The meaning of work for professionals in a substitute mental health service

Abstracts

The Psychosocial Care Center is seeing as a new strategy to address patients with mental disorders in that is has special features in everyday work that directly influence the practices developed by health professionals working in the area. To learn about the meaning of work for professionals working in a Psychosocial Care Center in the city of Belo Horizonte, Minas Gerais State, Brazil, a qualitative case study was conducted that included recorded interviews with 13 professionals from different categories. For data analysis, the technique of content analysis was used, and the results were as follows: professionals working in psychosocial care centers are satisfied with the new model of mental health care based on the anti-asylum proposal, and work fulfillment is due to the achievement of socially integrating individuals with mental disorders and helping them achieve autonomy.

Mental disorders; Health personnel; Mental Health Services; Mental Health

O Centro de Atenção Psicossocial tem sido visto como uma nova estratégia de atendimento ao portador de transtorno mental por possuir particularidades no cotidiano de trabalho que influenciam diretamente as práticas desenvolvidas pelos profissionais de saúde que nele atuam. Por meio de um estudo de caso qualitativo, realizaram-se entrevistas gravadas com 13 profissionais de diferentes categorias, a fim de conhecer o significado do trabalho para os profissionais que atuam em um Centro de Atenção Psicossocial da cidade de Belo Horizonte. Para análise dos dados foi utilizada a técnica de análise de conteúdo, com os seguintes resultados: a satisfação dos profissionais que atuam no centro de atenção psicossocial devido ao novo modelo de atenção à saúde mental baseada na proposta antimanicomial; a realização no trabalho pelo fato de conseguirem a reinserção social dos indivíduos com transtorno mental e os meios para o alcance da sua autonomia.

Transtornos mentais; Pessoal de saúde; Serviços de Saúde Mental; Saúde mental

Se considera al Centro de Atención Psicosocial como una nueva estrategia de atención al paciente de transtorno mental, por poseer singularidades en el trabajo cotidiano que influencian directamente en las prácticas desarrolladas por los profesionales de salud que allí actúan. A través de un estudio de caso cualitativo, se realizaron entrevistas grabadas con trece profesionales de diferentes categorías, objetivando conocer el significado del trabajo para los profesionales que trabajan en un Centro de Atención Psicosocial de Belo Horizonte. Para análisis de los datos se utilizó la técnica de análisis de contenido, con los siguientes resultados: la satisfacción de los profesionales actuantes en el centro de atención psicosocial en razón del nuevo modelo de atención de la salud mental basada en la propuesta anti-manicomial; la realización laboral por el hecho de conseguirse la reinserción social de los individuos con transtorno mental y los medios para el alcance de su autonomía.

Trastornos mentales; Personal de salud; Servicios de Salud Mental; Salud mental

INTRODUCTION

In recent decades, contemporary society has faced profound social transformations that demonstrate the hegemony of economic power and the growing influence of globalization on people and social dynamics. The characteristics of modern world values, such as efficiency, productivity, competency, excellence criteria, the customer, and product and performance, leave factors related to subjectivity in the background, including those of a mental and emotional nature that influence human behavior.

The difficulty of focusing on issues related to mental health in the workplace is evidenced by the growing number of people suffering from some type of psychological distress. According to data from the World Health Organization (WHO), psychiatric and mental health problems have become the leading cause of disability and a major cause of morbidity in society today^{( 1 )}.

Mental disorders, such as depression, alcohol dependence and schizophrenia, have in the past been underestimated because traditional approaches had only analyzed mortality rates, ignoring the number of years lived with the disability caused by the disease^{( 1 )}.

Also, according to WHO, of the 10 leading causes of disability, 5 are psychiatric disorders; and there are still those who have an undiagnosed disorder that can be considered subliminal, that is, they do not meet the diagnostic criteria for psychiatric disorders, but they are suffering and would benefit from interventions^{( 1 )}.

