CARE PRACTICES IN PSYCHOSOCIAL CARE CENTERS: A CONVERGENT-CARE RESEARCHABSTRACT
Objective: to analyze care practices carried out in the process of embracing the user in Psychosocial Care Centers, with impacts on psychosocial rehabilitation.
Method: qualitative, convergent-care research carried out in the Psychosocial Care Centers of the city of Porto Velho/Rondônia with the participation of four nurses, three social workers, one psychologist, one user and his family member. The data came from the research-care groups and were analyzed through the processes of apprehension, synthesis, theorization and transfer.
Results: the following categories emerged: “Selection and classification of the user embracement process as an activator of the psychosocial rehabilitation process” and “Strategies and implications of the use of an embracement approach aimed at psychosocial rehabilitation”. Due to its potential to establish therapeutic bonds and adherence to treatment, promote programs and new therapeutic approaches that induce psychosocial rehabilitation, the user embracement process constitutes an emancipatory care practice. The participation of users during the process of embracement enriches the construction of the Singular Therapeutic Project and captures important elements for team care.
Conclusion: the user embracement process focused on mental health is one of the care practices that achieves effective results to strengthen the stability of the psychosocial rehabilitation network. However, in the scenario studied, it is necessary to include an intersectoral approach to facilitate the users’ therapeutic itinerary.
DESCRIPTORS:
Mental health; Mental health services; Psychiatric rehabilitation; Cooperation and adherence to the treatment; Integrality in health
RESUMO
Objetivo: analisar práticas de cuidado a partir de processos de acolhimento em Centros de Atenção Psicossocial, com reflexos na reabilitação psicossocial.
Método: Pesquisa convergente assistencial, qualitativa realizada nos Centros de Atenção Psicossocial de Porto Velho/Rondônia com a participação de quatro enfermeiros, três assistentes sociais, um profissional de psicologia, um usuário e seu familiar. Os dados são provenientes dos grupos de pesquisa-assistência e foram analisados pelos processos de apreensão, síntese, teorização e transferência.
Resultados: emergiram as categorias: Seleção e classificação do acolhimento como ativador do processo de reabilitação psicossocial e Estratégias e implicações do uso do acolhimento com vistas à reabilitação psicossocial. Por seu potencial de estabelecer vínculo terapêutico e adesão ao tratamento, promover programas e novas abordagens terapêuticas indutoras da reabilitação psicossocial, o acolhimento constitui uma prática emancipatória de cuidado. A participação dos usuários no momento de acolhimento enriquece a construção do Projeto Terapêutico Singular e capta elementos importantes para o cuidado em equipe.
Conclusão: o acolhimento em saúde mental é uma das práticas de cuidado pela qual se obtém resultados efetivos para consolidar a estabilidade da rede de reabilitação psicossocial. Contudo, no cenário estudado é necessário incluir a intersetorialidade para facilitar o itinerário terapêutico dos usuários.
DESCRITORES:
Saúde mental; Serviços de saúde mental; Reabilitação psiquiátrica; Cooperação e adesão ao tratamento; Integralidade em saúde
RESUMEN
Objetivo: analizar prácticas de cuidados basadas en procesos de admisión en Centros de Atención Psicosocial, con impactos en la rehabilitación psicosocial.
Método: investigación convergente, cualitativa sobre cuidados, realizada en los Centros de Atención Psicosocial de Porto Velho/Rondônia con la participación de cuatro enfermeros, tres trabajadores sociales, un profesional de psicología, un usuario y su familiar. Los datos provinieron de grupos de asistencia e investigación y fueron analizados a través de los procesos de aprehensión, síntesis, teorización y transferencia.
Resultados: surgieron las categorías: “Selección y clasificación de la recepción como activador del proceso de rehabilitación psicosocial” y “Estrategias e implicaciones para el uso de la admisión con miras a la rehabilitación psicosocial”. Por su potencial para establecer un vínculo terapéutico y adherencia al tratamiento, promover programas y nuevos abordajes terapéuticos que induzcan a la rehabilitación psicosocial, la admisión constituye una práctica de cuidado emancipador. La participación de los usuarios en el momento de la admisión enriquece la construcción del Proyecto Terapéutico Singular y capta elementos importantes para la atención en equipo.
Conclusión: el apoyo a la salud mental es una de las prácticas de atención a través de las cuales se obtienen resultados efectivos para consolidar la estabilidad de la red de rehabilitación psicosocial. Sin embargo, en el escenario estudiado es necesario incluir la intersectorialidad para facilitar el itinerario terapéutico de los usuarios.
