Therapeutic activities: comprehension of families and profesionals at a mental health service

Abstracts

OBJECTIVE:

To analyze the understanding of family members and mental health professionals concerning the therapeutic activities implemented in the routines of Psychosocial Care Centers.

AIMS:

This qualitative study was conducted in a Psychosocial Care Center in the state of Santa Catarina, Brazil.

RESULTS:

The therapeutic activities reveal many possibilities for implementing actions and practices according to new trends guiding care in the field. The results also reveal there is a risk of services adopting authoritarian and crystallized postures compatible with traditional care models, which the Psychiatric Reform campaign has struggled for more than 20 years to overcome.

CONCLUSIONS:

This study is expected to encourage a new perspective of Psychiatric Reform in the studied context and discussions about the teamwork processes and the relationships between services and patients.

Psychiatric Nursing; Mental Health; Health Policies

OBJETIVO:

analisar a compreensão de familiares e profissionais de saúde mental sobre as atividades terapêuticas no cotidiano de um Centro de Atenção Psicossocial.

METODOLOGIA:

Trata-se de uma pesquisa qualitativa realizada em um Centro de Atenção Psicossocial do Estado de Santa Catarina, Brasil.

RESULTADOS:

As atividades terapêuticas, por exemplo, revelam o leque de possibilidades de atuação e imersão das práticas nas novas tendências de cuidado na área, assim como o risco de adoção de posturas verticalizadas e cristalizadas, mais compatíveis com modelos de atendimentos tradicionais, contra as quais a própria Reforma Psiquiátrica luta há mais de 20 anos.

CONSIDERAÇÕES FINAIS:

Espera-se que o estudo proporcione novos olhares sobre a Reforma Psiquiátrica no contexto estudado, de modo a problematizar os processos de trabalhos das equipes e a relação dos serviços com os usuários que atendem.

Enfermagem psiquiátrica; Saúde mental; Política de saúde

OBJETIVO:

analizar la comprensión de familiares y profesionales de salud mental sobre las actividades terapéuticas en el cotidiano del funcionamiento de un Centro de Atención Psicosocial.

METODOLOGÍA:

se trata de una investigación cualitativa realizada en un Centro de Atención Psicosocial de la provincia de Santa Catarina, Brasil.

RESULTADOS:

las actividades terapéuticas, por ejemplo, relevan las diferentes posibilidades de actuación e inmersión de las prácticas en las nuevas tendencias de cuidado en el área, y también el riesgo de posturas verticalizadas y cristalizadas, más compatibles con modelos de atención tradicionales que la propia reforma psiquiátrica busca superar hace más de 20 años.

CONSIDERACIONES FINALES:

se espera que el estudio ofrezca nuevas miradas sobre la reforma psiquiátrica, para que se pueda problematizar los procesos de trabajo de los equipos y la relación de los servicios con los usuarios que atienden.

Enfermería Psiquiátrica; Salud Mental; Políticas de Salud

INTRODUCTION

For centuries, people have been intrigued by a number of complex phenomena encountered in the health field. Madness, for instance, is one of the biggest dilemmas of mankind that still lacks explanations accounting for the richness and uniqueness that accompany it.

Madness has been differently described over the course of history. It ceased to be an eccentricity, becoming instead a punishment foisted by gods. Insanity that was allowed but that was also contained within the boundaries of what is considered "to be normal" until it was captured as a domain of medical knowledge, insanity moved from the sphere of odd manifestation, or even an expected manifestation, to a phenomenon of human inadequacy to be corrected in specialized institutions¹.

This period in which madness gains a new status - this time that of illness- emerged in the 18^(th) and 19^(th) centuries. It is at this time that the birth of a new science is evidenced, a dualist and experimentalist science that has survived to the present day because it questions doubt and uncertainty, seeking regularity and absolute truths. Madness was no longer seen as a multifaceted manifestation of life but as a transitory experience with illness that deserved a rigorous classification and disciplinatory treatments. As a justification of this practice, psychiatry brought to the fore the need to re-conceptualize the areas of activity occupied by the physician to permit its knowledge to emerge, making the asylum the ideal place to exercise dominion over the manifestations of people and a scenario for the success of medical interventions².

