Work and illness risks in Territorial Psychosocial Care: implications for mental health care management

The study aims to analyze precarious work due to working conditions that influence the management of mental health care and occupational health. This single case mixed study was conducted in six Psychosocial Care Centers (CAPS) in a Decentralized Health Sector. The Work and Illness Risks Inventory was applied to a total purposeful sample of 35 workers, 15 of whom participated in the projective interview. Data were processed in SPSS 26.0.0.0 as measures of central tendency and dispersion. The interviews were categorized based on the evaluation axes proposed by the inventory, contextualized, and discussed from Edgar Morin’s Complex Thought. The result is critical for most predictors that evaluated the context, human cost, pleasure, distress, and harm related to work in the CAPS. Data illustrated by the workers’ narratives describe the precarious work conditions. Local Unified Health System managers quickly incorporated neoliberalism’s productivist principles, perpetuating substandard work conditions. Mental


Introduction
The vaunted modernization of labor rights currently in force in many countries, including Brazil, carries some elements that feature precarious work in the face of the loss of rights and social security, scrapping services, low wages, fluid recruitment rules and formats, and the non-guarantee of occupational safety 1 , which has been implemented in the Territorial Psychosocial Care (APT) against the logic of building what was intended as a new paradigm for mental health care proposed by the Brazilian Psychiatric Reform Movement (MBRP).
Today, the modernized Consolidation of Labor Laws (CLT) is not aligned with the development of a State policy on mental health, which can offer psychosocial services aimed at the subject-family-caregiver-community in its entirety 2 and is the foundation for developing work in the APT, through which it seeks to build care through humanizing care, appreciating workers and producing interdisciplinary, community-based creative work, essential for individual and collective mental health 2 .Thus, workers' health has been weakened due to insecure working conditions, especially given the possible psychosocial risks of practices developed in Psychosocial Care Centers (CAPS) services.
If nothing is done, mental health care management as a set of organizational theories and practices, amid the production of nonhierarchical, collaborative, and interdisciplinary work 3 , will tend to permanent fragmented care, communication, and human relationships.These tend to affect workers and the entire production chain required for implementing APT, which is the interrelationship between the users-family-caregivers-communities-professionals groups.It tends to extreme conditions that foster human body, mind, and soul illness due to the work conditions 4 .
To this end, we should debate this event in permanent dynamics in its agreements and disagreements so that the elements of precarious work in the APT can be addressed in the real world.Therefore, the mixed and blended complexity of the parts and the constituent whole must be understood in their convergences, divergences, and contradictions 5- 7 .Thus, the study analyzes work precariousness from the working conditions that influence mental health care and occupational health management.

Material and methods
This is a single case study 8 on the influence of precarious work on mental health care and occupational health management in the APT anchored in methodological triangulation, employing critical, analytical 9 , quantitative/qualitative exploratory techniques, considering its complex, common, and longitudinal nature.
Its setting was six CAPS from the Decentralized Health Sector (ADS) of Crateús, Ceará, Brazil, comprising 11 municipalities, of which five had Caps, namely Crateús, Novo Oriente, Nova Russas, Monsenhor Tabosa, and Tamboril.The demand of clients of other cities -Ararendá, Independência, Ipaporanga, Ipueiras, Poranga, and Quiterianópolispresent there is covered by services in neighboring cities, according to intermunicipal agreements or by local Primary Health Care services.
The ADS is a set of municipalities grouped by regional, socioeconomic, and cultural characteristics, which form a Health Region (RS).The Crateús ADS is, therefore, part of RS Norte, with a population size of 300,372 inhabitants in 2022 10 .
The study was divided into two stages, meeting the following inclusion criteria: midlevel or higher education-level professionals with at least six months seniority in the CAPS actively participating in these services' mental health care processes.Professionals on vacation, on sick leave, or with conflicts of interest were excluded.Thus, the Work and Illness Risks Inventory (ITRA) was applied in the first stage.Projective interviews were held in the second stage.Fiftyone questionnaires were distributed in the first stage of the study, making up the 'total sample of CAPS workers' within the inclusion criteria, with (n=35) responses (31% loss).These professionals had the following types of employment relationships: public servants (12), temporary contracts (12), cooperative members (six), residents (three), and CLT contracts (two).This is, therefore, a total 'purposeful sample' organized into two groups: .Box 1 describes the organization of the ITRA scales.The inventory was designed based on the dimensions of the life-work interface and the subjectivation of these concrete fields, considering the context, effects, and causes that work implies in life, especially health, affecting workers' way of existing.Thus, the ITRA aims to investigate work and the resulting risks of illness by describing the work, occupational/ psychosocial health, and safety contexts.The instrument was validated per Mendes et al. 12 .This article will present the data analysis on the classification of the primary means of the items on the EACT, ECHT, EIPST, and EADRT scales.The factors and predictors were analyzed as satisfactory, critical, or severe.Satisfactory indicates a positive result related to the production of pleasure at work.Critical indicates an average result, an indicator of an extreme situation, with negative costs and work distress, signaling an alert condition and requiring immediate measures in the short and medium term.Severe is a negative result, which produces human costs and work distress.It produces a substantial risk of illness and requires immediate action to address the causes and resolve them 12 .Statistical analyses were performed using SPSS 26.0.0.0® software, and data were expressed as measures of central tendency and dispersion.

