Children-Adolescent Psychosocial Care ambience: a study at CAPSi

Abstracts

O Centro de Atenção Psicossocial Infanto-Juvenil (CAPSi) organiza-se como um ambulatório diário voltado para crianças e adolescentes com transtornos mentais graves, configurando-se como um modelo de atenção pautado em bases territoriais e comunitárias. Por ser um novo serviço direcionado a crianças e adolescentes com transtornos mentais graves e entendendo que a saúde engloba os aspectos do ambiente, o objetivo deste trabalho foi conhecer e descrever a ambiência no atendimento de crianças e adolescentes com transtornos mentais graves no CAPSi da cidade de Vitória, ES. Foram priorizados os componentes expressos na forma da atenção dispensada ao usuário e da interação estabelecida entre profissionais e usuários. Empregou-se a técnica de coleta de dados da observação participante. Verificou-se, com base na teoria de Winnicott, que a presença, a atenção aos objetos disponíveis nos espaços, a sustentação e o manejo das atividades são aspectos importantes na constituição da ambiência na atenção psicossocial, pois podem facilitar o oferecimento de um ambiente seguro e adequado às necessidades das crianças e adolescentes que sofrem com transtornos mentais graves.

Serviços de saúde mental; Crianças; Adolescentes; Ambiente; Winnicott

Children-Adolescent Psychosocial Care ambience: a study at CAPSi

^IMaster's in Psychology. Psychologist at the Instituto Federal de Educação, Ciência e Tecnologia do Espírito Santo (IFES). Address: Rua Elizabeth Minete Perim, s/n, São Rafael, CEP 29375-000, Venda Nova do Imigrante, ES, Brasil. E-mail: [e-mail]

^IIPhD in Clinical Psychology. Professor, Department of Social Psychology and Development (DPSD) and Postgraduate Psychology Program (PPGP), Universidade Federal do Espírito Santo (UFES). Address: Av. Fernando Ferrari, 514, CEP 29075-910, Vitória, ES, Brasil. E-mail: [e-mail]

ABSTRACT

The Children and Youth Psychosocial Care Center (CAPSi) is configured as a daily outpatient clinic for children and adolescents with severe mental disorders. It is a healthcare model based on territorial and community bases. Because it is a new service intended for treating children and adolescents with severe mental disorders, and taking into account that health care involves aspects of environment, this study aimed to understand and describ the ambience of health care services for children and adolescents with severe mental disorders at CAPSi in the City of Vitória, ES, Brazil. It prioritized the components expressed in the form of care provided to users and interaction established between health professionals and users. The participant observation data collection technique was used. The study verified, based on Winnicott's theory, that the presence of and attention to available materials in these spaces, as well as sustainability and handling of activities, are important aspects in the constitution of the ambience in psychosocial care because they can provide children and adolescents who suffer from severe mental disorders with a safe environment, adequate to their needs.

Keywords: Mental Health Services; Children; Adolescents; Environment; Winnicott.

Introduction

In the Brazilian public health care system - Sistema Único de Saúde (SUS), the policy of humanization is a milestone in considering the environment in promoting health. One of the guidelines of this policy is to provide improvements in health care service environments, establishing physically comfortable, subjective spaces for more effective interventions, using appropriate furnishings, agreeable visuals, places appropriate for private conversations between users, valuing holistic attention to health care and encouraging commitment to health care and to the subjects (Brasil, 2004).

In the national literature, there a various studies which look at the importance of ambience in planning and implementing health care programs, so as to offer the user comfort, the possibility of subjective production and instruments to facilitate the work processes (Cohen et al., 2007; Gaioso and Mishima, 2007; Olschowsky et al., 2009; Schneider et al., 2009; Warschauer and D'Urso, 2009; Fontana, 2010).

Gaioso and Mishima (2007) emphasize that care within health care services can manifest itself in the environment referring to the physical space, and also in inter-personal relationships. Thus, they highlight the importance of paying attention to the health care service ambience, as they produce forms of healing.

