This study was carried out in a psychiatric crisis hospitalization unit, with the aim of drawing up a proposal for implementing therapeutic follow-up, as part of the therapeutic program at this unit. The concept of therapeutic follow-up was envisaged as an important resource to be included in psychosocial rehabilitation projects, with the following goals: linking users with extra-hospital services, avoiding rehospitalization and achieving inclusion in social networks. The study consisted of an exploratory-descriptive case study with a qualitative approach to the data. Participant observation and a field diary were the techniques used for data gathering and recording. The difficulties experienced were correlated with the spheres of social networks, family, institutional relationships and society. The results included heeding the patient's and the family's suffering and including users in social networks, extra-hospital services and community organizations.
Mental health; Mental health services; Therapeutic follow-up; Rehabilitation; Social inclusion