The treatment delivered in the asylum focused on the impossibility of idleness, in addition to isolating the individual from family relations, which were considered factors that impeded an insane individual's readjustment. The only way to return an insane individual to society was controlling diverted reason, that is, disciplining not only bodies but also distressed minds. A set of therapeutic activities was developed initially aiming to control excessive manifestations of latent passions, reorganizing the insane individual's thought and intellect. An increase in the incidence of chronic institutionalization was, however, observed in the 1960s and 1970s due to the massive influx of psychiatric hospitalization, which usually lasted up to three months. In this context, activities served more as an occupation than actually as a therapeutic resource, so that everyone should take part in activities to avoid idleness hindering treatment³.

In the last 30 years, we have witnessed different changes in the profile of services and also in mental health practices. With the development of psychiatric reform, the challenge is to question madness as an object of some to become an object of many and also to question the organicist bases that sustain it, shifting to the ground of complexity. Madness has been characterized as a complex phenomenon in which different (biological, psychological, social, cultural and spiritual) determinants are involved. In the context of Psychiatric Reform, it is not only necessary to reconceptualize our view of madness but also what we do with it, that is, construct/restructure relationships, people, professional competencies and health services.

These transformations are in agreement with the guidelines recommended by the Brazilian mental health policies in recent decades. We highlight decrees GM/MS 189/91 and 224/92, which regulate the establishment of multidisciplinary teams, the services' basic standards according to the Brazilian Unified Health System (SUS), and the remuneration of extra-psychiatric procedures within the SUS sphere, such as patient embracement, group interventions, home visits, and therapeutic workshops. It is also important to mention law 10.216/2001, which provides for the rights of people with mental disorders in Brazil and decree GM/MS 336/2002, which establishes Psychiatric Care Centers ⁴.

In the context of mental health care that takes place in the community, therapeutic activities, such as therapeutic workshops and collective creation, return to the scene of practices performed in Psychosocial Care Centers. The role these activities play in the lives of individuals, their therapeutic purposes and the symbolic value they add to the development and autonomy of human beings, are currently being examined. We have also being examined the simple fact of patients having the freedom to "come and go", to participate or not, the desires of these individuals and also what they do or do not want to do. More than a simple pastime, the therapeutic activities that take place in community services should revitalize the relationships among subjects and serve as a means for the expression of human creativity and give new meaning to the fullness of life.

More than re-conceptualizing the role of therapeutic activities implemented within community services, there is a need to incorporate, into thinking and action, that these activities cannot be treated as static processes unable to accompany the complexity of the individual's suffering and incompatible with the dynamism of life. These activities should be contemplated and constructed, not only from the perspective of professional skills, but primarily based on the patients' needs. The desires, demands, requests, and the potential repercussions these may have for the vicissitudes of human life should be analyzed. More than keeping these activities simply to "have them", we should consider them as effective care technologies, in addition to powerful opportunities to empower people and for symbolic exchanges.

In this context, this study's objective was to analyze how family members and mental health professionals view and understand the therapeutic activities that take place in the routine of a Psychosocial Care Center. We aim to analyze strengths and limitations of these activities within the dynamic of this service and in the teamwork process in order to discuss the incorporation of the Psychiatric Reform principles into the routine of mental health practice.

METHOD

This study is part of a larger study called "CAPSUL" - Assessment of Psychosocial Care Centers in the South of Brazil, developed by the Federal University of Pelotas in partnership with the Federal University of Rio Grande do Sul and the Universidade Estadual do Oeste do Paraná. CAPSUL was financially supported by the Ministry of Health and was designed to quantitatively and qualitatively assess the service provided in three states in the south of Brazil. The study's objective was to understand the routines of services and the researchers had the participation of the staff, patients and family members with the objective to learn the dynamics of the services, how the actors interact, and the meanings these individuals attribute to these practices.

This study was based on a qualitative assessment of the Psychosocial Care Center in the state of Santa Catarina, Brazil. We discuss how the patients' family members and professionals from the service's staff understand the therapeutic activities implemented by the service.