For Olschowsky et al (2009) health care encompasses aspects of the environment which can be therapeutic. Health care and ambience cannot be separated, as they are co-related and inter-dependent. The authors state that understanding the ambience in mental health care enables the health care setting to be qualified, providing better quality of life for the users. They highlight physical structures, human resources and social relationships within the work space, aspects which characterize comfort, subjectivity and the work process are all elements which affect the treatment of the user

Franchini and Campos (2008) affirm the need to investigate factors which influence the work carried out in psycho-social care centers. The authors use Winnicott as a reference in ratifying the need for these services to provide an appropriate setting, with the aim of facilitating the patient's maturational process.

Based on Winnicott, Franchini and Campos (2008) state that in the CAPS there are often large numbers of psychotic patients: thus, an appropriate environment is essential in providing these patients with the care they need to experience, something which was not possible at earlier stages in their development.

Based on the importance of the environment in promoting health, the aim of this study was to understand and describe the ambience in caring for children and adolescents with serious mental health disorders in the Children and Youth Psychosocial Care Center in the city of Vitória, ES. This study prioritized components expressed in the form of care provided to the user and in the interaction established between health care professionals and users which, according to Brasil (2006), constitute the affective aspects expressed in social relationships, so important in the composition of the atmosphere.

Winnicott, an English pediatrician and psychoanalyst, emphasized the importance of the environment in human psychological health in his writing. Thus, we take his work into consideration, aiming to add greater reflection to the concept of ambience presented by Brasil (2010).

Environment in the theory of Donald Woods Winnicott

For Winnicott the environment plays a fundamental part in the development of the baby's health – without a environment which provides care, there is no baby. The environment may be harmful and lead to instability, producing disturbances in emotional development; or it may be facilitating, enabling healthy growth and development (Abram, 2000).

Winnicott's theory of human maturation is based on the individual's innate and inherited trend in the direction of development. Illness signifies gaps in development and it is only through appropriate care that the baby can move towards health. The author shows the importance of an environment which adapts itself to the baby's needs, fundamental to emotional development which encourages the integration of the individual (Winnicott, 1983d, 1994a, 1994c, 1997).

Emphasizing the environment's influence on the subject's psychological constitution, Winnicott (1983b) affirms that a baby does not exist without its mother, as it is though what he calls "primary maternal preoccupation" that the mother can adequately meet the baby's care needs. "Primary maternal preoccupation" is defined by Winnicott (2000d) as a special psychological state in which the other is capable of consciously and unconsciously identifying the baby's needs. This state is characterized as a phase of heightened awareness in which the mother adapts herself to the baby's needs in its first moments of life. When the mother reaches this state, what Winnicott (2000d) calls a "good enough atmosphere" exists, which enables the baby to move forwards in its development, achieving satisfaction and dealing appropriately with environmental reactions, which are not seen as intrusive but appropriate to the baby's capabilities at each stage of development.

For Winnicott the baby is, at first, totally dependent on its mother; little by little, when an appropriate environment is provided, the baby manages to evolve in the maturational process, passing through a stage of relative dependence before achieving independence (Winnicott, 1983a; Dias, 2003; Avellar, 2004).

However, if the baby is not provided with this environment during the initial stage, it is unable to constitute itself as a person and does not achieve integration (Winnicott, 2000d). For Abram (2000) this is a fundamental aspect of winnicotian theory: the etiology of psychosis lies in the individual-environment structure. Deficiencies in the environment may lead to devastating consequences for the baby's mental health:

In the initial development of the human being, the environment which acts as good enough allows personal growth to take place. In this case, the "I" processes remain active in an uninterrupted line of live growth. If the environment is not good enough, the individual starts to react to the intrusion, and the "I" processes are interrupted (Winnicott, 2000c, p. 389, author's italics).

For Winnicott (1994a) "fear of breakdown" is due to deficiencies in the environment provided for the baby, which can lead to: childhood schizophrenia or autism; latent schizophrenia; false self, and schizoid personality (Winnicott, 1983c). The author affirms:

in my view, certain types of anxiety exist at the start of childhood which can be avoided by good enough care, and which can profitably be studied. In my view, those states which can be avoided by caring properly for the baby are those which, when found in adults, would naturally be grouped under the term madness (Winnicott, 2000a, p. 165).