DESCRIPTORES:
Salud mental; Servicios de salud mental; Rehabilitación psiquiátrica; Cooperación y adherencia al tratamiento; Integralidad en salud
INTRODUCTION
Psychosocial rehabilitation consists of one of the pillars of the National Mental Health Policy (Portuguese Acronym: PNSM) and involves the social network, work and habitat tripod in a community-based approach1. In Latin America2-3, in countries that have developed psychiatric reform processes based on community care, psychosocial rehabilitation programs must be currently reviewed, showing the need for establishing community mental health services and effective rehabilitation strategies, combined with the sense of autonomy and emancipation of people.
On the other hand, the conceptual similarity between the terms psychosocial rehabilitation and social insertion or inclusion requires clarification and understanding, given that they are distinct processes that must be guided by intersectoral policies4-5.
Psychosocial rehabilitation must involve practices that promote effective changes in the living conditions of individuals and in their contractual power, respecting their uniqueness and individuality and not being limited to the act of enabling or disabling functions6. It involves the development of a set of emancipatory actions in the various fields of work, education, culture, housing and health7.
Rehabilitation processes still face limitations, mainly due to the setbacks in the mental health policy that have been viewed as a threat since 2017, when the psychosocial rehabilitation component was removed from Ordinance No. 3.088/11, neglecting the guarantee of rights, the recovery of contractual power and the enhancement of care services committed to rehabilitative processes such as initiatives focused on the generation of income and work8.
Care practices focused on mental health must suffer changes to achieve effective psychosocial rehabilitation care, which is still incipient in the country, and require professional training, strengthening of the Psychosocial Care Network (Portuguese Acronym: RAPS) and the protagonism of initiatives aimed at providing social inclusion through work9-10.
In this sense, the lack of training, the failure to include the rehabilitation topic in the program of undergraduate courses and the lack of a networking structure are major difficulties that have already been highlighted and that weaken the user's therapeutic itinerary2.
Within the scope of the RAPS structure, the contextualization of psychosocial rehabilitation is based on the principle that social exclusion exacerbates the psychological suffering of users, which means that early actions take on greater responsibility within the logic of including people in their family and community contexts based on the user embracement process carried out at the Psychosocial Care Center (Portuguese Acronym: CAPS), given that this technology has the potential to establish bonds and integrality11.
That said, the objective is to analyze care practices based on user embracement processes carried out at Psychosocial Care Centers, with impacts on psychosocial rehabilitation.
METHOD
Qualitative study derived from a doctoral thesis in which the Convergent-Care Research (Portuguese Acronym: PCA) method was used, suitable when the researcher is immersed in the care practice and intends to transform it to qualify care, counting on the adherence of the health team12.
The scenarios used consisted of three CAPS that serve adults in the city of Porto Velho, capital of the state of Rondônia; two type II CAPS, and one CAPS for Alcohol and Other Drugs (Portuguese Acronym: CAPS-AD), also type II. Regarding the selection of the participants, from a total of six multidisciplinary teams made up of 18 professionals including nurses, social workers and psychologists who cared for users by providing them with an embracement approach, the convenience sample of this study included four nurses, three social workers, one psychologist, one user and his family member.
The inclusion criteria were being a CAPS professional, having worked for more than 12 months in user embracement teams, in addition to being users and family members who had been through this embracement process and who were being monitored by the Singular Therapeutic Project (Portuguese Acronym: PTS). Professionals on vacation or leave, and users and family members with cognitive difficulties were excluded.
The main researcher works as a professor of an undergraduate nursing course in practice settings, and, for data collection, she spent approximately 450 hours between November 2018 and July 2019, when she conducted nine sequential moments of the PCA. These moments included the instrumentation and investigation phases: 1) participant adherence; 2) presentation of the theoretical framework to the research participants; 3) dialogue about nursing care at the CAPS; 4) reflective dialogue regarding the limits and possibilities of care technologies at the CAPS; 5) selection of the embracement process as the most complex care technology by the participants; 6) identification of emancipatory strategies with the potential to promote psychosocial rehabilitation at the CAPS; 7) reports resulting from the process and evaluation of the embracement approach; and moments 8) and 9), related to the discussion of the partial and final results of the research.
The data collection instruments used in the study were the following: a guideline for the activities to be performed in the individual and group meetings, two digital recorders, one tablet for taking notes of subjective data, data show projector and slides (moments 2 and 5). The group moments lasted an average of 50 minutes, and the recordings were transcribed in full.
