and funding: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) - Process nº. 2015/00139-4

Publication Dates

• Publication in this collection
  05 Oct 2020
• Date of issue
  2020

History

• Received
  22 Mar 2018
• Accepted
  22 May 2020