Winnicott, then, establishes the importance of environment in treating the patient, especially the psychotic patient.

For the author, in an analytical piece, it is fundamental to provide the patient with the opportunity to relive the situation of deficiencies in an environment which can meet his needs, so that he can resume the development process at his own pace. For Winnicott (2000c), in therapeutic work, both the technique used by the health care professional as well as the environment in which it takes place are important. Winnicott (2000c) clearly states:

Psychotic illness is related to an environmental deficiency at an early stage of emotional development. [...] The patient and the context amalgamate to create an original successful state of primary narcissism. [...] In this way, psychotic illness can be treated simply by providing a specialized environment, combined with regression of the patient (p. 386-384).

For Winnicott (1983c) environment should provide appropriate care and handling for the baby to move in the direction of integration, personalization and establishing relationships with objects. Holding, "handling" and "object presentation" provide conditions for the individual to develop.

When providing initial care such as feeding and changing, the mother holds the baby securely and handles its body, providing it with the capacity to be, it is in environments like this which the baby individualizes itself.

Object presentation, in turn, presents the world to the baby in an appropriate manner in which it can, gradually, come to deal with elements in its context. Thus, the baby moves and finds an object which the baby itself seems to have created, and if the environment can create this illusion in the baby, that whatever it needs is available, it can then develop healthily, relating itself to objects in the world around it and coming to realize the separation between I/not I (Winnicott, 1983c; Avellar, 2004).

Based on this theoretical perspective, a therapeutic environment may enable the deficiency which was processed at the start of the individual's development to be relived and given new meaning. Thus, the following description and discussion enable reflection on the environment in the psychosocial health care provided to children and adolescents, using Winnicott's theories in order to understand how different elements of the environment in a health care service can facilitate therapeutic work with children and adolescents.

Method

This clinical-qualitative research was carried out in the only CAPSi

Data collection

Participant observation was used to collect the data, which consists of the presence of an observer in direct contact with the phenomenon in question, aiming to collect data in the context in which they occur, in order to carry out a scientific investigation (Minayo, 1994).

As indicated by Becker (1997), the participant observer, in addition to observing situations in the context in which they occur, converses with the participants in these situations, discovering their interpretations of the events observed.

Thus, the results presented and discussed in this study take into consideration the meanings given by the participants in conversations which took place during the observations, enabling a more detailed description of the phenomenon in question. The observations followed a script covering aspects of the concept of environment as given by the Ministério da Saúde (Brasil, 2006, 2010). In this study, we considered the following components: the care given to patients; activities offered to users; and interaction between users and health care professionals.

Daily visits of around two hours took place, interspersed between morning and afternoon/evening visits. This was because it was noted that the routines were different depending on the patients and the team, which changed according to day and shift. Thus, we aimed to observe a variety of environmental contexts within the CAPSi. The criterion of data saturation was used so that, after three months, a degree of repetition was noted in the observations, indicating that the data collected were sufficient for the objectives of the research. Thus, 143 hours of observation took place between March and June 2011.

All of the observations in the institution were recorded, producing a field diary, an essential element for researchers using participant observation. The data were recorded immediately following the observation, at the CAPSi, in spaces where no activities were taking place.

Data analysis

To analyze the data, a specialization and refinement of the content analysis technique was used, as proposed by Turato (2003), given the characteristics of the clinical-qualitative method.

Firstly, Turato (2003) states that the data collected should be organized. In this case, the material organized itself throughout the research as, every day, after the observation, the data were recorded at the CAPSi itself. Thus, on the final day of data collection, the field diary, already organized, was completed. Secondly, the researcher skim read the field diary to familiarize themselves with the data as a whole. Thirdly, the material collected was organized, selecting the elements most relevant to the study from the original data. Finally, the work was edited with descriptions of the phenomenon investigated according to the data collected, as well as interpretation which added to the description of theoretical elements which enabled greater reflection on the organized material.

As stated by Avellar (2009), selecting the material form the research implies:

[...] a certain discontinuity, certain cuts and empty spaces which certainly, possess their own meanings, which are often passed over, with the aim of reducing the elements presented. In some cases, there are losses which are difficult to replace. It is a risk you take. (p. 16).