It is estimated that approximately 95 million people worldwide suffer from depression without appropriate treatment, and another 25 million unmedicated individuals also have problems caused by epilepsy. One in every four people worldwide are prone to developing mental illness throughout their life, and in most countries less than 2% of resources allocated for health is spent on treating mental and neurological illnesses; as a result, the majority of people with these disorders receive inadequate attention, which further worsens their situation^{( 1 )}.

According to Ministry of Health data^{( 2 )}, 21% of the Brazilian population need or will need attention and care from some form of mental health service. Of these, 99% get positive results from outpatient services, such as outpatient clinics, Psychosocial Care Centers (CAPS), and beds in general hospitals; however, 1% still require psychiatric hospitalization. In other words, at least 180,000 psychiatric beds would be required to treat such patients^{( 2 )}. Unfortunately, this need is increasing exponentially owing to the explosion of crack cocaine use in Brazil.

Mental and behavioral disorders constitute a major public health problem that has considerable economic and social effects. They affect people at their most productive ages, and often require monitoring by specialized professionals^{( 1 )}. Despite their magnitude and social impact, mental and behavioral disorders are not treated with the same importance as problems of a physical nature, and this differential treatment has implications in developing countries.

Mental health care policies have reflected the efforts of experts to provide specialized services and monitor patients with mental disorders, with focuses on social and family reintegration and changing the way in which the individual is viewed and treated in the health services network^{( 3 )}.

This redirection of the care model for mental health was inspired by the Movimento Nacional da Reforma Psiquiátrica (National Movement for Psychiatric Reform), which foresaw the phasing-out of psychiatric hospitals and their replacement by a network of territorial and community-based psychosocial care services nearly four decades ago. This reform movement also inspired a change in how to approach the so-called crazy defending their personhood and questioning the disability and dangerousness so often associated with them^{( 3 )}.

The project to replace psychiatric hospitals with an open network of mental health care services - the CAPS service - comprises institutions geared to treat patients suffering from mental illness, including care and attention to maintaining and strengthening the ties of these patients with their family members and society, with the ultimate goal of promoting their autonomy and citizenship because they are rejected by society^{( 4 )}. In this sense, CAPS facilitates the processes of autonomy, building rights, citizenship, and new possibilities of life, and should ensure access, openness, accountability, and the production of new types of care for psychiatric suffering^{( 5 )}.

From this perspective, the CAPS setting is of particular relevance to new mental health practices in the country. It is characterized as a strategic device in reversing the old hospital model; in addition to medication, the centers offer diverse activities, including individual and group consultations, therapeutic and creative workshops, physical and recreational activities, and art therapy^{( 6 )}. Moreover, CAPS programs involve family members and the community in the treatment, which features specific care and free access to the service^{( 7 )}.

The everyday work performed in the CAPS setting directly influences the practices developed by health professionals. Many who are currently working in this service were previously involved in traditional hospital activities, such as asylums. Mental health care is quite different in CAPS, as professionals focus on their relationships with their patients and comprehensiveness is the focus of intervention. For these professionals, care also involves the patient's family^{( 6 )}.

Human work has been changing throughout history. In the health sector, the work is unique because its product is consumed in the act and in its development, depending on the worker and whether the work's consumer participates actively or passively. The concept of interdisciplinary work, including the notions of embracement and listening therapy, individualized treatment plans, and psychosocial rehabilitation, requires the renewal and expansion of professional roles in mental health care^{( 8 )}.

In view of these considerations, this study aimed to understand the meaning of work from the view of professionals working in a CAPS center in the city of Belo Horizonte.

METHOD

This case study adopted a qualitative approach that allowed the researcher to incorporate questions of meaning and intentionality as inherent to the acts, relationships, and social structures of the object being studied^{( 9 )}. This was considered an appropriate strategy to investigate issues that are present in contemporary phenomena embedded in real-life contexts, as it can portray the daily lives of workers at a CAPS center, emphasizing the complexity of situations and identifying interrelationships among its components.

