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GROUP INTERVENTIONS IN PSYCHOSOCIAL CARE CENTERS FOR ALCOHOL AND DRUGS: CHALLENGES OF CARE PRACTICE

INTERVENCIONES GRUPALES EN CENTROS DE ATENCIÓN PSICOSOCIAL ALCOHOL Y DROGAS: DESAFÍOS DE LA PRÁCTICA DE ATENCIÓN

ABSTRACT

Objective:

to understand the challenges of care practice with group interventions Psychosocial Care Centers for Alcohol and Drugs.

Method:

qualitative intervention research developed with 30 professionals from four Alcohol and Psychosocial Drug Care Centers in a municipality in central Brazil from March to April 2019. We used a professional characterization instrument and conversation wheels to collect data that were submitted to the thematic modality of content analysis.

Results:

some challenges that permeate the practice with group interventions in CAPSad were evidenced, from the professionals' perspective, such as inadequate physical structure and scarcity of material resources; issues related to aspects of users such as difficulty in adhesion and commitment to groups, incompatible work schedules and lack of financial resources for travel to the centers; factors related to the competence of professionals as not having affinity to work with groups, absence of specific training, prioritization of other practices, demotivation, absence of care records and difficulty in performing the patient discharge and; aspects of work processes such as outpatient organizational culture, very high demand, insufficient human resources, lack of external supervision, few offers of therapeutic groups and lack of criteria for the definition of group coordinators.

Conclusion:

the challenges experienced include issues of inadequate physical structure and deficient material resources, difficulties related to the life contexts of users, competence of professionals and factors of the work processes of the services.

DESCRIPTORS:
Mental health care; Substance abuse treatment centres; Community mental health services; Mental health; Group processes

RESUMEN

Objetivo

comprender los desafíos de la práctica asistencial con intervenciones grupales en Centros de Atención Psicosocial de Alcohol y Drogas.

Método

investigación de intervención desarrollada con 30 profesionales de cuatro Centros de Atención Psicosocial de Alcohol y Drogas de un municipio del centro de Brasil de marzo a abril de 2019. Utilizamos un instrumento de caracterización profesional y ruedas de conversación para recolectar datos que fueron sometidos a la modalidad temática de análisis de contenido.

Resultados:

se evidenciaron algunos desafíos que permean la práctica con intervenciones grupales en CAPSad, desde la perspectiva de los profesionales, como estructura física inadecuada y escasez de recursos materiales; cuestiones relacionadas con aspectos de los usuarios como dificultad para incorporar y compromiso de grupos, jornada laboral incompatible y falta de recursos económicos para desplazamiento al servicio; factores d la competencia de los profesionales como no tener afinidad para trabajar con grupos, ausencia de formación específica, priorización de otras prácticas, desmotivación, ausencia de registros de atención y dificultad en la realización del alta de los usuarios y; aspectos de los procesos de trabajo como cultura organizacional ambulatoria, demanda muy grande, recursos humanos insuficientes, falta de supervisión externa, pocas ofertas de grupos terapéuticos y falta de criterio para la definición de coordinadores de grupo.

Conclusión:

lo vivido incluye cuestiones de estructura física inadecuada y recursos materiales deficientes, desafíos relacionados con los contextos de vida de los usuarios, competencia de los profesionales y factores de los procesos de trabajo de los servicios.

DESCRIPTORES:
Atención a la salud mental; Centros de tratamiento de abuso de sustâncias; Servicios comunitarios de salud mental; Salud mental; Procesos de grupo

RESUMO

Objetivo:

compreender os desafios da prática assistencial com intervenções grupais em Centros de Atenção Psicossocial Álcool e Drogas.

Método:

pesquisa-intervenção de abordagem qualitativa desenvolvida com 30 profissionais de quatro Centros de Atenção Psicossocial Álcool e Drogas de um município da região central do Brasil de março e abril de 2019. Utilizou-se instrumento de caracterização profissiográfica e rodas de conversa para coleta de dados que foram submetidos à análise de conteúdo, modalidade temática.

Resultados:

evidenciou-se alguns desafios que permeiam a prática com intervenções grupais em CAPSad, sob a ótica dos profissionais, como estrutura física inadequada e escassez de recursos materiais; questões ligadas a aspectos dos usuários como a dificuldade de adesão e comprometimento com os grupos, agenda de trabalho incompatível e falta de recursos financeiros para deslocamento ao serviço; fatores da competência dos profissionais como não ter afinidade de trabalhar com grupos, ausência de formação específica, priorização de outras práticas, desmotivação, ausência de registros dos atendimentos e dificuldade de realizar a alta dos usuários e; aspectos dos processos de trabalho como cultura organizacional ambulatorial, demanda muito grande, recursos humanos insuficientes, falta de supervisão externa, poucas ofertas de grupos terapêuticos e ausência de critérios para a definição de coordenadores de grupos.

Conclusão:

os desafios vivenciados englobam questões de estrutura física inadequada e recursos materiais deficitários, dificuldades ligadas aos contextos de vida dos usuários, competência dos profissionais e fatores dos processos de trabalho dos serviços.

DESCRITORES:
Assistência à saúde mental; Centros de tratamento de abuso de substâncias; Serviços comunitários de saúde mental; Saúde mental; Processos grupais

INTRODUCTION

Abuse and dependence on alcohol and other drugs is a public health problem which impacts various dimensions of human and social life. It is a chronic illness and is not always diagnosed early. A factor that can be explained by the singularities of each individual associated with the characteristics of each substance11. Lopes LLT, Silva MRS, Santos AM, Oliveira JF. Multidisciplinary team actions of a Brazilian Psychosocial Care Center for Alcohol and Drugs. Rev Bras Enferm [Internet]. 2019 [cited 2022 Oct 14];72(6):1624-31. Available from: https://doi.org/10.1590/0034-7167-2018-0760
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.