The data were analyzed through the processes of apprehension, synthesis, theorization and transfer, which structure the PCA, characterizing the stages of data analysis12. In the apprehension stage, data emerged and were organized as notes related to group meetings and individual meetings with the user and his family member, which were coded, and similar phrases were tracked and grouped by familiarity to construct the categories. In the stage of synthesis, the participants selected the user embracement process, especially highlighted for being perceived as the most complex care technology and they identified strategies and implications for the psychosocial rehabilitation process. In the theorization stage, it was possible to analyze the aspects of the user embracement process that promoted psychosocial rehabilitation processes, as well as the difficulties and strategies faced to implement bonds and an autonomous and emancipated therapeutic itinerary. In the transfer process, mental health care and psychosocial rehabilitation were brought together based on the assessment of the user embracement technology. Particularly the care provided after the application of the user embracement process and its contributions to the integrality and longitudinality of mental health care, which contribute to the therapeutic itinerary and, consequently, to the psychosocial rehabilitation process.
To present the data, the groups were organized into alphanumeric codes: G5, G6, G7, G8 e G9, and the terms ‘user’ and ‘family member’ were also used.
Elizabeta Nietsche's middle-range theory13-14 was adopted to support the analysis. Her concept of Emancipatory Technology relates to the development of instruments and means in the work process based on the evolution of human knowledge. The sense of emancipation reflects the right to conquer a space of freedom and autonomy that enables the individual to experience their own citizenship13. In this way, she supported the conduction of the PCA by incorporating the concepts of health technology and emancipatory care technology into the knowledge of the participants, bringing together a set of knowledge and assumptions that enable thinking, reflecting and acting from a perspective of exercising critical awareness and citizenship.
This article emerged from the results of the aforementioned research, showing the role of the PCA in the process of qualifying the healthcare practice. With the simultaneous occurrence of research and practice12, the conceptual frameworks of the former were incorporated by the participants involved, which allowed the writing of this article.
The production of the data processed in this study occurred specifically between moments 5) and 9) of the PCA, with the professionals who offered user embracement and developed the PTS. They were involved in the analysis of the user embracement process and its implications for psychosocial rehabilitation under the premise that users who were provided with the embracement approach and were monitored by the PTS had better therapeutic itineraries, which naturally favored the involvement of the service with the PCA method.
The study was approved by the research ethics committee, and participants gave their consent by signing of the Free and Informed Consent Form.
RESULTS
Selection and classification of the user embracement process as an activator of the psychosocial rehabilitation process
When working with a multidisciplinary team during a PCA, research participation agreements that greatly enrich data collection are established, and in this case, the user embracement process stood out among the care practices provided in the CAPS. At a specific moment experienced by integrated research-care groups, the professionals of a multidisciplinary team chose the user embracement process as a care technology and set out to evaluate criteria for its qualification:
[…] when you evaluate the user embracement process, you are also evaluating yourself as part of the service framework [...] (G6). […] it’s the patient's first contact with the service unit and with the professionals; it is the moment when they can establish a bond with the reference professional. At this point, they can learn about how the service works and about the course of treatment. It may be the time to bring the patient closer to the service or to push them away (G5). […] it is indeed part of psychosocial rehabilitation, because through the user embracement process you’ll be able to identify even the first step towards building a unique therapeutic plan for their future (G6).
Strategies and implications of the use of an embracement approached aimed at psychosocial rehabilitation
Psychosocial rehabilitation practices permeate the user embracement process and its evaluation process by constructing bonds, providing follow-up care and ensuring adherence to the therapeutic process, as observed in the following transcripts:
[…] to evaluate, this second appointment is necessary, this re-evaluation (G6).
In addition to verifying the establishment of a bond, we need to get closer to the patient so that we can follow their steps closely and know if they are actually managing to stop taking the substance; anyway, it’s about being closer (G7).
Reflections on the goals proposed by the multidisciplinary team proved to be an essential method for reassessing these goals and their implications for the therapeutic itinerary, aiming at psychosocial rehabilitation:
[…] now the user takes part, interacts, shares his experiences, his life stories [...] he can interact; he has matured. It is so important to see his growth as a person; his ability to identify his drug problems; his family problems; the risk and protective factors. And he has even brought people over, people he identifies as being in a situation of chemical dependency, to participate in the groups (G8). […] he takes part in all CAPS groups. He is a regular […] He brings his own experiences as reference to other people. […] He went back to taking care of his son […] Every time he has problems, CAPS is his refuge […] You can see that the whole team is a reference for him [...] (G8). […] this is what would be ideal for him: go back to studying; put his ideas on paper and, who knows, write a book, since he wants to discuss the cure for drug addiction (G9).