The research subjects were members of different professional categories (nurses, nurses' aides, physicians, psychologists, pharmacists, and social workers) of both genders, who provided care to patients with psychological disorders at a CAPS center in Belo Horizonte. The inclusion criterion was that the respondents should have at least 1 year of experience working in the institution, thus enabling greater knowledge of the services and directives that guide the working process. There was no a priori delineation of the number of respondents. This definition was adopted during the study, in accordance with the criteria of data saturation^{( 10 )}.

In qualitative research, classifying a sample as significant does not depend on the numerical criterion, given that the primary concern is with the depth and scope of the case studied. The option of data saturation is justified as one of the criteria used and recommended for qualitative research because it assumes the recurrence of the information contained in the interviews^{( 9 )}. Thus, data saturation occurred at the 13th interview.

The data were collected by means of recorded semi-structured interviews with pre-written questions. For data analysis the content analysis technique was used, which consists of a set of communication analysis techniques that reveal aspects and knowledge about the message that is intended to be explored through systematic and objective procedures^{( 11 )}.

Participation in the survey was voluntary. The participants were informed about the risks and benefits of the research, particularly the right to anonymity, according to the legal requirements of the Research and Ethics Committees of the Municipal Health Department in Belo Horizonte (CEP/PBH); opinion CEP/PBH Nº 07/2007 and the Federal University of Minas Gerais (COEP/UFMG) and opinion COEP/UFMG Nº 52/2006 were both supportive of the research.

RESULTS

A recurring aspect in the subjects' statements in this research was job satisfaction, which is related to their participation in the change process for the mental health care model because the new practices enable an overview of the patient, including the recovery of autonomy and inclusion within their family:

I think the main meaning is trying to enable the patient to have another quality of life that hospitalization does not provide (...) what motivates me is seeing the patient, they come, but they have a family life, and rightly or wrongly they sleep at home and have a bond with the family (I16).

For me, working in mental health is to assure, putting in to practice the patient's right of access to treatment, so they can be heard, valued and treated with dignity, and that this may become a return to the family. So that they can be set up in continuity, they can stay in the family, they can move, they can study, work and it is very rewarding for the mental health worker (I5).

Working within the new mental health service was considered as an main factor in the sphere of the personal lives of professionals, as it offers them the opportunity to learn and develop both as a person and as a professional, as well as showing recognition and appreciation of the worker:

I do not drink, but the rum that is this mental health, I drink that! Because, there is no way, once you enter, you cannot get out, because it is something that is challenging, it is enthralling. When you see that your work is paying off, you become enchanted, you say, Oh! Man, this is cool! (I5).

Here I redeem myself as a human being, before being a Professional, because I can see myself in the other person. While working here I feel professionally fulfilled in the sense that I'm contributing concretely to a citizen, which society, the family or community sometimes rejects, and I'm trying to rescue, to search for, you know? Patients who have been hospitalized for 20, 30 years, they are looking to redeem their personality. Who am I? Their identity is lost. It is the person finding themselves as a human being, and gradually and completely engaging in society, you know? I like what I do (I11).

What is a substitute service like? I find the dynamics interesting, how it tries to aggregate patients into society. The significance of helping others, this is what motivates (I14).

The professionals' feeling of belonging when providing such assistance is related to the usefulness and contribution of their work to society. In addition, they felt they were participating in the construction and verification of the contemporary model of mental health care:

It means believing in Psychiatric Reform, working in practice and seeing that which is theory working out, getting to work with critically ill patients, without getting locked away there, without being interned there for many years (I20).

It means participating in the construction of a project. For me it is gratifying to see this improvement, participating in the construction and maintenance of this new proposal (I9).

From the viewpoint of some of the professionals interviewed, the CAPS model of health care offers patients possibilities for change, reconstruction, and full exercise of their citizenship and autonomy:

Working in a substitute service helps, because you see what the patient has gone through, the patient who went through the process of admission, staying in Galba, in Raul or even in other hospitals. You see the way they are treated in a substitute service, feeling valued, feeling part of the process, even the improvement index for them is something else (I18).