In Brazil, the Psychosocial Care Centers for Alcohol and Drugs (CAPSad), are the reference services for the care of users of alcohol and other drugs, aimed at all age groups according to their configuration, form of organization, functioning and population size. These community services are composed of teams of professionals from various backgrounds for interdisciplinary care and among the therapeutic offerings, group assistance with different strategies such as psychotherapy, operative groups and therapeutic workshops22. Ministério da Saúde (BR). Portaria de Consolidação n° 3, de 28 de setembro de 2017. Dispõe sobre a consolidação das normas sobre as redes do Sistema Único de Saúde [Internet]. Brasília. 2017 [cited 2022 Oct 14]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prc0003_03_10_2017.html
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.

In the second decade of the 21st century, the challenges of interventions in CAPSad are changes in care policies today, with the appreciation of hospitalization. Conservatism movement of society, aiming at a social order, which contradicts the treatment in the territory of people with problems with alcohol and other drugs33. Bastos TF, Roza CN, Serrão TSM. Desafios atuais do trabalho em CAPS Ad: conservadorismo e retração da RAPS. Serv Soc Debate [Internet]. 2020 [cited 2022 Oct 14];3(2):109-20. Available from: https://revista.uemg.br/index.php/serv-soc-debate/article/view/4872/3561
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, with immeasurable damage to psychosocial resocialization.

To this end, the National Mental Health Policy (PNSM) recommends that group practices be implemented in services given their value in the socialization of group members44. Brasil. Lei n° 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental [Internet]. Brasília. 2001 [cited 2022 Jun 14]. Available from: http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm
http://www.planalto.gov.br/ccivil_03/lei...
. Thus, in the context of Psychosocial Care, group care is one of the powerful care tools that allows the emergence of numerous therapeutic factors to group members, contributing significantly to their psychosocial development55. Andrade JMM, Farinha MG, Sousa JM, Vale RRM, Esperidião E. Presence of therapeutic factors in group care in the waiting room. Rev Eletr Enferm [Internet]. 2022 [cited 2022 Jun 14];24:68907. Available from: https://doi.org/10.5216/ree.v24.68907
https://doi.org/10.5216/ree.v24.68907...
.

The group interventions in CAPSad present numerous potentialities to users, such as the sharing of experiences that contributes to the strengthening of those who are more fragile, it favors the construction of bonds, helps in the change of unhealthy behaviors and facilitates their adherence to group services as it is an attractive therapeutic activity for them66. Sousa JM, Farinha MG, Silva NS, Caixeta CC, Lucchese R, Esperidião E. Potential of group interventions in Psychosocial Care Centers for Alcohol and Drugs. Esc Anna Nery [Internet]. 2022 [cited 2022 Jun 14];26:e20210294. Available from: https://doi.org/10.1590/2177-9465-EAN-2021-0294
https://doi.org/10.1590/2177-9465-EAN-20...
.

Furthermore,studies55. Andrade JMM, Farinha MG, Sousa JM, Vale RRM, Esperidião E. Presence of therapeutic factors in group care in the waiting room. Rev Eletr Enferm [Internet]. 2022 [cited 2022 Jun 14];24:68907. Available from: https://doi.org/10.5216/ree.v24.68907
https://doi.org/10.5216/ree.v24.68907...
,77. Sousa JM, Vale RRM, Pinho ES, Almeida DR, Nunes FC, Farinha MG et al. Effectiveness of therapeutic groups in psychosocial care: analysis in the light of yalom’s therapeutic factors. Rev Bras Enferm [Internet]. 2020 [cited 2022 Jun 14];73(Suppl 1):1-9. Available from: https://doi.org/10.1590/0034-7167-2020-0410
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show that group care in the context of CAPSad provides several therapeutic factors to its members, such as providing hope, universality, information sharing, interpersonal learning, group cohesion, existential factors, altruism, development of socialization techniques, imitative behavior, corrective re-editing of the primary family group and catharsis. Which contributes to treatment progress and the prevention of diseases, especially in the resocialization of the person.

Despite all the benefits that group interventions provide to users of alcohol and other drugs and their families, the challenges in the daily routine of the services are frequent, as demonstrated by an investigation carried out in a CAPSad in the northern region of Brazil. In order to analyze the criticism, praise and suggestions of users, family members and workers through the implementation of an Ombudsman service in the service, which in the users' view, revealed the therapeutic workshops as insufficient with regard to the greater diversity of these practices88. Bittencourt MN, Oliveira DCP, Souza RPO, Pena JLC, Pantoja PVN, Pereira MO. Ombudsman’s experience in Psychosocial Care Centers for alcohol/drugs. Rev Bras Enferm. [Internet]. 2018 [cited 2022 Oct 14];71(Suppl 5):2421-8. Available from: https://doi.org/10.1590/0034-7167-2017-0924
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.

In this direction, another study conducted with users of a CAPSad pointed out that they associate individual care with safer practices because of the confidentiality and privacy regarding what is exposed. The challenge for professionals was to make group and collective activities more welcoming and safe in this regard99. Stahelin DM, Reis JJL, Silva JP, Vitali MM. Atitudes de usuários de um CAPSad frente às práticas de cuidado. Psi UNISC [Internet]. 2022 [cited 2022 Oct 14];6(1):69-81. Available from: https://doi.org/10.17058/psiunisc.v6i1.16451
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.

Given the above, this whole scenario reinforces the importance of research aimed at deepening and elucidating the dilemmas faced by the multidisciplinary teams of CAPSad in relation to their work with therapeutic groups in mental health care to support actions to resolve or minimize losses in the treatment of mental health and drug addiction. Thus, this study aims to understand the challenges of care practice with group interventions in Psychosocial Care Centers for Alcohol and Drugs.

METHOD

Intervention research with a qualitative approach. In this type of study, the interaction between researcher/investigated object is dynamic in the course of the investigative process, which characterizes a collective and participatory construction for the mapping and understanding of everyday phenomena of socio-political life and its implications, without worrying about carrying out an instantaneous change of actions, as this transformation is the result of the interactive processes between praxis, subject and object. Therefore, the intervention is linked to the use of analyzers that provide the capture of the senses1010. Aguiar KF, Rocha ML. Prácticas universitarias y formación socio-política. Rev Psicoanálisis y Cultura [Internet]. 2000 [cited 2022 Jun 14];(11). Available from: http://www.acheronta.org/acheronta11/socio-politica.htm
http://www.acheronta.org/acheronta11/soc...
-1111. Rocha ML, Aguiar KF. Pesquisa-intervenção e a produção de novas análises. Psicol Ciênc Prof [Internet]. 2003 [cited 2022 Jun 14];23(4):64-73. Available from: https://doi.org/10.1590/S1414-98932003000400010
https://doi.org/10.1590/S1414-9893200300...
.