D'Allones (2004), based on Levi-Strauss, states that, often, it is not about the loss of material collected but about the constructing the study in the most comprehensible way. Resorting to bricolage, D'Allones (2004) cites Levi-Strauss, for whom the term has no pejorative connotation, as there may be many solutions to a problem. Bricolage, in this sense, provides the possibility of combining different edits without any rigidity, freely produing a new object.

In this research, given the large amount of notes, there was a risk of selecting those which enabled, in the view of the researcher, the CAPSi environment to be understood. Thus, what is thought, reflected and experienced in a research experiment which consists of interaction between researcher and subject is presented as a bricolage.

To interpret the data, Donald Woods Winnicott's theoretical framework was used, as presented above, concerning the fundemantal role environment plays in the psychological health of an individual.

Ethical aspects

The research project was presented to the Municipal Health Department of the Municipality of Vitória, ES, and to the director and the team at the Children and Youth Psychosocial Care Center, in Vitória, ES, in order to inform them of the objectives of the research and to obtain consent to carry it out. They were also informed that the results would be reported at scientific congresses and in articles, with the confidentiality ensured. It was explained that no identifying data on any users involved in the study would be divulged (Brasil, 1996). All requirements were met and consent obtained to carry out the research. This study was approved by the Research Ethics Committee of the Social Sciences Center, Universidade Federal do Espírito Santo (n.º 226/10).

Results and Discussion

The results and discussion which follow consider the components expressed in the form of care provided to users and in interaction between health care professionals and users, aspects of the concept of environment presented by the Ministério da Saúde (Brasil, 2006), based on Winnicott's theory, for whom the environment facilitates the psychological development of the individual. The results and discussion enable us to reflect on different aspects which can make up the environment in mental health care services for children and adolescents, and are presented in the following topics: arrival at the CAPSi, in which we reflect on the care the health care professionals provide to users on arrival at the service; the users' routine in the CAPSi, in which we discuss how the health care professionals interact between themselves and how that interaction reflects on the care provided to the users; and, finally, the activities developed by professionals and patients in the CAPSi, which aims to discuss interactions between professionals and patients in the activities developed in the service.

Arrival at the CAPSi

Arrivals are received by security personnel, who stay at or near the gate. Some children and adolescents showed closeness to this employee, which often proves important in effective entrance to the service, as, through conversation established at the gate, they can show their interest in entering.

After arrival, the children and adolescents can wait in the reception, waiting to be invited to participate in activities such as workshops, and individual appointments. While they wait, they can make use of the toys available in the reception. Or they can enter the service themselves, looking for someone with whom to converse and play, or for something to do. This freedom to make use of the CAPSi environment enables chance encounters with other patients and professionals.

As evinced by Souza (2003), the new organization of mental health care services contrasts with that of large psychiatric hospitals, which provokes changes in the relationship between users and health care professionals in the institution. For the author, the informal areas of the institution, places in which there are no programmed activities, such as the waiting room and the great, can provide rich opportunities for intervention.

In the CAPS investigated by Souza (2003) reflection on intervention in informal areas of the service lead to the team practicing an activity which they called environmental. In other words, the health care professionals organized themselves to be available in these informal areas, which enabled them to get to know the users better and also provided a constant and frequent presence to users in the institution, enabling a trust relationship at unforeseen moments.

In CAPSi investigated in this study, we did not observe the health care professionals systematically circulating in the service areas, but we observed that some of them, depending on their clinical understanding, circulating in different areas of the CAPSi, providing their presence and listening to and welcoming the patients at times when no programmed activity was taking place.

In Winnicott, as affirmed by (1999), the central characteristic of the environment facilitating human maturation is that it enables the experiences of trust, as there will be someone concerned with ensuring the environment is regular, monotonous, i.e., predictable. As the author explains, "the baby can only retire to relax because they begin to trust, through repetition of the experience, that the world will remain alive and will stay that way for as long as the baby needs it to" (Dias, 1999, p. 294).