It is possible for you to give the patient treatment with dignity, so that they can circulate many places within the network and really have a life, without them being excluded, and that they can be treated in a more dignified way (I5).

When we can get a user to start walking alone around town, and they can go to the Palace of Arts exhibition, the cinema, the Unibanco Plant, where the majority of the population does not attend, as it is a cult cinema, right, and we can get them in there, well, this gives us some return, we are indeed playing a role with these patients who had been excluded for many years (I6).

Regarding the dynamics of mental health care, it was evident that professionals recognize that working in CAPS is based on questioning, reflection, preparation and, above all, experimentation, with more dialogical interpersonal relationships, which justifies its clinic social impact:

Mental health is different from any other area, very different, because in a hospital you know the routine, today you will go, give a bath, give medication. Not here, here each day is one way, there are days when the patient is well, tomorrow they arrive agitated, totally different. The worst disease that exists is a mental one, because they are at the mercy of others, in the hands of others. Just like if you do not pick them up, do not put them in the bath, they do not bathe, sometimes you have to put food in their mouth because they are so bad that they cannot eat alone. It really is the mind that is not helping (I4).

Because I think in the entire health area the patient has to be cared for, but in mental health, it is much more, you know? It is not a surgical case, not a clinical case that has to be done there, changing a bandage and all. It is making them feel appreciated, make them feel like someone. You show them that they are someone. For me, that is the answer that I have, to see the difference in them(I3).

DISCUSSION

The new mental health service broke with the assumptions of clinical psychiatry established in the 18^th century when it consolidated a network of services currently implemented in CAPS, and its formalization as a core instrument of technology in the process of working in mental health^{( 12 )}. The CAPS centers were organized based on intense study of the form of mental health care that resulted from Brazilian Psychiatric Reform, which developed the idea of psychosocial rehabilitation directed towards achieving greater autonomy in patients with mental disorders^{( 13 )}.

The materialization of this new model of care in the national context of mental health care initially occurred through localized experiences, such as CAPS Luis da Rocha Cerqueira, São Paulo, in 1987; the Nuclei for Psychosocial Care (NAPS), Santos, in 1989; and CAPS Castelo, Pelotas/Rio Grande do Sul, in 1993. These experiences were later consolidated, and since 2000 the technical, administrative, and financial aspects have been standardized by regulatory instruments from the Ministry of Health and determined by Law Nº 10.216/01^{( 14 )}. There has been a rapid expansion in the CAPS network, which in 2006 totaled 1011 services. As of December 2010, patients with mental disorders were treated in the mold of CAPS in more than 1620 units throughout Brazil, increasing coverage to 66%^{( 15 )}.

As observed in the results, job satisfaction is an important aspect of the mental health professional's performance, given the need to host the patients, stimulate their social and familial integration, and support their search for autonomy-seeking initiatives. There are different goals from those expected in the biomedical model prior to the reform.

Based on these ideas, it is believed that professional activities that have a positive meaning for the worker facilitate both themselves and others. It is worth emphasizing that, for there to be a life full of meaning away from work, it is necessary to have meaning within that work^{( 16 )}. In the case of this study, significance would also fit this understanding. The new dimensions and forms of work broaden and expand the complexity of work activity, as they are also linked to the subjective feelings of the worker.

Performing a task without material or emotional involvement demands willpower, which is supported by motivation and desire^{( 17 )}. Although this cannot be seen in the results because involvement is explicitly stated by the professionals, it also highlights the motivation and desire to achieve work goals.

In the relationship between human beings and the significance of their work, it is plausible to consider two components: the object and the significant content in relation to the subject^{( 17 )}. This relationship must progress and advance, and if these are blocked for some reason, the individual may suffer at work. Work without these feelings can lead to alienation and suffering, in as much as they can be instruments in the service of emancipation and learning, as well as experimentation of solidarity and democracy^{( 17 )}. It is further understood that for humans the job itself is not an inevitable necessity, but rather it frees them as regards nature. Through work, individuals' needs are met and their goals achieved, which allows them to feel accomplished as a person^{( 18 )}.