The study included 30 professionals selected by non-probabilistic sampling, for convenience, who worked in four CAPSads in a municipality in the central region of Brazil. Those who were 18 years of age or older, who were performing group interventions during the data collection period or who reported having experience with this type of care for any period were included. Those who were on official leave of absence due to vacation or leave were excluded. In the researched CAPS there were 89 professionals linked, meeting the inclusion and exclusion criteria, howevere only 30 made up the sample.

Initially, a pilot test was carried out in a CAPSi, specialized in the care of children and adolescents with mental disorders and victims of violence, so that the simulation of the collection phases with the team of researchers were aligned, in addition to considering whether the collection strategies and techniques of data met the objectives initially outlined.

After the necessary adjustments, the team of researchers scheduled a face-to-face meeting at each CAPSad in order to sensitize professionals to participate in the study, explaining the objectives and dynamics of data collection. Therefore, the collection took place in March and April 2019. All meetings with the participants were agreed between the researchers and managers of each service, respecting the availability of the health institution, on the day of the team meeting, in order to consider the work routine.

Data were obtained through a questionnaire to outline the professional profile of the participants, containing questions of sociodemographic characterization and professional contextualization such as level of education, technical training, graduation and specialization, whether working with group interventions in CAPS at the time of data collection or if they had previous experience with this type of care, in addition to aspects of the group structure that include information from planning, conducting, recording and group evaluation.

The conversation circle with the participants, considered a research intervention, was also used to obtain data and build a dialogic and reflective space1212. Ribeiro LDM, Krüger-Fernandes L, Borges FT. Roda de conversa mediada por leitura dialógica com crianças: Uma proposta metodológica de pesquisa qualitativa sobre processos argumentativos. New Trends Qualiti Res [Internet]. 2020 [cited 2022 Oct 14];2:83-95. Available from: https://doi.org/10.36367/ntqr.2.2020.83-95
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for the participants regarding their professional practice. There were four conversation circles, one in each CAPSad, lasting approximately two hours, recorded by audio recording and notes in a field diary, which were conducted by the main researcher, a postgraduate student in group dynamics and team management, a master teacher with training in group dynamics and a research assistant nursing student with the role of participant observer.

The conversation wheel began with the reception of the participants, who received material to produce their own badge, with the name they would like to be called. The self-presentation was through a personal characteristic with the first letter of their name. Next, the participants were instructed to fill out the instrument for professional characterization.

From there, the discussion about the practice with groups of professionals began, guided by the questions of the semi-structured script containing 11 questions, highlighting the following: Do you identify, in your group consultations, factors that facilitate and factors that hinder the conduction of the groups? And to end the meeting, the soliloquy technique1313. Gonçalves CS, Wolff JR, Almeida WC. Lições de psicodrama: introdução ao pensamento de J. L. Moreno. 11th ed. São Paulo: Ágora; 1988. was used, in which each member of the group reported a word that summarized the way they were after experiencing this whole process.

The content analysis technique was chosen for the analysis of the research corpus, in the thematic modality, following the reference of Bardin1414. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2018. that proposes three steps: 1. pre-analysis; 2. Exploration of the material and; 3. Treatment of the results obtained: inference and interpretation. Initially, the selection of the material to be analyzed, the transcripts of the conversation circles, followed by a floating reading for the formulation of the initial hypotheses was performed. Concomitantly, data coding was operationalized through the identification of registration and context units that were later grouped by similarity, which made it possible to create nuclei of meaning. Finally, the thematic category Challenges of care practice with group interventions emerged, which describes these barriers in four thematic axes: physical structure and material resources; users' life contexts; competences of professionals and work processes of the services. The ATLAS.ti software was used to aid data organization.

In accordance with the recommendations of Resolution 466/2012 of the National Health Council, the research was submitted to the Research Ethics Committee. All participants signed the Free and Informed Consent Form and to ensure confidentiality and anonymity, all were coded with the letter P, followed by the speech order number on the conversation wheels (P1 to P29) and the CAPS to which they attended (CAPS 1 to CAPS 4).

RESULTS

The study included five professionals in CAPSad 1, nine in CAPSad 2, eight in CAPSad 3 and eight in CAPSad 4, the majority were females (27), the age range ranged from 28 to 64 years and the professional categories were as follows: nursing (2); psychology (10); social work (5); music therapy (3); occupational therapy (2); physical education (1); arts (3); nursing technician (3); and public management (1). In relation to mental health education, only six had specialization in the area.

Regarding the practice with group interventions, 25 of the participants were working with groups at the time of data collection, and 21 of these had more than six months of experience. The other five participants had previous experiences with this modality of care.

From the content analysis process, four categories emerged to express the different challenges of practices with group interventions in CAPSad that encompassed issues of physical structure and material resources, life contexts of users, competencies of professionals and work processes of community mental health services as illustrated by the code tree (Figure 1).

Figure 1 -
Code tree of the study categories. Goiânia, Goiás, Brazil, 2019.

Category 1 - Challenges of care practice with group interventions related to physical structure and material resources

In this category, the barriers faced by professionals for the coordination of groups related to the scarcity of material resources of CAPSad, the little involvement of higher spheres to overcome this weakness were included resulting in them needing to take money out of their own pocket or start to promote actions with the community to raise money to operationalize group care:

I think one of the things that makes it difficult to conduct the group is the scarcity of material [...] (P4 - CAPS 1).

Lack of printer paper, expired ink, lack of material (P11 - CAPS 2).

It is good to say that, financially, on the part of the Municipal Secretariat, we do not have material for the groups (P24 - CAPS 4).

We buy the Popcorn and soda on the day of the film(P7 - CAPS 2).

The professional who wants to do it takes it out of his pocket, when he has a bazaar does, but it is so, it is what we feel like doing, we do (P11 - CAPS 2).