It was observed that having professionals circulate in the areas of the children and adolescent's mental health care service may enrich therapeutic work, as in enables them to know the users better and to create connections with them, as well as enabling the children and adolescents to trust the environment to meet unforeseen needs, by the constant presence of someone to look after them if necessary.

In the definition of environment, the Ministério da Saúde (Brasil, 2006) states that the affective component, expressed through the welcome and care provided to users of health care services, is essential to creating the environment. Thus, it was verified in this study that affect in the relationships between users and health care professionals can be expressed through having a constantly present figure, as this may facilitate the patients experience of predictability in the environment and, moreover, facilitate communication that perhaps would not occur in a group or workshop. Often, the patients talk about their experiences at the gate or through material provided in the waiting room, which prove themselves to be good opportunities for intervention.

The children and adolescents' routine in the CAPSi

Within the CAPSi service, the children and adolescents are cared for by different health care professionals, depending on the day, the shift or what the team see as appropriate to their treatment, according to the Individual Treatment Plan

The differences in the interventions of the teams on the different shifts in the CAPSi demonstrate the challenge of interaction between different professionals which, according to the Ministério da Saúde (Brasil, 2006, 2010), influences the environment within health care services. At some points, difficulty was observed in coordinating interventions, especially taking into account different professional training which led to prioritizing of different aspects of therapeutic work.

It was verified that the different technical-theoretical behavior of the health care professionals could interfere with the environment offered in a mental health care service, as the actions are directed by different foci according to each professional's training and approach. As noted by Maalouf (1998), the heterogeneity of the teams with regards theoretical and technical approaches, sometimes conflicting, produce discord between professionals, resulting in "[...] a disjointed technical-theoretical ‘body', reflecting what is found in the psyche" (Maalouf, 1998, p. 4).

As stated by Winnicott (1983c), integrating the human ego only occurs under favorable environmental conditions; and when the environment does not adequately meet the baby's needs, the psyche may configure itself in reaction to the environment which failed to facilitate human maturation.

Based on this theoretical perspective, differences in interventions by the teams on different shifts at the CAPSi – one prioritizing more individual activities, the other valuing group interventions – may facilitate understanding the complexity of psychological suffering, bearing in mind the integration of different types of knowledge and practice in a single theoretical-technical unit. However, this difference is the motive for internal conflicts, considering the clinical understanding of each health care professional, which can produce the organization or a divided, unintegrated team.

So, many things that could be used to encourage treatment – different spaces and interventions making up a wide range of ways of meeting the users' needs – sometimes appears as a challenge. The spaces are often not designed based on the patients' needs but rather according to the organization of the professionals, who do not appear to use their different skills to diversify patient interventions.

With regards to the CAPSi routine, it was observed that many of the children and adolescents appeared to turn to the service in order to eat. When they arrived at the CAPSi for group activities, they received a snack which, in general, in the mornings, marked the start of the health care professionals' work. Normally, at this time, the health care professionals greeted the users and offered activities. In the afternoon, the snack generally marked the end of work.

It was noted that in the CAPSi, the snack represented a routine for the patients. For Winnicott (1994c) we need to be attentive to the communication which accompanies the process of eating. The baby's need for food needs to be understood by the mother who can provide it. The mother's adaptive behavior makes it possible for the baby to find everything it needs and expects in the environment. For example, waiting for the baby's movement in direction of the breast is important, as it enables it to find the object it needs in the environment.

Schlichting et al (2007), aiming to study and discuss the experience of lunch as a moment for treatment in an information and reference center for alcoholism and drug addiction, stated that preparing a suitable environment for lunch for the female alcoholic led to group work emerging: "the setting of the lunch set the necessary tone for the women to manifest almost childlike emotions" (Schlichting et al., 2007, p. 387, author's italics). Thus, the authors affirm that the health care professional, on preparing the place and organizing the eating ritual for the group, takes into account the specific subjects which make up the group, provide integrated care to that group, an arrangement which is fundamental to creating a link between health care professional and client.

