Medicação pactuada como recurso terapêutico no processo de trabalho de um CAPS: contribuições para a enfermagem

This descriptive and exploratory study with a qualitative methodological approach aimed to analyze the use of negotiated medication as a therapeutic resource for social reintegration and its contributions to nursing, in the work process of a Psycho-Social Care Center. It was undertaken in a Psycho-Social Care Center II in the municipality of Alegrete in the state of Rio Grande do Sul-RS in the period May - June 2006. The field diaries kept by three researchers were analyzed according to Minayo's thematic analysis; the record of observations totalled 390 hours. Among the principal results, the negotiation of the medication - which was presented as effective in the service under study - and the interpersonal relationship between health professionals and the user stood out. It is concluded that it is relevant to approach medication in a negotiated manner, as in this way the user has autonomy to give opinions and make decisions regarding issues referent to his or her treatment.


INTRODUCTION
The Brazilian Psychiatric Reforms are an important process for changing the view of madness, and aim to change the knowledges and practices which constitute mental health care.In addition, they seek to resignify the object of intervention and psychological suffering, with the aim of breaking with the internal and external mental asylums, thus altering how society thinks and acts.
The objective of the mental health professionals who provide care is the rehabilitation of the individual with psychological suffering so as to promote his social reintegration.Psycho-social rehabilitation is understood as a way of linking the individual with reality, taking into account his historical and social context and his subjectivity.In this ambit, the mental illness is considered one more fact intrinsic to the person's life. 1 In this context, in which de-institutionalization is prioritised, construction was begun of a mental health care network to substitute hospitalization in psychiatric hospitals, offering bio-psycho-social care to the individual with psychological suffering, within the community in which he lives, so as to provide his needs. 2Thus, the substitute services which make up this network are: the Psycho-Social Care Centers (CAPS), day hospitals, outpatient centers and psychiatric beds in general hospitals, among others. 3he CAPSs have stood out in the context of the Psychiatric Reforms, as they represent one of the most significant advances in psychosocial care and social reintegration.They also perform the role of articulators of the community mental health care network, and are substitute services for centralized care in hospital-based psychiatric care, being the Ministry of Health's principal strategic service. 4he CAPS' functions are daily clinical care, the promotion of the social reintegration of the person in psychological suffering through intersectorial actions of regulation of the gateway to the mental health network within their area of functioning, and of support to the basic network regarding mental health care.In this way, the CAPSs are the articulators of the network and the mental health policy in a given territory. 5urther, it stands out that these services seek to promote the user's autonomy and responsibility such that he may be a protagonist in the rehabilitation process, in addition to using access to work, the preservation and strengthening of support networks, leisure activities and the exercising of civil rights as strategies for social reintegration, as well as participation in workshops and groups.
In this approach of the psychiatric reforms in which it is necessary to change the perspective regarding the object of intervention, changes in the therapeutic practices also become relevant.For this reason, the aim of the work, in mental health, ceased to be the cure, and passed to be psychosocial rehabilitation and social reintegration, thus needing new work instruments such as listening and valuing of the person with psychological suffering as a citizen, in addition to traditional physical and chemical means. 3Therefore, in the field of psycho-social care, the medication is seen as support for the quality of life to be potentialized.
However, it is known that the prescription of the medication, a work instrument belonging to the field of medicine, also becomes a reflection of professional power when this professional totally appropriates a discourse which labels a specified individual with a specified pathology, and based in these signs and symptoms plans interventions.It is observed that drug therapy, used in a context in which the medication is not negotiated, remains a priority indication in psychiatric interventions, associated with descriptive diagnostic procedures grounded in the scientific discourse.In addition to this, considering the socialization of the medical discourse established by the marketing campaigns financed by the pharmaceutical industry and the media, one can recognize, highlighted, the paradigm of the medical discourse in the production and veracity regarding psychological suffering and its essence. 6owever, one must reflect on this work instrument.In the asylum model, there is emphasis on the consideration of the organic determinants of the problems which are to be treated, thus implying that the basic means of treatment should be on the basis of medication.There is no responsibilization of the individual in their treatment, as their subjective existence is not considered and also because it is believed that what really has the effect is the medication.Therefore, from another angle, one could say that it is not the body, but rather the organism, which is the principal recipient of the actions. 7n the psycho-social model, however, there is empowerment of the individual in his treatment, and the focus ceases to be drug therapy, with his social networks, family, friends and neighbors being valued as agents contributing to the success of the psycho-social rehabilitation.