Inadequacies in the physical structure of services and the precariousness of the physical space were also pointed out as one of the complicating aspects for working with groups:

I want to talk a little bit about the room. I consider it to be a small room, I consider it inadequate because of the acoustics, the insulation is bad (P4 - CAPS 1).

There was a day when the fan broke and almost fell on a user's head (P5 - CAPS 2).

Category 2 - Challenges of care practice with group interventions related to users' life contexts

This category refers to phenomena that relate to the life contexts that are part of the groups that express obstacles with group interventions or permanence in the service, such as the difficulty of some users adhering to psychosocial treatment. In addition, the frequency inconstancy in the group was also highlighted, which ends up causing frustration in the group coordinator who plans the meeting according to the users' demand:

It happened to a pregnant woman, a user of alcohol and crack, right? The girls did everything for her to stay in the institution, at least during the pregnancy period, she went and stayed one day and then left (P23 - CAPS 4).

There are users who have not been in my group for three months, we ask someone else to take it, or I will welcome him at another time to re-act the PTS (P3 - CAPS 1).

And sometimes, we also prepare content thinking about those individuals and they don't come [laughs], then you prepare: 'Where are those guys? Didn't they come today?' So, it's like this, I have to deal with it (P11 - CAPS 2).

The lack of commitment of some users in the group was also externalized as a barrier to working with groups, impairing the construction of bonds:

The person has no commitment to the group, sometimes she does not come in her group, so she has no commitment, no bond with this group, then she arrives at any time: 'Oh, I want to be attended by someone' (P6 - CAPS 2).

Work and financial situations were verbalized as obstacles for the members of the groups to remain in the meetings, such as the lack of money to travel to the CAPS and their work schedule being incompatible with the schedules of certain groups:

The family group was very full, right? Because they received the bus pass from the city at that time, from the moment this pass was no longer sent, it was perhaps one of the first reasons for the family group to lose members (P21 - CAPS 3).

Work harms because, perhaps, the user identifies with the group that is on Tuesday, right? And maybe on the day that is more flexible due to the days off, there is an employee who may have a day off, and they attribute this time off to him here, so he ends up coming to a group that allows him to reconcile work and the group (P27 - CAPS 4).

Category 3 - Challenges of care practice with group interventions related to the competencies of professionals

This category expresses the perceptions of mental health professionals about what hinders the implementation of group care in CAPS, such as those who do not like to work with this therapeutic modality, by demotivation of the coordinators of these activities, or even the prioritization of individual care practices, which culminates in the scarcity of group therapeutic offers:

Yes, we have here in this case some professionals who already say beforehand that they do not like the group, they do not want to do group work (P14 - CAPS 3).

[...] often, they [users] also come when they realize that we are excited about the activity. When the professional is not motivated, it is bad for the group for sure (P14 - CAPS 3).

[...] because if you are going to check vital signs in all patients there is no way to do group work (P9 - CAPS 2).

You came at a CAPS service schedule that has the most group, because the afternoon has the most groups, we have a family group in the morning, the rest is individual care (P14 - CAPS 3).

The absence of specific training on group technology in the academic environment, especially in psychology, was a raised weakness. Moreover, the scarcity of training on the theme of groups as a care tool was also highlighted:

They [professionals] question the issue of training, especially in psychology courses, they do not have a specific training for this (P14 - CAPS 3).

[...] family care together, user/family, we realize that this is important, but sometimes we do not feel able enough to do this (P7 - CAPS 2).

The lack of registration regarding the evaluation of the groups was another barrier evidenced that makes it difficult to revisit the memory of the group, the progression of group interventions in the medium and long term and the development of the participants:

We do not take notes no, but we know, the people who lead the group for a long time, we know how that group started, how it was linked together, how it was changing (P7 - CAPS 2).

It is something that bothers us a lot, this difficulty that we have to reflect the practice of evaluating. We all make our assessment, each in their own way, and what is missing is this, it is a challenge that we have (P24 - CAPS 4).

The difficulty in interrupting group treatment through the discharge of some CAPSad users and giving support in this transition period was a reported difficulty. It was also mentioned that this movement of non-completion of group care while the subject is already strengthened, creates the feeling of dependence of the service:

There's a discharge group, because we can't set the time, no time for that. It's like the exit door doesn't exist, we need to open it, it exists, we need to open that exit door, but... (P24 - CAPS 4).

Category 4 - Challenges of care practice with group interventions related to work processes

In this category, professionals' reports were included regarding factors in the CAPSad work processes that negatively interfere with group work, such as the consolidation of an outpatient organizational culture of the care offered by physicians and the predominance of individual consultations that end up influencing the users not to attend the groups diligently:

We also have a restriction that it is very serious, which is the non-involvement of physicians, so they end up developing an outpatient activity within the CAPS (P23 - CAPS 4).

The boys [adolescents] were here with a culture of not having a group too, so getting the boys out of this culture is very difficult, so there won´t be such a wonderful frequency for sometime (P14 - CAPS 3).

[...] without having anything to offer, there is also no way to set up groups, so we had to do this process of thinking about what could be attractive to our clientele. This is a process that happened, it is happening mainly in the afternoon group, this process has not yet happened in the morning group(P14 - CAPS 3). (P14 - CAPS 3).

Few professionals who make up the workforce, very high demand that overwhelms the team and lack of definition of systematized criteria for choosing professionals who will develop groups were also cited as barriers:

[...] in CAPSad also if we had more professionals we could open more groups (P25 - CAPS 4).

[...] there is this difficulty of ours, which is doing so many groups that we do with so many appointments in this region that is full of demands. We don't have enough CAPS here, we don't have children's CAPS, sometimes even the demand from schools comes here at CAPS, so we have to deal with what is most urgent (P25 - CAPS 4).

I think it's a little loose in that sense, that there's no definition of which professional forms a group, it's usually more for who is a psychologist (P7 - CAPS 2).

The absence of external supervision of the services was also pointed out by one of the managers who participated in the study as difficulties that emerge in the daily life of the CAPS, including group care:

[...] an outside supervision to assist us, there are time i go on calls and when I talk about here it seems that we are knowing more than the people who are there. I have not found anyone to help us, who will give us support (P23 CAPS 4).