Work
In the second stage, participants' adherence was reduced due to work overload, lack of time, non-availability of a restricted location to hold interviews, and fear about recording interviews, which would be recorded by Google Meet in view given content addressed, characterized by one of the respondents as 'politically conflicting' for professionals to remain in employment.Thus, 15 interlocutors participated in this phase, including: • Group I -Coordinators (five participants): three nurses and two social workers.
• Group II -Healthcare Workers (ten participants): seven psychologists, one nurse, one occupational therapist, and one social worker.
The reduction in participants did not harm the analysis of the event since information saturation was reached, ensuring the quality and reliability of the interviews produced.The analysis occurred by organizing and systematizing statements per the ITRA pre-existing categories, which focus on assessing work organization, working conditions, socio-professional relationships, occupational health, professional achievement, freedom of speech, lack of recognition, and lack of freedom of speech.
Initial stage data were discussed grounded on Edgard Morin's Complexity Theory 5-7 based on the critical analysis of the statements and literature relevant to the investigated object.It is, therefore, an active and creative proposal that contextualizes the problem in the face of reflections over uncertainties, incompleteness, and doubts about the objectivity that initially emerges in the observer-researcher's eyes.
This thought proposes to fight against the simplification of the event, which reduces the meanings before the multidimensional object, the non-linear cause-effect proposed by the retroactive circle, the mutual producer-product repercussion from the recursive circle's perspective, in which the aim is to break the event's duality through dialogical thinking, which seeks to promote the reintroduction of knowledge in all knowledge, given the object's historical, political, and social becoming 5-7 .
The Research Ethics Committee of the State University of Ceará approved the study under CAAE: 46699621.2.0000.5534and Opinion N° 4.784.241.The participant's anonymity was preserved through codes corresponding to the letter P= Professional, with the acronym CAPS, and the interview order, as in the following example: (PCAPS1).

Results and discussion
The results with the application of ITRA (n=35) in the EACT (table 1) showed a critical illness risk classification for the three factors: work organization, socio-professional relationships, and working conditions, therefore indicating an extreme situation, with negative costs and distress derived from working in the APT.
The critical risk represented in the predictors underpinning work organization, socio-professional relationships, and working conditions factors of the EACT suggests strong characteristics and elements that represent and are concrete precarious work related to the excessive work pace, pressure to achieve tasks/goals, demand for results, and disrupted actions, with a possible division of labor 3 due to the organizational hierarchy established by local management regarding action planners and executors.This situation contributes to possible hurdles and power struggles and is, therefore, a set of factors escalating the work but not producing APT.
In this context, the organization of work and socio-professional relationships in the APT also suffer from the CAPS working conditions due to insufficient supplies and materials, inadequate and irregular facilities, acoustics, and furniture, which hamper mental health management and affects the occupational health of workers in these services.Other studies with mental health workers provide results similar to the data in this research.The main problems are associated with the fragile public management of services, which has intense repercussions on work organization, socio-professional relationships, and substandard conditions of services 14- 16 .
The PCAPS2, PCAPS3, PCAPS5, and PCAPS11 reports bring, as information, the illustration of the materialized predictors (table 1) referring to the organization of work and socio-professional relationships experienced on-site at the CAPS.The professional psychiatrist has reduced hours.While I and other colleagues work eight hours a day [...], the psychiatrist works three shifts a week.So, many patients are left waiting.First, they go on a waiting list [...], and he will work with the pent-up demand of several days that still needs to be met.It turns out he's not even part of the team.He comes to provide service: diagnose, provide certificates, prescriptions, and referrals.(PCAPS9).