Along with the changes in the model of care in mental health, therefore, there has been a change in the entire context of practices which solidified over the years, and with this, nursing in its area of functioning outside of the asylums must be constituted as a socially-transformative agent, changing the model of care and the paradigm. 8aking into account that in this context the medication is not synonymous with medicalization, it should be emphasized how important this change of paradigm is, in the trajectory of the lives of the individuals with psychological suffering.Consequently, when it is necessary to use this change in the treatment, it is necessary for it to be administered responsibly, taking into account the individuals' life histories and not just the clinical symptoms; in this way it becomes an effective process in the ambit of psycho-social care.In this regard, the nursing becomes strategic, as in a certain way it is made responsible for the administration and guidance of the drug therapy, and must be aligned with the essential objectives of the psychiatric reforms so that it may truly be a transformative agent.
Because of this socio-historical-cultural construction around madness, which divides the treatment in two distinct contexts (the drug approach and the psycho-social approach), and because of the fact that the studies [9][10][11][12] address only the clinical and pharmacological aspects of the medications, the elaboration of this study was considered, with the aim of emphasizing the work process which uses medication in a negotiated way as a therapeutic resource, so as to strengthen the professionaluser bond and the reintegration of the latter into society.The present study's objective, therefore, was to analyze, in the work process of a CAPS, the use of negotiated medication as a therapeutic resource for social reintegration.

METHODOLOGY
This study is characterized as having a descriptive and exploratory character with a qualitative methodological approach and was undertaken based on data from a Psycho-Social Care Center (CAPS II) in the municipality of Alegrete -RS, with data collection occurring in the period May -June 2006.
The municipality of Alegrete is on the west border of the state of Rio Grande do Sul, 506 km from the capital, Porto Alegre.It has a total of 78,984 inhabitants, with the age range concentrated between zero and 50 years of age. 13ts economic base is centered on agriculture and cattle-raising. 14he municipality's mental health network is made up of CAPS II, CAPSi (Psycho-Social Care Centers-Children) and CAPSad (Psycho-Social Care Center -Alcohol and Drugs), Residential Therapeutic Services (RTS) and psychiatric beds in a general hospital.There is a general coordination of the services and there is a specific coordinator in each center.15 In 2009 there were 212 psychiatric hospitalizations in the general hospital, corresponding to 3.7% of the hospitalizations among the other specialities.13 It is also worth highlighting that there is no psychiatric hospital in this municipality.The individuals with psychological suffering have available to them a diversified and effective mental health care network, based in the substitutive and territorialized services.
The CAPS II under study offers individual and group attendance, its principal concern being the individual's social inclusion.In relation to the activities which make up the service, the collective mental health workshops occur daily, being facilitated each day by a professional with different training; the themes are diverse, prioritising the individuals' integrality.Workshops on manual work, pedagogical activities, gardening activities, theater, yoga, capoeira, an obesity group, a literacy group and a family workshop also form part of the schedule of activities. 15he meetings of the CAPS with the municipal mental health coordination, and the team meetings, are weekly.The professional team is made up of doctors, nurses, nursing technicians, therapeutic companion, a social worker, psychologists, an occupational therapist, and workshop instructors who are trained in physical education and pedagogy.There are also receptionists, a cook, cleaners, a driver and volunteers. 15hree researchers, previously trained for this purpose, participated in the data collection.They spent around a month in the context of the work, observing the dynamics of the same, with the record of observations totaling 390 hours.At the start, the observation was little structured and broader, allowing the observer to investigate the work in a more general way, perceiving what it was more important to emphasize.It later became more focused so that the objectives proposed could be achieved. 16The observation routine covered aspects such as the structure and dynamics of the work, the forms of attendance, the organization of the records, the participation of the users and their family members, and the professionals' work process.