DISCUSSION

In general, the participants expressed the lack of physical structure and appropriate materials for working with groups in mental health, which puts the entire care apparatus at risk and highlights the precariousness of working conditions and services and the proposal of the care model of psychosocial care. A study carried out in a community mental health service in the western Amazon with the objective of understanding the professionals' conceptions about their daily practice, pointed to the presence of dissatisfaction due to the lack of material resources in the service1515. Batista EC, Ferreira DF, Batista LKS. O cuidado em saúde mental na perspectiva de profissionais de um CAPSi da Amazônia. Rev PsicoFAE [Internet] 2018 [cited 2022 Jun 14];7(1):77-92. Available from: https://revistapsicofae.fae.edu/psico/article/view/152
https://revistapsicofae.fae.edu/psico/ar...
. In this direction, a literature review to identify the difficulties faced by nurses in community mental health services, including CAPSad, identified that the physical structure of the service is characterized as a barrier1616. Souto RSF, Silva TV, Souza SAN, Santos WL. As dificuldades enfrentadas pelo enfermeiro no Centro de Atenção Psicossocial (CAPS) - revisão de literatura. Rev Inic Cient Ext [Internet]. 2018 [cited 2022 Jun 14];1(2):226-36. Available from: https://revistasfacesa.senaaires.com.br/index.php/iniciacao-cientifica/article/view/84
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, which affects the quality of group care.

When implementing groups in a space that does not guarantee secrecy and confidentiality and that puts the integrity of users at risk by scrapping services and structural weaknesses together with the lack of a diversity of materials as pointed out by professionals, revealed the dismantling and setbacks of mental health polices. In a therapeutic environment, people with mental disorders are guaranteed the right to confidentiality and, to be cared for44. Brasil. Lei n° 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental [Internet]. Brasília. 2001 [cited 2022 Jun 14]. Available from: http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm
http://www.planalto.gov.br/ccivil_03/lei...
, the CAPSad should contain adequate space for group care22. Ministério da Saúde (BR). Portaria de Consolidação n° 3, de 28 de setembro de 2017. Dispõe sobre a consolidação das normas sobre as redes do Sistema Único de Saúde [Internet]. Brasília. 2017 [cited 2022 Oct 14]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prc0003_03_10_2017.html
https://bvsms.saude.gov.br/bvs/saudelegi...
. There is a mismatch with the reality of the CAPSad investigated, both in the present research, as well as in another study carried out in community psychosocial care services in the central region of Brazil, which indicated an insufficient number of rooms for groups in the units, environments with cracks and infiltrations in the physical structure, with risk of collapse1717. Nunes FC, Sousa JM, Pinho ES, Caixeta CC, Barbosa MA, Cósta PA. Driving and restrictive factors of group practice in community psychosocial care services. Cien Saude Colet [Internet]. 2022 [cited 2022 Jun 14];27(1):183-92. Available from: https://doi.org/10.1590/1413-81232022271.19992021
https://doi.org/10.1590/1413-81232022271...
.

The participants mentioned the difficulty of users in joining and having commitment to the groups, some reported cases went months without attending the group,impairing the bond. In this direction, knowing and analyzing the life contexts of users of alcohol and other drugs and their needs by the CAPsad multidisciplinary team is fundamental to enable strategies to boost participation in the groups offered by the services and thus avoid models of care that blame users for setbacks in the development of group care.

The life contexts of users, being the triad substance - individual - society, is an important premise for the expanded understanding of their drug use. It is common to treat the substance and its action in the body, but not to consider the individual as a biopsychosocial being and the influence on the effects of the drug and the patterns of its consumption1818. Alves YDD, MacRae E. Uma abordagem teórica sobre o contexto social do uso de drogas. Rev Tomo [Internet]. 2019 [cited 2022 Oct 28];(34):81-114. Available from: https://seer.ufs.br/index.php/tomo/article/view/9850
https://seer.ufs.br/index.php/tomo/artic...
.

Moreover, to understand the individual it is necessary to consider the interaction between biopsychic subject on one side and the context on the other with macro-social factors, cultural differences, external events, socio-economic conditions, lack of adequate social support, adverse relational environment. All these elements impact the individual and his/her health condition1919. Saraceno B. A cidadania como forma de tolerância. Rev Ter Ocup Univ [Internet]. 2011 [cited 2022 Oct 28];22(2):93-101. Available from: https://doi.org/10.11606/issn.2238-6149.v22i2p93-101
https://doi.org/10.11606/issn.2238-6149....
. Thus, CAPSad professionals should consider the life contexts of their users for a better understanding of the factors that interfere with group adherence.

Bearing in mind that the socioeconomic conditions of the users served by CAPSad are often very vulnerable and the lack of a support network that supports the treatment is a phenomenon that interferes with their permanence in the services. Regarding the profile of 369 users attended at three CAPSad in the Triângulo Mineiro, (80.5%) were male, aged between 41 and 60 years (45.8%), without a partner (55.2% ), without a steady job (34.7%) and alcohol was the most consumed drug throughout their life (89.7%)2020. Trevisan ER, Castro SS. Centros de Atenção Psicossocial - álcool e drogas: perfil dos usuários. Saúde Debate [Internet]. 2019 [cited 2022 Jun 14];43(121):450-63. Available from: https://doi.org/10.1590/0103-1104201912113
https://doi.org/10.1590/0103-11042019121...
. Knowing the characteristics of users and their families in the biopsychosocial scope is essential for understanding the restrictive factors that influence their involvement in therapeutic activities offered by community mental health services, including groups.

The production of care in mental health, alcohol and other drugs in the context of RAPS is still burdened by moral judgment, stigmatization and the lack of reception of users' needs by professionals who still persist in the services2121. Leão A, Taño BL, Jacob DG, Pimentel KS. Obstáculos à produção do cuidado em álcool e outras drogas na perspectiva dos trabalhadores de saúde mental: prelúdios do cenário atual? Pesq Práticas Psicossocais [Internet]. 2021 [cited 2022 Oct 28];16(3):e3733. Available from: http://www.seer.ufsj.edu.br/revista_ppp/article/view/e3733/2707
http://www.seer.ufsj.edu.br/revista_ppp/...
. This consideration must be faced by psychosocial practice in a sociocultural dimension. Therefore, the epistemological transformation of care practices aimed at users of alcohol and other drugs is imperative, which must be guided by the psychosocial care model, whose purpose is centered on the development of the person's autonomy for the reconstruction of their life projects.