Weak employment contracts imply changing professionals. This ends up breaking the bond with the patient. This relationship of changing professionals is not a good thing: the patient feels abandoned. I have received patients who felt abandoned because the professional left. The patient needs to understand that the professional left for contractual reasons. (PCAPS12).
The statements show recursively 7 the CAPS public management weaknesses.These, in turn, trigger some harmful effects on developing mental healthcare management, such as fragile work relationships, which lead to work discontinuity, specialization, and centralization of mental healthcare practices restricted to CAPS; poor understanding of how APT works, which corroborates the insufficient continuing education for managers and other professionals in the territory and health education for family members/caregivers of clients of these services; and poor management of financial resources or deficiency, to adapt the structure, furniture, supplies of the CAPS, besides instability and duality 7 , which are the diverse and precarious types of employment relationships.
How could one develop a therapeutic project with fragile work relationships that may last less than twelve months?The therapeutic processes consolidated by APT knowingly aim to rebuild the autonomy and citizenship of CAPS clients through individual and collective actions to re-establish mental and physical health amid their socioeconomic conditions 2 , on a pathway that seeks to project a new conscious, autonomous, and self-producing becoming.
We understand that the central cause from the viewpoint of the retroactive circle 7 includes neoliberal principles, relaxing employment contracts, and reducing financing of SUS public services, according to the private market rules, which tend to require high production with a minimum commitment of resources 4 .Along this path, the constant becomes escalating work processes to meet the goal of high production (appointments, prescriptions, referrals, and certificates), assigning significant exchange value regarding the low production of mental health.
When analyzing the ECHT, we note that it had a critical risk classification for the affective, cognitive, and physical cost factors (table 2), indicating an extreme situation with negative cost and labor distress.Such results signal a warning when compared with data from the application of ECHT to nursing workers in a reference psychiatric hospital in Teresina, Piauí 17 .
The affective and physical costs were satisfactory in the study in question.Only the cognitive cost was considered a critical risk due to the work complexity with clients with severe conditions, chronic situations, or who have been hospitalized for a long time 17 .It warns that this precisely occurs because this service originates from and is instead aligned with the Classical Asylum and Psychiatric models 2 : the former is focused on the exclusion and marginalization of untreated clients; the latter centralizes mental illness in the face of biomedical-assistentialist and curative practices, which oppose the APT model, considered innovative and original because it stemmed from the community that formed the MBRP, which established the CAPS in its various classifications, as a replacement model for the hospital-centric/asylum model.The PCAPS4, PCAPS7, and PCAPS13 reports discuss the implication of the affective, cognitive, and physical cost factors in their lives as CAPS workers.Given the statements, we can deduce that, even with the implementation of an APT network from scratch, in this ADS in Crateús, Ceará, Brazil, where psychiatric hospitals never existed, implementing the APT through the CAPS faces hurdles that do not substantially favor political and social acceptance of the ideal ways to manage mental healthcare to produce authentic and positive impacts for the APT.