For analysis of the data, the three researchers' field diaries were used, which provided support for analyzing the use of negotiated medication as a therapeutic resource for social reintegration in the work process of a CAPS.To this end, an exhaustive reading of the three field diaries was undertaken, and the data was later organized into thematic nuclei. 17his

RESULTS AND DISCUSSION
The medications are significant elements in the therapeutic resources available.They are used with a view to the person's physical and mental well-being and therefore constitute an important impact factor in the health services' ability to resolve issues.The first synthetization of a psychopharmaceutical used in psychiatric treatment dates from 1952.Since then, year after year, the pharmaceutical industry has invested more resources in establishing research in the area of psychopharmacology and invests a large proportion of the resources in the marketing of new drugs. 6n the context of the psychiatric reforms, as a result of the changing from the hospital-centered model to psychosocial care, centered on the individual as an active social actor, there also arises the transformation of the practices which permeate the organization of the work process in the field of mental health.It stands out that the medication is used in a different way, ceasing to be coercive and alienating, and becoming a therapeutic instrument which contributes to the individual's social reintegration and to his living in freedom.
Currently, there is a contrast of standards.On the one hand, there is the mental asylum model, in which the medication is distributed in many places in a random way and without responsibility towards the individuals, who are treated as people without names, without identities, without desires, and with their subjectivity repressed; while on the other, there is a modern society, which claims to be revolutionary and strong, but in which depression is ranked as one of the principal incapacitating illnesses, even being termed the "illness of the century".Today, any sign or symptom is synonymous with the consumption of, or need for, medication.In this regard, it is necessary to reflect on the issue of medicalization, previously stochastic and today all-embracing, remembering that the proposal for psycho-social care is that this should be negotiated between the team and the user.This is not, however, a matter of rejecting any and all uses of the psychopharmaceuticalsas some of their positive effects are undeniable, both in some people's lives and in the possibility of transforming the care system and the treatment of madness in the XXI century -but of evidencing the effects of a discourse which banalizes the existence of the affected individuals, naturalizes their suffering, blames them for their problems and makes them responsible for their self-care. 6evertheless, the psychiatric reforms and their benefits for the life trajectories of the individuals are defended.The individuals are considered protagonists of their own paths, broadly supported by their wishes and desires.It follows that in this ambit there is a differentiated view for the use of drug therapy.

Negotiated medication in the context of psychosocial care
In the CAPS in Alegrete, where the study was carried out, it was noticed that the use of medication is considered a work instrument which empowers the individuals who receive care, because it is discussed with the user.As a consequence, it is evidenced that the negotiation contributes to the individuals' psychosocial rehabilitation, that is, the individual with psychological suffering now interacts with the team in negotiating his treatment.The account below evidences the professional's concern with reviewing the medication so that the user will be able to afford it, as this articulation with the psychologist touches upon: [...] in the first consultation, she mentions nervousness, she stopped with the treatment claiming that she didn't have money to buy Fluoxetine and Diazepam [...].The professional proposes reviewing the medication and asks about the follow-up with the psychologist.Ms X says that she has stopped, including with the literacy workshop which she had been attending (Obs.02).
In the observation, one can see the care which the users receive when the medication is the subject of attention, as when the individual mentions that she does not have the financial conditions to buy the medications in use, the professional proposes re-assessing them, and further is concerned with the individual's general context and whether she is being monitored by other members of the team.
The responsibility in the field of psychosocial care consists of a process of negotiation, delegation and division of duties between professionals, users, family members and individuals from the community who are linked to the individual with psychological suffering.In various ways, these are made responsible for shouldering part of the care, thus forming social support networks which aim to construct another path for the individual, different from that involving hospitalization and helplessness. 18n this perspective of transforming the model of care, even the way one refers to the individual with psychological suffering has been changed.The term "user" was inserted by the Unified Health System's (SUS) legislation, with the aim of emphasizing that this person is the principal actor in the process of his or her care, as previously this person had been referred to a as "patient", that is, a passive individual resigned to his or her condition.This expression was introduced with authority in the area of mental health, leading the individuals with psychological suffering to change social place.