Semi-structured interviews were used to collect data. A total of 10 family members and 18 workers were interviewed in this specific service. Among the mental health workers who were interviewed psychologists, nurses, physicians, social workers, occupational therapists, nursing technicians and auxiliaries and those working in the workshops were highlighted. But there are also other employees working in this service, such as security guards, cleaning aids, and administrative workers, who were important to include in data collection since these are workers in daily contact with patients and family members.

All the participants were informed of the study's objectives, received clarification regarding confidentiality issues and signed informed consent forms. In order to preserve anonymity of the interviewees' identities while identifying their testimonies, we used the letter F for family members and the letter P for professionals followed by a number that corresponds to the order of the interviews.

The project was submitted to and approved by the Institutional Review Board at the Medical School, Federal University of Pelotas, RS, Brazil (Of. 074/05 November 11^(th), 2005).

From the analysis of the empirical data, units of information emerged that were grouped into broader thematic cores, which enabled establishing preliminary themes, one of which refers to the implementation of activities as therapeutic support.

These themes were later gathered into thematic axes. These axes emerged from careful reading and re-reading of qualitative data, gathered by nuclei of meanings. Based on a systematic grouping of a nucleus of meanings, we collected the information required to proceed with the discussion. In this study, we opted to report the results found in data concerning the families and professionals, trying to identify similarities and differences between their perceptions.

RESULTS

The service addressed in this study is a CAPS II, accredited by the Ministry of Health in January 2002. It provides daily intensive, semi-intensive and non-intensive monitoring, in contrast with ambulatory care. It is a referral service for mental health care in its micro-region.

The professionals interviewed included one psychiatrist, three psychologists, one nurse, two social workers, two occupational therapists, three nursing auxiliaries/technicians, one pharmacist, one public health agent, one administrative worker, a security guard, and one cleaning aid. The family members of patients were those who participate in any of the service's therapeutic activities.

The study's results are presented followed by the discussion.

The understanding of family members

The family members report that the activities are diversified and have a two-fold function: they enable the establishment of bonds and adherence of patients to the service; and they serve as a therapeutic resource for those participating in the activity:

They listen to music, dance, she has a manicure, styles her hair, puts some make up on; sometimes they cut her hair the way she wants, all these things. She likes it here a lot (...) I guess there're tricot and tapestry. All this is good for them, the more the better because nothing good comes from an idle mind . So, having something to do, whatever it is, is good. [F7].

He enjoys the rides a lot. [F1].

The activity is good because they exercise, play soccer...there is workshop. It's good. This is a very good aspect, because it another kind of therapy. [F3]

Listen, walking helps a lot. [F6]

The family members also report that a positive aspect is the fact that the workshops offered by the service are different and meet the needs of patients at the time. When the patient arrives at the service, usually in crisis, his/her Therapeutic Project is more restricted to internal workshops that are specifically designed to reestablish their affective and relational dimensions. As the patient's condition improves, s/he starts to participate in interventions of a more inclusive nature in the community, such as workshops to produce and generate income. The following testimonies confirm this tendency:

When they recover a bit, they... work on rugs, do other things: clamps for clothes, handicrafts. [F10]

There are painting and woodworking workshops, group therapy; there are those who prefer the TV room. There is no discipline and it is not mandatory, it's at the patient's discretion... It is as if the patient re-learned to enter a work environment: has responsibility, a schedule, so hopefully, some day, they see whether the patient is ready to be discharged[F8]

The family members report that the service should invest in other activities that might be of interest of patients. The following report portrays this reality:

[...] they offer some services, only that my daughter likes music a lot, but it wasn't available. She likes cooking, but since there are many people, she rarely participates in the cooking classes. It would be a very interesting thing and I believe the secretary should give greater support so that there would be a larger number and varied therapies, meeting the diverse tastes of each. There are people who were rural workers. My daughter was a college student, studied journalism [...]. Because, sometimes what one person likes is not the same that another person likes. There is a diversity of different cultures and customs [F2].