The psychosocial care model is a dynamic process, under construction in Brazil, guiding knowledge and actions in mental health. In this model, its assertiveness and ability to meet the health needs of the community are not questioned, but rather, it is alerted to its vulnerability in the absence of reflective-criticism, creativity, solid and permanent policies that guarantee investment and sensitivity to mental illness, and even those caused by drug abuse or dependence.

Another aspect to be considered is that, in the daily practice of CAPS, the Singular Therapeutic Project should be an instrument for organizing work processes and expanding the clinic, with clear therapeutic goals and careful evolution. The lack of this care planning by professionals and user/family co-responsibility makes it difficult for users to link and adhere to therapeutic activities, including group activities2222. Silva NS, Sousa JM, Nunes FC, Farinha MG, Bezerra ALQ. Challenges in the operationalization of singular therapeutic projects in Psychosocial Care Centers. Psicol Estud [Internet]. 2020 [cited 2022 Oct 28];25:e49996. Available from: https://doi.org/10.4025/psicolestud.v25i0.49996
https://doi.org/10.4025/psicolestud.v25i...
.

In this direction, the low adherence to the treatment of people who abuse alcohol and other drugs has been an object of study, as it is constant in CAPSad spaces and becomes a challenge not yet fully understood. Specifically, in relation to group care in community mental health services, low adherence is also pointed out as a restrictive factor for group work, as many users do not stay until the end of the meetings or the group as a whole, as they prefer individual care, which makes it difficult to understand the need for group interventions, causing constant absences and delays1818. Alves YDD, MacRae E. Uma abordagem teórica sobre o contexto social do uso de drogas. Rev Tomo [Internet]. 2019 [cited 2022 Oct 28];(34):81-114. Available from: https://seer.ufs.br/index.php/tomo/article/view/9850
https://seer.ufs.br/index.php/tomo/artic...
. However, the lack of professional preparation and systematization of practice with groups, employees who do not identify with working with this type of care and the little flexibility of the days and times of the group interventions, are factors that were identified in the speech of the participants that reflect in the low adherence of the users.

The unavailability of users' time to participate in the meetings due to the work schedule is also another aspect that interferes with group practices. Considering that drug abuse impacts beyond the health of the user and extends to their families and the entire community, and when it comes to economically vulnerable populations, the consequences are even more harmful. A situation that limits the assertiveness of therapeutic actions, since the effects of the approach and family participation are expressive and positive for the treatment of drug use, whatever the therapeutic orientation applied, there will always be gains2323. Ignaszewski MJ. The Epidemiology of Drug Abuse. J Clin Pharmacol [Internet].2021[cited 2022 Jun 14];61(Suppl 2):S10-S17. Available from: https://doi.org/10.1002/jcph.1937
https://doi.org/10.1002/jcph.1937...
-2424. Filges T, Andersen D, Jorgensen AMK. Effects of Multidimensional Family Therapy (MDFT) on nonopioid drug abuse: a systematic review and meta-analysis. Res Social Work Pract [Internet]. 2015 [cited 2022 Jun 14];28(1):68-83. Available from: https://doi.org/10.1177/1049731515608241
https://doi.org/10.1177/1049731515608241...
.

Lack of financial resources of the families of CAPSad users to attend the family group was cited as a barrier to this type of care. An investigation implemented in a CAPSad in Minas Gerais revealed that 34.7% of the users of the service were unemployed2020. Trevisan ER, Castro SS. Centros de Atenção Psicossocial - álcool e drogas: perfil dos usuários. Saúde Debate [Internet]. 2019 [cited 2022 Jun 14];43(121):450-63. Available from: https://doi.org/10.1590/0103-1104201912113
https://doi.org/10.1590/0103-11042019121...
. These data dialogue with the results found in the study and demonstrate a deficient financial situation of this group that interferes in the displacement of services and consequent permanence in the therapeutic groups offered.

The weaknesses in supporting families to participate in community mental health service activities adds to the risks to the quality of mental health care for people with mental disorders. The psychosocial care model that guides the assistance offered by CAPS perceives the family as an important care agent that also needs therapeutic follow-up, however, the approach to this public is still a challenge faced by the service teams2525. Ferreira TPS, Sampaio J, Oliveira IL, Gomes LB. A família no cuidado em saúde mental: desafios para a produção de vidas. Saúde Debate [Internet]. 2019 [cited 2022 Jun 14];43(121):441-9. Available from: https://doi.org/10.1590/0103-1104201912112
https://doi.org/10.1590/0103-11042019121...
.

All dimensions should be seen, especially management, health care policies, network formatting, available resources; because what was presented in this study was the voice of the professional who is isolated and desolate at the tip of the mental health care process. Similarly, the context we experience of dismantling the health system and the logic of psychosocial care directly reflect on the quality and appreciation of a service (CAPSad). A device that is against the social isolation, desired contemporary for the person with problems with alcohol and other drugs.

The findings of the study show that the user who is employed needs to adapt to CAPSad groups and not the other way around. It is important that both the management and the service professionals can reflect on the possibilities of welcoming these specificities, as it is perceived that a large portion of the users served at CAPSad have non-existent or fragile employment relationships, as revealed by a study carried out in a CAPSad III in the northeast region of Brazil, which identified that most users are self-employed or unemployed2626. Carvalho IAB, Menezes KS, Magalhães JM, Amorim FCM, Fernandes MA, Carvalho CMS. Psychoactive substances users’ profile. Rev Fun Care Online [Internet]. 2020 [cited 2022 Jun 14];12:326-31. Available from: https://doi.org/10.9789/2175-5361.rpcfo.v12.7095
https://doi.org/10.9789/2175-5361.rpcfo....
, therefore, it is necessary for CAPS to provide care on days and times different from the usual so that the people who are working can continue with their treatment.