This being the case, these users need to be guided and involved in the referrals, solutions and treatments, which must be constructed in conjunction with the team, making them protagonists throughout the therapeutic process. 19he quality of the relationships established between the user and the others (among whom stand out the health team, the family and friends), which he considered important, can facilitate or hinder the treatment. 20Considering this meaning of articulating the team with the individual experiencing mental illness, in the service under study one can perceive the professionals' intermediation in the issue of the medication.
At the time that the user was not feeling well, she was attended and her vital signs were checked, the use of the psychopharmaceuticals she was taking also being questioned: [...] X and I sat next to the user.X was talking to her, and said that her blood pressure was 200x50mmHg because she had become so nervous, but that with the sedative which she had taken the tendency would be for her pressure to drop.She said she had spoken with the doctor and that she had to put her on different medication (Obs.03).
This being the case, one can perceive in the colocation of Obs.03, that in the context of the CAPS, the staff feel responsible for the user, as there is a transversality linking the individual and the team, so that the care/treatment may be effective and beneficial in the life of the individual with psychological suffering, where listening and receptiveness are present.
It is known that the link, in the context of the production of care, is differentiated from that which is produced in the heteronomous link, which refers to the relationship of linking in which one of the individuals does not obtain the opportunity to establish her autonomy, much less conditions for her social and subjective emancipation. 21e can perceive in the dynamics of the work process within the CAPS in Alegrete, specifically involving the negotiation of the medication, that the way in which the users' relationships with the team are negotiated directly influences the individual's compliance with her treatment, she being seen as a protagonist in this process.
One of the most important points for improving individuals' compliance with their treatment is the approach to the side effects of the medications which they use.Whenever possible, these must be researched in depth, with a view to eliminating them or, at the very least, minimizing them.Changing the medication, reducing the doses and using concomitant medications for the relief of extrapyramidal symptoms are highly relevant initiatives. 9 X prescribes Amplictil and Diazepam, gives advice on the reactions, and advises the user to return should she not perceive improvement (Obs.02).
The importance stands out of guiding users on the objective of the use of the medication, the medication's possible side effects, and the possibility of it not producing the desired effect, emphasizing that the professionals will be available to help them whenever necessary.It is also important to highlight that using the medication will bring her life closer to normality, contributing to her physical and psychological well-being and promoting more effective social reintegration.This will help in the user's compliance with the proposed treatment.

The interpersonal relationship between professionals and users
In accordance with Ordinance 336 of February 19 th 2002, which defines and establishes directives for the functioning of the CAPSs, 22 another work instrument used in the mental health services is the Home Visits (HV), which can be exemplified in the account below.
X arranges that she'll do a HV to see the situation tomorrow morning; she advises her to bring the medication to take here in the CAPS, and to come to the CAPS daily until she gets well.She arranges that afterwards she'll pass her on to another therapist [...].One patient X, clumsy, dirty and smelling, comes in to collect her medication.X asks her if any Amplictil is left over, she says yes, so X says that somebody will do a HV to see the medication which is left over (Obs.01).
The home visits are for administering injectable medication to a user with a non-intensive character (Obs.02).
They also told me that there were medications to do in the home (Obs.03).
The HV is a work instrument which allows the mental health professionals to offer the user comprehensive care.Further, it promotes the establishment and strengthening of the users' bond with the team, and organizes the work in a way that ensures continuity of care, a trusting relationship, and a knowledge of the families. 23n this regard, the HVs serve as support for individuals in psychological suffering, who are not abandoned when it is necessary to be medicated in their homes.This time is propitious to the health professional to visualize the user's social context, enabling the planning of qualified care which encompasses the individual's needs and promotes her social reintegration, and highlighting that the family must be coadjuvant in this process.
Further, in the work process within the CAPS, the medications can also be negotiated within a space known as therapeutic workshops.These are activities which allow individuals with psychological suffering to meet, promoting the exercising of their citizenship, co-existence with people different from them, and, principally, the expression of liberty.These are taking on a different nuance in the field of the psychiatric reforms and of psycho-social care, and have the character of social reintegration, respecting each individual's uniqueness and culture. 24n the service in Alegrete, these workshops are known as Medication Groups.In this space, there is discussion with the CAPS users concerning their therapy, their doubts are clarified, and they receive information which contributes to the efficacy of their treatment.