Management often asks the CAPS team to carry out non-CAPS activities, such as how to support other campaigns that CAPS could develop, but in another way, like the Pink October campaign. They put us on the street and the radio, and we do everything. However, that ends up shifting the focus. I already said, 'Let's work on health cam
We see a clear overlap of actions repelling each other but coexisting in a predatory manner within the same system, given the struggle waged by the APT against the hegemony of the old models, such as the Classical Asylum and Psychiatry models.This factor was also reported in the study by Feitosa et al. 18 on the models and paradigms guiding multidisciplinary work in CAPS in a Brazilian municipality, strongly associated with the understanding of public, curative, and medication-related health, which marginalizes and causes dependence 19 in clients of such services.
The EIPST had a satisfactory risk classification related to work pleasure.Thus, it was a positive result associated with the dialogued production of work between the members of the CAPS teams.Concerning the appreciation and recognition factor, the illness risk classification was critical.Both professional burnout and lack of recognition had critical risks (table 3) and were characterized as extreme situations due to the negative cost and work distress.Pleasure at work related to freedom and professional fulfillment was correlated in studies by Fidelis et al. 14 and Trevisan et al. 15 , mainly with the excellent relationship and integration between team members, who tend to produce collective work in a given way, considering the professionals' sensitivity to understanding the problems faced by their peers in the face of CAPS clients' needs and issues.
Based on recursive thinking 7 , we understand that this work form is close to what is desired as APT, as it favors shared management and interdisciplinarity, as shown by PCAPS10 and PCAPS14.

[...]
There is much dialogue with the current coordinator, a whole issue considered so that you are well.He has that perspective and is a partner.As a coordinator who knows CAPS comes in and familiarizes with the health structure with a modern mindset.He treats the client as a person with rights, making us more comfortable.(PCAPS10).
Interdisciplinary group work is positive.It flows better; we interact more with patients, and our peers collaborate whenever we need individual care.You call, they come, they are available to work with you, depending on your needs.We feel safer making some decisions, even regarding the service.(PCAPS14).
Appreciation and recognition tend to be unsatisfactory due to the effects caused by professional burnout and lack of recognition, which generate work distress from work overload and the devaluated mental health production developed by CAPS workers.These effects were reported in studies with CAPS professionals by Fidelis et al. 14 and Trevisan et al. 15 , and can be better illustrated in the reports of PCAPS11 and PCAPS15.
[...] The doctor doesn't punch the clock at CAPS, and we must.If he earns ten times more than me, how do we feel?The coordinator needs to fill in the doctor's hours.Why the pressure on mine?Why can one do it and the other not?Despite this, the CAPS team has a good relationship with professionals and the coordination office.There is no gossip or anyone wanting to take each other down.What makes us sick is work overload, devaluation, and lack of recognition.(PCAPS8).
I felt very distressed because of the pressure: people demand care because we have a huge demand.People demand it because their sons are autistic... Our hands are tied for a demand like this, with people pressuring us.We try to do our best to serve everyone but find ourselves in a desperate situation.(PCAPS15).
The lack of or deficient actions that seek to appreciate and recognize workers for their commitment and dedication to the service provided in mental healthcare were also reported in studies by Fidelis et   18 , when considering the density and complexity of the type of occupation.Working conditions tend to increase emotional burnout, stress, dissatisfaction, overload, frustration, fear, and indignation in the face of contradictory and antagonistic conduct against the APT model, which should be implemented by SUS management in its entirety.
Finally, the EADRT analysis had a severe risk classification for the headache item, suggesting occupational disease risk, which requires immediate action on the causes to eliminate or relieve the effects.The other items of the physical, social, and psychological damage factors were classified as critical risk, which results in negative costs and distress correlated to the work performed in the CAPS (table 4).At this point, reintroducing all knowledge in discussing reflection-action 5-7 , we understand that substandard working conditions in the APT in the studied setting have affected the development of the productive mental health processes of the CAPS and possibly harmed workers' occupational health.Moreover, this is precisely due to the ambiguity and contradictions promoted by neoliberal productivist principles that undermine APT work.First, by superimposing the actions of old, retrograde models on the new progressive ones in the face of underfunding and scrapping.

Conclusions
In this context, implementing CAPS has yet to facilitate work processes aligned with the APT model entirely.Its mental health care management ways are subverted by political and social non-acceptance, non-addicted to old models, which tends to affect the fragmented actions and the deficient structure, insufficient supplies/human resources for the CAPS, and workers' illness.
We observe that the model tended to be amorphous rather than hybrid in the CAPS of this region, with different employment relationships among public servants, temporary contractors, or cooperative members, which continue in their isolated cores under the productivist principles of neoliberalism quickly incorporated by local SUS managers, preserving substandard work, which distances itself from SUS principles of universality, comprehensiveness, and equity of care.Furthermore, workers' appreciation should have been remembered.
It is urgent, therefore, to implement the National Humanization Policy as an innovative strategy to improve the organizational and structural conditions of the SUS network, the recognition of its workforce, and the review of mental health care management processes, financing, and legal occupational and contractual conditions to align with the APT.
The sample size is the limitation of this study.However, all CAPS professionals in the municipalities were invited to participate.The interviews allowed greater solidity for data interpretation, discussion, and understanding.