Regarding the challenges of practice with groups related to professionals, the issue of unmotivated employees emerged, who do not like to work with the group service modality in CAPSad and end up prioritizing other actions, which leads to a low repertoire of groups to be that may be offered to the users. An alternative to transform this reality is the insertion of group technology resources in the context of the teaching-learning process in mental health, making future professionals to already learn approaches to group strategies during their training process, as demonstrated by an experience carried out with nursing students2727. Sousa JM, Esperidião E, Nunes FC, Caixeta CC, Landim JSS, Farinha MG, et al. Ensino de enfermagem em saúde mental: foco na tecnologia grupal. Res Soc Develop [Internet]. 2021 [cited 2022 Jun 14];10(12):e117101220057. Available from: https://doi.org/10.33448/rsd-v10i12.20057
https://doi.org/10.33448/rsd-v10i12.2005...
.

Furthermore, it is important to emphasize that the training processes go beyond the walls of the training institutions through actions of permanent and continuing education together with the accountability of professionals in their continuous improvement. The study showed the low commitment of the multidisciplinary teams with psychosocial care, as when they attribute their unpreparedness to the lack of training, they do not consider their responsibility for their own training, including postgraduate studies. These findings corroborate studies that explain the fragile knowledge regarding group technology and group movements1717. Nunes FC, Sousa JM, Pinho ES, Caixeta CC, Barbosa MA, Cósta PA. Driving and restrictive factors of group practice in community psychosocial care services. Cien Saude Colet [Internet]. 2022 [cited 2022 Jun 14];27(1):183-92. Available from: https://doi.org/10.1590/1413-81232022271.19992021
https://doi.org/10.1590/1413-81232022271...
,2828. Nunes FC, Caixeta CC, Pinho ES, Souza ACS, Barbosa MA. Group technology in psychosocial care: a dialogue between action-research and permanent health education. Texto Contexto Enferm [Internet]. 2019 [cited 2022 Jun 14];28:e20180161. Available from: https://doi.org/10.1590/1980-265X-TCE-2018-0161
https://doi.org/10.1590/1980-265X-TCE-20...
.

The absence of records on group care was another barrier to working with groups, identified especially for the evaluation of the repercussions of the meetings, and when performed, it is done intuitively. When there are few or no records of group interventions, the perception of the therapeutic evolution of the users can be compromised,77. Sousa JM, Vale RRM, Pinho ES, Almeida DR, Nunes FC, Farinha MG et al. Effectiveness of therapeutic groups in psychosocial care: analysis in the light of yalom’s therapeutic factors. Rev Bras Enferm [Internet]. 2020 [cited 2022 Jun 14];73(Suppl 1):1-9. Available from: https://doi.org/10.1590/0034-7167-2020-0410
https://doi.org/10.1590/0034-7167-2020-0...
which impairs the coordinators' visualization of the advances and setbacks of the users, the group and the facilitators' performance.

The difficulty of determining the discharge of the users served, including in groups with this purpose, is a marked obstacle. An investigation carried out in five CAPSad in São Paulo showed that there were no systematized criteria for the implementation of discharge processes, revealing many barriers, including the difficulty of breaking bonds and the institutional dependence of users2929. Silva LLP, Almeida AB, Amato TC. A perspectiva dos profissionais sobre o processo de alta de pacientes do Caps-AD: critérios e dificuldades. Saúde Debate [Internet]. 2019 [cited 2022 Jun 14];43(122):819-35. Available from: https://doi.org/10.1590/0103-1104201912213
https://doi.org/10.1590/0103-11042019122...
.

The weakness in training on group technology during undergraduate courses, especially in the psychology course, together with the scarcity of training during professional practice were mentioned as barriers. The training of the group coordinator needs to be based on competences, which includes theoretical aspects, supervised practice and personal analysis2727. Sousa JM, Esperidião E, Nunes FC, Caixeta CC, Landim JSS, Farinha MG, et al. Ensino de enfermagem em saúde mental: foco na tecnologia grupal. Res Soc Develop [Internet]. 2021 [cited 2022 Jun 14];10(12):e117101220057. Available from: https://doi.org/10.33448/rsd-v10i12.20057
https://doi.org/10.33448/rsd-v10i12.2005...
. Experiencing the group process that, in the context of community mental health services, provides the identification of the therapeutics of the groups,77. Sousa JM, Vale RRM, Pinho ES, Almeida DR, Nunes FC, Farinha MG et al. Effectiveness of therapeutic groups in psychosocial care: analysis in the light of yalom’s therapeutic factors. Rev Bras Enferm [Internet]. 2020 [cited 2022 Jun 14];73(Suppl 1):1-9. Available from: https://doi.org/10.1590/0034-7167-2020-0410
https://doi.org/10.1590/0034-7167-2020-0...
which is also another equally important factor in improving the practice of coordinating groups.

Regarding the institutions' work processes, the perpetuation of an outpatient organizational culture was mentioned by professionals as a hindrance, which is characterized as an obstacle to the consolidation of collective and group practices in the context of psychosocial care. This reality can be aggravated by the fact that training in mental health is not yet a priority for working in CAPS, which can contribute to the cultivation of the outpatient model, as revealed by an integrative review that aimed to investigate the main difficulties faced by nurses in community mental health services, in which 11 studies highlighted this variable1616. Souto RSF, Silva TV, Souza SAN, Santos WL. As dificuldades enfrentadas pelo enfermeiro no Centro de Atenção Psicossocial (CAPS) - revisão de literatura. Rev Inic Cient Ext [Internet]. 2018 [cited 2022 Jun 14];1(2):226-36. Available from: https://revistasfacesa.senaaires.com.br/index.php/iniciacao-cientifica/article/view/84
https://revistasfacesa.senaaires.com.br/...
.