Another aspect of the subjects statements in this research concerns job satisfaction related to their participation in the process of changing the mental health care model. The new practices enable a global view of the patient and contribute to their quality of life with regard to recovery of citizenship and inclusion within the family. The meaning of work in this respect is understood as an integral part of human life. You could say that for modern man, work mobilizes a range of psychological processes that affect individual and collective identity and the whole living experience of the subject in society ^{( 19 )}.

With these reports, it is also possible to observe that work in the new mental health service provides the professional with self-awareness and a means to produce meaningful activities. In addition, the subjects reported that feeling like participants in the work process provided greater self-awareness and improved the means of production, enabling them to develop freedom of choice in the context of work and, by extension, society, thus fulfilling their citizenship.

The work is characterized as an embodiment of something that adds value and contributes to society. Studies^{( 20 )} show that most people, even if they are able to live the rest of their lives comfortably, continue to work. Besides being a source of livelihood, work is a means of relating to others, feeling part of a group or society, having an occupation, and achieving life goals. In this study, the usefulness and contribution of labor to society strengthened the professionals' sense of belonging and made them feel as they were involved in the construction of the contemporary model of mental health care.

Another observation related to the meaning of work in the new mental health service that emerged from their comments refers to the treatment and monitoring of patients with mental disorders in CAPS centers. From the perspective of some of the professionals interviewed, the CAPS health care model offers possibilities of change, reconstruction, full citizenship, and autonomy for the patients. These reports indicate that the service practices a psychosocial mode of care in which the person is seen in their entirety, emphasizing the biopsychosociocultural and political factors as determinants of the illness^{( 13 )}.

Professionals say that the work process in CAPS has collective characteristics with respect to the work objective. That is, it takes the focus off the disease, body, and mind of the individual to centralize actions on a subject with desires and contradictions who is contextualized within a particular family and social group^{( 8 )}. In their comments, professionals emphasized that the patients who come to specialized mental health care do not have their needs met by the technologies used in specialties, but by creative efforts and sets of professionals that mobilize and articulate institutional, community, individual, material, and subjective resources to help the patient integrate into their social network^{( 21 )}.

Regarding the dynamics of mental health care, it became evident that professionals recognize that working in CAPS is rooted in inquiry, reflection, preparation and, particularly, experimentation in interpersonal relationships as dialogical and listening to each other, which justifies its clinical and social impact. With regard to the testimonies, it has been viewed that work on mental health should not be based solely on the identification of clinical signs and symptoms of the illness; rather, it should be guided by changes in human beings that disturb their entirety^{( 4 )}.

Actions directed at people with mental disorders are no longer a procedure or an intervention; rather, they are now a relationship in which one provides help to improve the patient's quality of life while respecting them, understanding them, and reaching them in a more emotional way^{( 3 )}. Furthermore, it is important that professionals see patients with mental disorders as citizens with rights and duties who share responsibility for their treatment and living conditions^{( 6 )}.

CONCLUSION

This research has elucidated the meaning of the work of professionals employed in a substitute mental health service in Belo Horizonte; their experiences demonstrate that their ties with the institution go beyond those of employment.

The new mental health care model based on the anti-asylum proposal led the professionals in this study to feel satisfied with their work. That is, it is possible to perform actions directed at patient integration into society through multidisciplinary activities involving education, work, sport, culture, and leisure.

For CAPS professionals, their work has meaning when they participate in the life and treatment of patients with mental disorders, with the goal that they achieve autonomy. When this occurs, they are reintegrated into society, providing the professional with job satisfaction and a sense of belonging in the construction and maintenance of the contemporary mental health care model.

Another aspect highlighted by CAPS professionals was the divergence between the processes of working in mental versus physical health. Mental health professionals claim that it is not enough to carry out a technical procedure or a medical intervention. Rather, it is important that relationships form between patients and professionals; these bonds facilitate empathy, respect, and understanding, which further motivate mental health professionals to help patients recover their autonomy.

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Publication Dates

• Publication in this collection
  June 2013