Meeting of intensive users and members of their families.This meeting precedes the assembly of the users and takes place at two different times: the first only with men, and the second with the women.It's coordinated by X, and after the meeting, the medications are distributed to the users in packets containing the medications for each one until the next meeting (Obs.02).
She is attended in a group with four intensive patients: one person has to leave because he has akathisia, anxious -the others comment that he is heavily medicated; a young patient is wet, dribbling, she's cared for by a lady, and X says that she spoke with the psychiatrist, as they're going to initiate a reduction in her medication.Spoke a lot, a man, about 45 years old, he and his wife are users, says that he gets confused at home with the medications and doesn't know if he's taking them correctly (Obs.01).
The Medication Group is a very important space in order to work on the medication with the user, because it goes beyond simply dispensing it, extending to clarify doubts and makes the individual with psychological suffering and the team responsible for the drug treatment.
In this context, for the individual with psychological suffering, who previously experienced various episodes of hospitalization, the CAPS appears as an instrument which makes it possible to undertake treatment at liberty, with the help of the professionals and in particular the nurses, who are the workers who, in the majority of cases, have managed to offer comprehensive support to the users and their families.In this way, the patient manages to cope with the crises in her family context, avoiding hospitalization and, consequently, reducing the chronic nature of the condition. 25reviously, when there was no structured mental health network and, therefore, there were no services for substituting the asylum model, drug treatment was used as the principal method for containment at times of crisis.Today, however, the focus has changed, and there are some intervention strategies, such as affection and physical containment, for example.
In this context of change of strategies in the work process of the mental health team -more specifically, in that of the nursing team -regarding the individuals in psychological suffering, creative and innovative initiatives have appeared, which change the focus from the disease/cure to the individual and her potential as a social actor, emphasizing her subjectivities and her power to choose and decide in her treatment, which may be exemplified in the observation below: [...] an elderly lady said she prefers X to take the medication in the CAPS during the day and at night at home.She explains that she can't read, that she gets mixed up, and prefers it this way.The nurse says okay.The mother emphasizes to the patient that the medication at home will be only at night [...].The nurse calls the user and asks if she was given her injection; she answers yes.So they arrange for X to come and take her medication in the CAPS, and she agrees [...] (Obs.01).
In the observations, one can perceive that the nurse has the role of mediator between the health professionals and the user, in addition to carrying out the functions inherent to professional practice, such as those of a bureaucratic scope, administration and organization of medications, leadership of groups and management of the service.The nurse also undertakes health education activities, including guidance both for users and for their family members and caregivers, aimed at transforming the context in the psycho-social field.
The educational interventions must respect the user's uniqueness, needs and characteristics; hence there is no single, generic form of educational proposal.However, the sensitization and active participation of the actors involved in the process is an important requirement to guarantee educational practices which aim for the promotion of health and the prevention of poor health in the community. 26e more the nursing professional is aware of her personal and social responsibility, of her function as a worker integrated into a social context and as a citizen, the greater her capacity to select work instruments which aim to restore this same condition of individual-citizen to those individuals in psychological suffering. 3

FINAL CONSIDERATIONS
This study's theme -negotiated medication as a therapeutic resource for social reintegration -deserves attentive and ongoing scientific reflection, due to being an important question in the ambit of public health, on the subject of which there is a scarcity of Brazilian scientific studies.
The addressing of medication in a negotiated way is therefore relevant, as in this way the user has autonomy to give an opinion and make decisions on questions referent to her treatment, that is, the therapy is no longer centered in the biomedical model, where the main aim is the cure; rather, the aim is a treatment which allows quality of life and, principally, restores citizenship and gives back the liberty appropriate to each human being.It is stressed that the work instruments, such as the negotiated medication used in this process, contribute to the users' social reintegration.
study respected the ethical principles of research involving human beings indicated in Resolution n. 196/96 of the National Health Council, and was considered and approved by the Ethics Committee of the Faculty of Medicine of the Federal University of Pelotas, under Protocol n. 074/05, of November 11 th 2005.