The families understand that the CAPS should offer a set of possibilities to patients but, at the same time, be flexible to accommodate the families' demands for specific activities. In this specific service, these activities are part of the Group of Feelings, a therapeutic group in which the families are encouraged to talk about everyday challenges, involving the treatment and re-socialization of patients:

[...] the group of feelings is very important in my life, very important, it's where I find forces by which to live, where I've learned a lot... and cannot miss... because I miss it a lot in my heart. I have to always attend this group of feelings. [F1]

This is important, and in relation to the caregivers, we've suffered a lot; they have this group called Group of Feelings. [F2]

It's a group that talks about the patient, what we're thinking about, whether they are recovering, how they are responding (...). Very good too, because there we're informed of how they are responding, whether they are improving and we know everything and they ask us about when they are at home. Very good, a very good meeting [F7]

The understanding of the staff

The view the staff has concerning the therapeutic activities is very critical and productive in rethinking the mental health practice within CAPS. The staff reports both internal therapeutic activities and those that are implemented outside the service.

The home visits, interventions that take place outside the service, are reported as tools that diversify care without harming the patient's inclusion in society or continuity with the activities offered by the service.:

I guess that our CAPS is also concerned to care for those who cannot come here, so we make home visits...And we also learn about their life histories, go every 15 days, or once a month [...] it's a way to monitor the family. [P12]

When we realize through a visit, through visits like these... that the patient really needs housing, faces hardships, we make a report; the social worker is the one who becomes involved and we try to help; I guess that we have had this view toward our patients. [P3]

There seems to be a perception that the professionals should acknowledge the interests of each patient when implementing activities within the service and this is a premise established in the contract of care:

If she has the desire to be in that tapestry workshop, she'll be in that workshop because she wants to, because it's pleasant [...] at the time it can be rich, a moment of exchange, it can be a moment the professional will perceive a lot of things he might not perceive in another different, more restricted, moment...[P10]

The team is, however, aware that these activities need to be part of a dynamic process to avoid institutional inertia and the adoption of crystallized postures, which improve little. Even though the therapeutic workshops are important opportunities to enable the production of life, they need to be constantly discussed, especially with the patients. The following testimonies show this need:

I guess that sometimes it just a pastime really, or what I see, recently it has being like... "Well, today we have nothing' workshop"... if they are saying this, it's because they really don't want to do what we're offering [P12]

[...] the workshops do not work as they should, you know? There's no longer a concern [...] people entering the service try to do their best, but they do not have the support they should have...[P3]

[...] sometimes the person is not super-qualified, has good will and everything, but stays in that little needlework, needlework and doesn't work out the difficulties [...] [P13]

DISCUSSION

According to the families, the patients greatly enjoy the activities, which sometimes is translated as "they like the service". Some of the activities, such as those related to beauty care, leisure and exercises, are activities that take place in daily life, which is a welcoming surprise for the families of patients. It is known that the users of a mental health service have limitations in performing daily tasks like taking a walk, going to a beauty salon, or playing ball, among others. In this context, CAPS has a concern and has worked to bring users into contact with daily tasks, which is a differential for a treatment intended to be freely taken up and full of opportunities.

One study⁵ verified that families report that the workshops are excellent opportunities to discuss and problematize the situation of patients and also that of the service. According to the families, the fact that they frequently participate in activities and also in decision-making concerning the best strategy to follow enables them to understand how the unit functions, how the staff is organized, and the politics involved. Therefore, we understand that the participation of families in activities causes changes in the staff and in the service's routine, concretizing their role as protagonists of the process.

The testimony provided by F8, however, suggests an interesting issue that needs to be considered concerning the difficulties users may have when transitioning from the context of treatment to the job market. It is a fact that users seem to adapt so well to the service's dynamics and routine that they may become dependent or restricted to the development of the internal activities developed by CAPS. The objective of the mental health service developed within the community is, however, to strengthen the ties between the user and the world, enabling them to take part in work, trips, leisure, social life, social rules, shopping, travels and friendships. Even though it is a challenge to CAPS to enable patients, oftentimes with so many limitations in their context of life, it is essential that each service and professional develop, over the course of treatment, an efficient discharge plan including not only aspects related to treatment outside the institution's premises, but also discuss and problematize those things that are difficult and, those that are not so difficult, that users may face when living in society.