In the case of the CAPSi, the fact that the snack is served at a set time and with a nutritional pattern, may often make it difficult for the professional to be available to meet the particular needs of each patient, as the needs of the collective need to be met first. And the communication which may emerge while eating, through an environment suitable to the specific needs of each child and adolescent, pay be lost by the uniformity of the organization of snack time.

Therefore, the care given to the users is important, as set down by the Ministério da Saúde (Brasil, 2006, 2010), for example, paying attention to the general space used by the patients as, as reported, many possibilities for intervention can occur during snack time, as nutrition does not necessarily materialize in the food, but also in the environment which the care conditions provide, appropriate listening and welcoming, to meet the needs of each subject in a particular way.

Activities developed by the health care professionals and the patients in the CAPSi

The children and adolescents are offered different activities, such as individual and group sessions and workshops. Materials such as paper, pencils, paint, balls, puppets, musical instruments, toys and costumes are sometimes available.

According to Khan (1984), it is important to be aware of the setting offered to the patient, which is characterized by the physical environment provided by the analyst, with the configuration appropriate to the patient, including furnishings, light, the room and the presence of the analyst, as this can enable needs to emerge which were not satisfied at a previous point of development.

Thinking of the paradigm of the mother caring for her baby, the elements which make up the environment may facilitate the first object relations, as the baby starts to relate to the external world through object presentation. As Winnicott (1983c) explains:

The pattern is the following: the baby develops a vague expectation which originates in an unformulated need. The mother, adapting, presents an object or a movement which satisfies the baby's needs, so that the baby starts to need exactly what the mother presents. In this way, the baby begins to feel confident in its ability to create objects and create the real world (p. 60).

In this way, the activities provided in the CAPSi environment may enable children and adolescents to find objects of need. Thus, it is important that the health care professionals are attentive to what they provide to the patients, as, from Winnicott's (1983c) perspective, if the baby is given the object of necessity in place of what was expected, it can create what was there to be found.

Therefore, observing the patient's need and the materials with which they connect and express themselves is shown to be fundamental for significant communication. Sometimes, for example, a child who does not like to converse and shows defiant behavior becomes engaged with activities using musical instruments.

However, some professionals took him from this activity in order to play a memory game with the name of the patients. The memory game, at that time, led to chaos, the users were not engaged, and the game appeared rather to meet the needs of the health care professionals to carry out some kind of intervention, one associated with education and formal teaching.

This episode highlights the importance of being attentive to the materials provided to the patients in mental health care services, as they can enable the children and adolescents to find objects which satisfy their needs, including the act of creating reality.

Once again, the importance placed by the Ministério da saúde (Brasil, 2006, 2010) on the attention given to the user is highlighted, as it is only in this way that the objects with which they connect can be noted, with the aim of providing them with an environment suited to their needs.

Avellar (2004) states that, often, leisure activities can encourage a setting suitable to the needs of children and adolescents. As these patients have a different way of communicating psychological distress, verbal intervention is not always the most effective instrument. For the authors, working with children requires the analyst to provide leisure activities, allowing the patient's material to appear spontaneously, based on the relationship of trust built established on the care provided by the analyst and on the objects available in the environment.

The activities offered to the children and adolescents may also include the following types of workshops: cooking, art, stories and creativity, as well as expressive groups and groups with adolescents. Some health care professionals try to define the activities of the groups and the workshops, saying that they are not without direction, but rather have specific tasks according to the group from which they are formed. According to them, some workshops are not previously structured, but they state that: the children and the adolescents do something.

Meeting the demands of the patients every day, taking into consideration the specificities of each subject who makes up the group, this is work which values individuality. However, the lack of rules in the running of the workshops may affect the engagement of some of the users as, according to Maalouf (1998), norms and rules can work as organizers set limits for the patients, enabling them to establish a minimal framework for the activity to be carried out and its participants. According to the author, the workshops should offer the ability to create a bond, an intervention, listening, welcoming and care. The resources used in the workshops aim to construct an environment among health care professionals and the children through "holding".

For Winnicott (1983b) "holding" consists not only in the physical holding of the baby, but in all environmental provision given to it, which enables total experience of the beginning, middle and end. Thus, the workshops may offer surroundings, a feeling of being held in a safe environment which, for the author, enables the baby to develop the confidence that the environment will provide its necessities.