Another challenge for the practice with groups in CAPSad was the lower offer of this type of care for users of one of the institutions of the study, which is out of step with the recommendations of the care model based on psychosocial care. Community mental health services must have group and collective practices such as therapeutic workshops and community activities for the community, and experiencing group care enables the emergence of numerous therapeutic factors for users77. Sousa JM, Vale RRM, Pinho ES, Almeida DR, Nunes FC, Farinha MG et al. Effectiveness of therapeutic groups in psychosocial care: analysis in the light of yalom’s therapeutic factors. Rev Bras Enferm [Internet]. 2020 [cited 2022 Jun 14];73(Suppl 1):1-9. Available from: https://doi.org/10.1590/0034-7167-2020-0410
https://doi.org/10.1590/0034-7167-2020-0...
.

The shortage of professionals was mentioned as a challenge for the practice with groups in CAPSad, combined with a very high demand for the service. In this direction, the group interventions implemented in the context of psychosocial care need to be systematized taking into account a multidisciplinary character55. Andrade JMM, Farinha MG, Sousa JM, Vale RRM, Esperidião E. Presence of therapeutic factors in group care in the waiting room. Rev Eletr Enferm [Internet]. 2022 [cited 2022 Jun 14];24:68907. Available from: https://doi.org/10.5216/ree.v24.68907
https://doi.org/10.5216/ree.v24.68907...
. Therefore, when the service team is reduced or insufficient, the integration of different professional categories for the coordination of groups is impaired and consequently, they cannot meet all the demand assertively.

The absence of systematized criteria for defining the professionals who will coordinate groups in the services was reported by one participant as a complicating factor, highlighting that this practice is more the responsibility of the service psychologists. In this direction, it is important that the other categories have specific knowledge to implement group interventions, however, not all members of the multidisciplinary teams of community mental health services have theoretical and practical foundations on group technology77. Sousa JM, Vale RRM, Pinho ES, Almeida DR, Nunes FC, Farinha MG et al. Effectiveness of therapeutic groups in psychosocial care: analysis in the light of yalom’s therapeutic factors. Rev Bras Enferm [Internet]. 2020 [cited 2022 Jun 14];73(Suppl 1):1-9. Available from: https://doi.org/10.1590/0034-7167-2020-0410
https://doi.org/10.1590/0034-7167-2020-0...
.

The lack of external supervision was pointed out by a professional from one of the CAPSad studies as a complicating factor for actions carried out by the service. In relation to group interventions, it is necessary that group facilitators integrate moments of constant training, in addition to institutional clinical supervision of their performance for a better improvement of their professional practice55. Andrade JMM, Farinha MG, Sousa JM, Vale RRM, Esperidião E. Presence of therapeutic factors in group care in the waiting room. Rev Eletr Enferm [Internet]. 2022 [cited 2022 Jun 14];24:68907. Available from: https://doi.org/10.5216/ree.v24.68907
https://doi.org/10.5216/ree.v24.68907...
.

The study brings contributions to the field of professional training, because by highlighting weaknesses in the competence of professionals who coordinate groups, it signals the theoretical and practical aspects that need investment during the training process of the teams working in the services, which lack systematization in relation to the psychosocial care for people who abuse alcohol and other drugs, so that they are not merely bureaucratic activities and actually serve the purpose of psychosocial rehabilitation.

In this direction, a survey carried out with 66 workers from community-based mental health services revealed that despite all the benefits arising from the group interventions offered by the services, the teams face restrictive factors in relation to this care practice related to aspects of the services, users and the professionals themselves1717. Nunes FC, Sousa JM, Pinho ES, Caixeta CC, Barbosa MA, Cósta PA. Driving and restrictive factors of group practice in community psychosocial care services. Cien Saude Colet [Internet]. 2022 [cited 2022 Jun 14];27(1):183-92. Available from: https://doi.org/10.1590/1413-81232022271.19992021
https://doi.org/10.1590/1413-81232022271...
, which highlights the importance of looking at these issues to minimize losses for the full success of group coordination.

Thus, it is expected that the results of this research can foster other reflections of the subjects who are involved in the assistance to users of psychoactive substances in order to work with these barriers that interfere in the resolution of mental health care. Above all, to consider the provocations pointed out as guides for the transformation of practices in the services, through permanent education. Thus, it is suggested that further studies are carried out in other CAPS modalities to map these challenges, so that they can later be minimized or resolved.

As a limitation of the study, the conduct of the research with only mental health professionals is highlighted. The incorporation of user of the groups would be important for a better understanding of the phenomenon, which suggests the realization of new studies with this public. In addition, we highlight the limitation of the comparison with international studies on group therapy or group interventions considering the different conceptual and political orientations of the psychosocial mode of care for users of alcohol and other drugs is also highlighted.

CONCLUSION

The results of this study made it possible to broaden the understanding of the challenges of care practice with group interventions in CAPSad, giving voice to workers who experience this process. It was possible to identify that the challenges experienced encompass issues of inadequate physical structure and deficient material resources, difficulties related to the users' life contexts, professionals' competence and factors of the services' work processes. Therefore, only with the resolution of these obstacles through articulated actions between the government, training institutions, management of community mental health services and multiprofessional teams will it be possible to reaffirm and put into practice the full potential of the group therapy modality.

ACKNOWLEDGMENT

To Fernanda Costa Nunes, Raquel Rosa Mendonça do Vale, Eurides Santos Pinho and Daniel Ribeiro de Almeida for their collaboration in data collection.

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NOTES

  • ORIGIN OF THE ARTICLE

    Article extracted from the e dissertation - Group interventions in Psychosocial Care Centers AD, presented to the Graduate Program in Nursing, Universidade Federal de Goiás, in 2020.
  • APPROVAL OF ETHICS COMMITTEE IN RESEARCH

    Approved by the Ethics Committee in Research of the Universidade Federal de Goiás, initial opinion n. 821.767/2014, Certificate of Presentation for Ethical Appreciation 33417714.2.0000.5083 and final opinion n. 3.951.500/2020, Certificate of Presentation for Ethical Appreciation 33417714.2.0000.5083.

Edited by

EDITORS

Associated Editors: Laura Cavalcanti de Farias Brehmer, Monica Motta Lino. Editor-in-chief: Elisiane Lorenzini.

Publication Dates

  • Publication in this collection
    19 May 2023
  • Date of issue
    2023

History

  • Received
    26 July 2022
  • Accepted
    03 Nov 2022
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