In this context, looking to the issues that are part of the world of life, responding to adversities of daily life, and being included in a logic that enables users to reestablish social exchange, seem to be part of the work process of CAPS. It is a service intended from its conception to be differentiated because its purpose is inclusion and citizenship; at the same time, though, it does not abandon traditional practice in the process⁶. This means that CAPS is unique in providing a therapeutic option and a space for social inclusion, mixing daily living activities with those that seek the effective participation of individuals in the community.

The family members criticized the routine of the mental health service, especially in relation to the professionals' competencies and skills. F2's testimony seems to stress this process. This family member understands that the service needs to provide a range of options that adapt to the abilities of each professional. The development of the Therapeutic Project within community services is, however, flexible enough to include the demands of all those in the service (users, families and staff), since the professionals themselves may not have the competence and/or ability required to implement a given activity, but a family member or an user can. This is a powerful opportunity to learn, to be creative, and reinvent one's own training in mental health care.

As the families question the workshops and the (poor or diverse) supply of activities, they are also encouraging the rethinking of the city's policies concerning mental health care⁷. The restricted supply of activities shows that the service needs to enlarge a debate that incorporates the demands of users into reality. The purpose of such a debate is to prevent the service to collectively frame individuals⁶, that is, to serialize individuals who are unique by nature, to program individuals to comply with the service's pre-programed activities.

Traditional psychiatry assumed a peculiar task in the context of treating manifestations of madness, condemning the family for part of the problems detected in the mentally ill. Taking on the task to regulate social life, psychiatry also took for itself the task to regulate the family system, pedagogically acting on its participation, isolating, suppressing, and alienating it from the context of treatment for the good of the patient ⁸.

In the context of Psychiatric Reform, the family is no longer seen as a mere ill system, or one that is restricted to flaws and misguided interventions in the lives of individuals in psychological distress. The family is returns to view as a complex system that can and should participate in treatment, safeguarding its singularities. This is to say that the services need to adapt to the multiple facets of each family member, reducing excessively moralistic and/or overprotective behaviors and encouraging the dynamic and affective involvement with patients⁹.

When the studied service offers inclusive activities, not only to users but also to their families, it assumes the need to work with people and also with their bonds, preserving sophisticated ways to understand the wholeness of human life, the need to establish bonds, and the bio-psychological complexity of mental distress. When the user is included in the service's activities and the family, having an opportunity to open up, transforms the routine of CAPS, it makes CAPS a place of support, attentive listening, and care. Consequently, a relationship that was, for a long time, distant and impersonal, becomes a concrete possibility for the production of health and life, inside and outside, mental health services.

In relation to the position of the staff concerning its practice, home visits emerge as instruments that enable a dialogue between the service and the outside. These visits serve as tools that facilitate the re-inclusion of the patient into the family, as well as the re-signification of the contact the user has with the service^{10 - 11}. It is possible through these visits to understand the dynamics of family relationships, the involvement of the community in the user's treatment, the feelings of inclusion or exclusion that may be involved, among other aspects. Additionally, the home visits monitor and include the users in the family, working within constraints, exclusionary language, and singularities of the family as a whole¹⁰.

The testimonies show that, among the list of therapeutic activities, home visits emerge as a technology of care that promotes the necessary links among users, the services and the community. The visits are an excellent opportunity to identify the different contexts of life, the unique needs of each person or family, and to strengthen bonds between the users and the professionals in the service. Within a context of reform, home visits are another technology that offers continuous care outside the institutional space and are a way to generate feelings of belonging to the service in users and the commitment of the staff to the user's situation.

In relation to the service's internal context, the CAPS' therapeutic activities (workshops and groups) seem to constitute spaces to produce subjectivities, where there is dialogue, interaction, reciprocity and bonding. In relation to the workshops, P10 stresses the issue of exchanges, that is, acknowledges the choices of users. It is this movement toward autonomy that enables us to understand CAPS as a space where the individuals are free to come and go, a view that we believe to be compatible with a psychosocial model that produces mental health.