Collaborators
Lima ICS (0000-0002-1929-6142)* contributed to the preparation, conception, and design of the work; and acquisition and analysis of information for the work.Sampaio JJC (0000-0003-4364-524X)* contributed to the conception of the work, critical review of the relevant intellectual content, and final approval of the version to be published.Ferreira Júnior AR (0000-0002-1057-8688)* contributed to the critical review of the relevant intellectual content.s factors: professional achievement, freedom of speech, lack of recognition, and lack of freedom of speech.≤ 1.9 = bearable Source: Mendes et al. 12 and Ferreira, Mendes 13 .SAÚDE DEBATE | RIO DE JANEIRO, V. 47, N. 139, P. 878-891, Out-DEz 2023

Table 1 .
Classification of the means of the items of ITRA's Work Context Assessment Scale.Fortaleza, Ceará, Brazil, 2023 Source: Own elaboration.
14s share of the demand returned to me.Intermittent work is very complicated.It affects the progress of the service.(PCAPS3).don'tunderstandmentalhealthand want patients to leave CAPS cured.Family members and the manager want us to find a way.The Health Secretary needs to understand the processes: he wants us to work as if we were a Family Health Strategy unit or a hospital [...]He exaggerates demands regarding results.(PCAPS5).The reports mentioned above align with the statement by Fidelis et al.14, based on a study with professionals from CAPS I, CAPS alcohol and other drugs, CAPS children, and CAPS III from a municipality in inland São Paulo.The conditions that should be favorable for the discussion, planning, and development of work from the APT perspective are subverted by neoliberal 1,4 and biomedical assistentialist 2 hegemony, which tends to cause instability in the SUS, given production unrelated to the principles of equity and comprehensive care and humanization required by the APT model.In this context, working conditions indicate an inadequate number of professionals to meet demand, which tends to cause escalated SAÚDE DEBATE | RIO DE JANEIRO, V. 47, N. 139, P. 878-891, Out-DEz 2023 work due to the contingency of services amid insufficient or non-existent materials for developing work, besides discomfort, noise, and inadequate furniture (table 1), discussed by PCAPS1, PCAPS6, PCAPS9, and PCAPS12.structure of the building itself is old.It was a massive inconvenience during winter because it rains, and water enters through the roof.We need more rooms.Most of these rooms are unsuitable because the air conditioning is generally not working [...].The space is small, with few chairs.The occupational therapist needs materials to perform her service; an adapted room is unavailable.The Medical and Statistical Archiving Service (SAME) has many records and needs more space to keep it as it should be.We only have one computer for all employees, systems, and reports.(PCAPS1).[...] acoustics could be better.Something that could improve is the noise [...] it harms our health [...] and interferes with my work.I must try harder to stay alert, an energy I could save.Patients with extreme sensitivity to noise and phobias come here.(PCAPS6).

Table 2 .
Classification of the means of the items of ITRA's Work Human Cost Scale.Fortaleza, Ceará, Brazil, 2023 Source: Own elaboration.

Table 3 .
Classification of the means of the items of ITRA's Work Pleasure and Distress Indicators Scale.Fortaleza, Ceará,

Table 4 .
Classification of the means of the items of ITRA's Work-Related Harm Assessment Scale.Fortaleza, Ceará, Brazil,

table 4 ,
derived from work in the CAPS.The amount of work we have due to the low resolution, which generates a feeling of frustration and does not depend only on us, relies more on network factors, managers, and socioeconomic implications.(PCAPS9).I see illness as a result of work overload, which manifests through medical certificates.We have medical certificates due to stress, hypertension, and high blood sugar levels, compounded by work issues, making me ill.I had to put in a certificate to rest and escape it all.(PCAPS11).