The workshops enable not only "holding" but also "handling" to take place though adapting the environment to suit the needs of the patient. Winnicott (1994d) underlines the importance of the baby's caregiver being attentive not only to physical aspects, handling the body, but also to the psychological aspects, dealing with the baby's needs as a person. Being available at the right time, or even being concerned with keeping the physical space at the right temperature implies communication which can meet the basic needs of the person being cared for.

"Holding" and "handling" enable an environment to be provided which not only meets the patient's physical and psychological needs but also enables integration. The lack of this primary care in the baby's development leads to a defensive organization, which is related to a deficient facilitating environment, which, for Winnicott (1994a), is what occurs in psychological illness:

Through good enough care, through general holding and handling techniques, the shell is gradually overcome and the core (which until then gave the impression of being a human baby) can begin to become an individual (Winnicott, 2000a, p. 166).

Therefore, in the workshops, preparing the environment is related to providing an appropriate physical environment for the proposed activity, so that holding can take place in an organized time and space, with the presence of an individual available to communicate with the patients, so that initial care, which was deficient, can be offered in an appropriate way, allowing them to develop from healthy bases.

However, in some of the workshops, chaos, restlessness, aggression and lack of limits made it difficult for the health care professionals to operate, affecting the establishment of appropriate holding and handling. This context reduced the interventions to discipline and order.

Once, in view of the children's agitation, the health care professionals mentioned that it had to do with the phase of the moon. This was also mentioned by Maalouf (1998):

When we say, on days that the children are very agitated: ‘the witches are loose', ‘it's a full moon today', it was of course not really this that was processed, but rather they were chaotic moments, times when the team was fragmented and this reflected in the work, and vice versa. Psychological countertransference affected the team, or part of it, and their capacity to think, to be therapists, to care and to hold were lost. Non-integration of the children led to fragmented moments, which unbalanced the professionals. We still operated with a causal, deterministic, explanatory framework, when often there was not one or even several causes for the chaotic of distressing situation, but rather it was because of the moment of life and existence that the children were experiencing (p. 84).

As Maalouf (1998) puts it, health care professionals are often "swallowed" by the disorganization of the patients, by the fragmentation which psychosis presents, leaving them incapable of thinking or intervening.

Mental health intervention for children and adolescents have shown themselves to be challenging and difficult, whether because of a lack of parameters to psychosocial care or because of the complexity of dealing with madness which, often, as indicated by Winnicott (2000b), captures the environment.

An appropriate intervention may occur through the presence and availability of a professional listener. Once, a health care professional was conversing with an adolescent, saying what he thought he should say about himself, his house, his problems, as he often attended the CAPSi just passing though. The health care professional explained to the adolescent that the service should be there to help him in some way, adding that he would be there to listen to him. The adolescent left for a few minutes, then returned and asked to talk with the professional.

In this case, we can observe how the health care professional moved in the direction of welcoming and listening to the patient, and later signaled his availability and presence, waiting for the adolescent to make the move. As in the Squiggle Game, presented by Winnicott (1984), it is necessary to create means of entering in contact with the patient. In the squiggle game, the analyst draws a mark and waits for the child to move to construct something from the squiggle, with the aim of communicating elements of their experience. The availability of the analyst is, therefore, essential, as they make a gesture and then await the patient's gesture, hoping that the material communicated can be used in the therapy.

For some patients, the care provided by the health care professional, such as providing and maintaining the setting, is more important than interpretive work. In these cases, the therapeutic environment should enable regression to the needs which were not satisfied at the beginning of development, to provide them now and give them significance (Winnicott, 1994b). Thus, attention to the setting is needed, which translates into the preparation of the CAPSi activities, as they may facilitate communication being established.

Children and adolescents with serious mental illness are still historically associated with patterns of social work and educational intervention requiring protection and discipline. However, the new mental health care services question such interventions, requiring new forms of operating.