The mental health team also critically analyzes the limitations of these activities. Many of them, according to some testimonies, are offered more as an alternative to entertaining and as a pastime than as a strategy to reinforce autonomy and citizenship within the service's premises.

In this sense, some activities also evidence important contradictions for discussion regarding transformations in psychiatric care focused on territory. The "little embroidery, embroidery", which in the perspective of P13 is not only repetitive for the user, but also lacks an appropriate therapeutic purpose, since there is a lack of work focused on the difficulties of each individual and on the peculiarities of each user.

The therapeutic activities offered by mental health services generally obey the functioning logic closely related to the concept of madness and the repercussions of work in the lives of individuals. Since conceptions of madness do not always resemble or diverge, rather they blend, it is possible to extract different discourses concerning the purpose of activities in the context of mental health. This is to say that the workshops can serve as a differentiated means to express creativity and the state of art, enabling displacements that re-signify individuals and work tools. Likewise, it is possible that there is an inverted trend, that is, that the activity is transformed in a way to submit the insane to ruling, providing a means for the insane simply to readapt to the context of society¹².

Based on this identification, we can consider the existence of four distinct (though complementary) discourses concerning therapeutic activities in mental health. In the first group, we have the "deficit discourse", in which the workshops serve as ways to entertain and treat madness. It is an old strand of occupational therapy, captured by classical psychiatry, and which we know and seek to overcome. In the second group we have the "discourse of the unconscious", in which the insane individual's psychic subjectivity and the possibility of symbolizing life itself is what matters, culminating in the ideal of appeasement. In third group is the "discourse of citizenship". Here, the politician of the Italian Democratic Psychiatric model prevails as a way to recover the most intrinsic aspects, such as autonomy and citizenship, which the insane lost due to the traditional psychiatric treatment. Finally, in the fourth group, we have the "aesthetic discourse" in which madness is seen as a potential creative artistic expression included in the cultural expression of art¹².

Given this context, it is necessary to rediscover the meaning of therapeutic activities in mental health care. The workshops and art, or the attitude of socially including the users, should seek one's achievement or recovery of daily life. One should not adapt to an already established order, but should be reconnected to the world, in which one can (and should) participate and transform as part of a process of the production of material life. Hence, therapeutic activities should truly be used as catalysts of existential territories through artistic or recreational actions or handcraft that favor the inclusion of those who have been excluded and the recovery of one's citizenship potential^{13 , 14}.

Psychiatric Reform, as a complex movement that possesses an eminently dialectical nature, has questioned the role of an entire structure surrounding care provided to the insane in the routines of community mental health services (actors, institutions, knowledge and practice). The problematization of therapeutic activities revealed the range of possibilities to act and be immersed in the practice of new care trends in the field, as well as the risk of adopting authoritarian and crystallized postures, which are compatible with traditional care models that the psychiatric reform itself fought against for more than 20 years to overcome.

It is worth noting that Psychiatric Reform only survives as a movement to promote the tension required to cause changes in reality. In this case, thinking on the diversification of therapeutic activities and on the fact they are amid a dispute between institutional reinvention and inertia, reveals the power of a movement that was born to question and challenge the entire set of absolute knowledge concerning the insane, insanity, and related relationships. It is in this context that reform advances and recedes, always loaded with new contradictions, ready to be overcome.

FINAL CONSIDERATIONS

The understanding of the participants reflects their concerns and satisfaction in relation to the mental health activities implemented in the substitute service. These also reinforce general tendencies concerning the work process, the functioning dynamics and the organization of the practices and how they see madness in these scenarios.

We expect this study to enable an ongoing discussion concerning the advancements and setbacks of Psychiatric Reform in the Brazilian context in order to encourage new perspectives about new (and old) issues among the staff, services, health work and care provided to those in mental distress.

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Publication Dates

• Publication in this collection
  Jul-Sep 2013

History

• Received
  16 July 2012
• Reviewed
  27 Sept 2012
• Accepted
  15 May 2013