The environment, as the topic of this work, provides the possibility of thinking about interventions constituted in these new mental health care spaces, showing that the organization of the health care service environment can contain elements which facilitate therapeutic work, such as: the constant and frequent presence of someone who can look after the environment, meeting unforeseen needs; interaction between the health care professionals, as interventions can be designed according to the organization of their different types of knowledge; attention to the spaces used by the patients, with the aim of providing an setting appropriate to the users' needs, in which meaningful experiences can be communicated.

It is important to observe the activities and material provided in the CAPSi environment and the materials with which the patients connect, as they may enable the children and adolescents to find objects of necessity, essential in expressing meaningful communications which would be difficult to express in other ways.

In this study, it was observed that the environment in children and adolescents' psychosocial care not only involves having a physical space appropriate to the activity proposed for the users, but also involves the holding given to the activity by the health care professional, the time and space and the handling provided through adapting the environment to suit the patients' needs.

Final considerations

On including the environment as one of the aspects of the SUS humanization policy, the Ministério da Saúde, showed the importance of considering the environment in promoting health. In the area of mental health care, in the new models which are substituting the psychiatric model, the environment highlights the spaces of the services as facilitators in the therapeutic process, as they can influence the construction of care activities.

From this perspective, Donald Woods Winnicott's theory can facilitate understanding of the function of the environment in the individual's psychological development, enabling the elements which constitute an environment suitable for therapeutic work to be discusses. Presence, attention to the objects available in the spaces, holding and handling in the activities, for example, are important aspects in the environment in psychosocial care.

The CAPSi, as a new mental health care service, enables free circulation of the users through the service spaces, which provides new possibilities for interaction between users and professionals. Freedom in using these spaces may give the patient and their relatives more confidence that their needs will be met, as facilitated access to different elements of the atmosphere may enable understanding of the meaning that the subject makes of themsleves and the world, encouraging communication of mental states, which would otherwise be difficult to articulate, through the use of environmental objects.

Moreover, considering the interactions established between health care professionals and patients, a constant presence of health care professionals in the areas, available to listen, seems important for patients with psychological disorders, as it brings the possibility of experiencing a predictable and reliable environment, in which there is someone to take care of the environment, even in the case of unforeseen needs, in contrast to the environment that failed in providing the initial needs.

It was also found that the environment in a health care service can be influenced by different health care professionals who structure it and by their interactions, in view of their different objectives of study and intervention. Thus, a team of several health care professionals must prioritize integrated work, so that different knowledge can facilitate the understanding of the processes of human illness, aiming to provide an environment appropriate to the therapeutic process, making it more difficult for psychological fragmentation to be reproduced in work relationships.

The activities developed in the CAPSi should aim to structure a secure and reliable environment. Through handling, holding and object presentation, health care professionals can provide an adequate environment in order to meet the needs of children and adolescents. Thus, workshops and individual sessions must be offered by health care professionals as a possible situation in which experiences can be communicated and new environments experienced.

For Winnicott, the possibility of intervention is in a setting that allows the patient to regress to the time in their development when the environment failed to adequately meet their needs, so they are cared for and given the possibility of existence with meaning. Thus, his theory allows us to reflect on the creation of the environment in children and adolescents' psychosocial care, making it clear that providing an adequate environment in health care services is possible, when the needs that children and adolescents present and the materials with which they connect and manage to express themselves are observed, enabling the sharing of experiences through health care professional's presence and listening, facilitating the development of therapeutic work.

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¹

Juliana Peterle Ronchi^I; Luziane Zacché Avellar^II

²

in the state of Espírito Santo, located in Vitória, the state capital. According to Turato (2003), the clinical-qualitative research method is a specialism and refinement of the qualitative method which records clinical-psychosocial aspects, thus being appropriate to describe and understand phenomena in the environment of health care services. In this research, we aim to present elements of the environment in mental health care services for children and adolescents.

³

. We observed that, in general, the professionals who made up team on the morning shift prioritized privacy during sessions and the use of specific spaces individually, whereas those in the afternoon shift valued group sessions with various professionals working together.

Publication Dates

• Publication in this collection
  31 Jan 2014
• Date of issue
  Dec 2013

History

• Received
  21 Apr 2012
• Accepted
  05 Mar 2013
• Reviewed
  18 Dec 2012