Identifying care practices aimed at psychosocial rehabilitation reiterates how much the team's behavior and this identification process can improve the care offered to the user and their family:
[…] if you are a good listener and embrace the user, you develop an eye for the person and their needs, you are also able to explain to them what the service is about; if it is in line with what they are looking for at the moment, there is a greater chance of adherence and commitment to the service (G5). […] improving their self-esteem, but also helping people believe in themselves and that they can do it; keeping their dreams alive, and we even worked on this subject with yesterday's group (G7).
[…] I think it is possible to be cured. For the group participants, addiction is a demon and there is a cure. Maybe there isn't one now, but one day there will be. All the work I do is occupational therapy. I usually pay close attention to how I feel in terms of compulsion and obsession, and this helps me to have control over my panic disorder. I try to live in the present moment, and this makes everything easier (User). […] some are in college, but they come here from time to time, just for the group sessions, because there are no more medical records here. And when that happens, it makes us happy because we see the person walking on their own two feet (G7). […] CAPS helped uncover who my son really is: a loving child (Family member).
The difficulties in implementing psychosocial rehabilitation practices designed based on the user embracement process show how much development can still be achieved in favor of these practices:
[…] we had an idea of creating a space with computers for them to start making their own resumes, but given the difficulties, we started looking for partners outside (G7).
The PTS is a critical point for evaluating the care prescribed from the used embracement process. One of the difficulties is the participation of the doctor (G6). […] there is a lack of financial resources to further expand actions; to expand access and to create a space that is truly therapeutic. (G7).
[…] we have difficulties in developing the PTS which include the lack of professionals, because the number of patients is very large, therefore it is necessary to establish who are the major priorities, as it is not possible to provide the PTS for everyone (G6). […] there is harm to the family, because if patients are unable to be rehabilitated, they are unable to realize the damage they cause to their families (G7).
DISCUSSION
The research allowed the evaluation and classification of mental health care technologies with the potential to emancipate users and professionals by choosing the user embracement process as a full technology that can highlight emancipatory components for professionals and users such as critical awareness, citizenship, freedom and autonomy13,14, aiming to guarantee equity based on the evaluation of technologies as defined in one of the premises established by the World Health Organization15.
The assessment carried out within this premise contributed to highlighting the aspects of embracement and its connections with the work processes of professionals who perform the PTS. The team perceives the user embracement process as something that goes beyond the medical screening, favoring aspects such as bonding, follow-up care, adherence to the follow-up routine and the psychosocial rehabilitation process; in addition, a person who goes through a careful embracement process feels a greater sense of belonging that allows them to continue their therapeutic journey in the care service, therefore, both points of view complement each other and provide feedback to one another16.
This perspective demonstrates that the team is flexible, reviews its practices and indicates the PTS as a method that enables comprehensive psychosocial rehabilitation17-18.
The assessment also made it possible to detect problems, indicate improvements and promote a different perspective on the care practices developed with users and their families, which favored the perception of the embracement process and the emancipatory character involved in the construction of this type of care, identifying the importance of factors such as active listening, therapeutic dialogue, bonding19, as well as adherence and accountability, as corroborated in a study20 about the establishment of respectful and accepting relationships arising from user embracement, with contributions to adherence.
On the other hand, by identifying and understanding the factors that interfere in the process of adherence to treatment, programs and new therapeutic approaches can be developed. In this study, these approaches were also evidenced based on the embracement process, demonstrating the importance of developing the PTS focused on the users and necessary elements20.
Regarding the identification of emancipatory strategies in the embracement process with the potential to promote psychosocial rehabilitation, a specific issue made it possible to analyze and reflect on the lack of evaluation of the care provided in the CAPS setting. The fact that the user is left without a reference in the line of care hinders adherence and the validation of the therapeutic itinerary, implying the need for another care approach21 that can effectively assess this occurrence in the context of the RAPS and the referred territory.
The team, the user and his family member were able to construct and allow the evaluation of the meanings related to the care provided for the therapeutic context, their achievements and limitations, contributing to the understanding of the subjective issues involved in the longitudinal care through the PTS22.
During the data production process, the team presented some examples of care practices aimed at psychosocial rehabilitation and designed in the PTS such as inclusion through higher education degree, recovery of self-esteem, embracement of needs, identification of subjectivities and participation in group therapy. However, further support is needed so that the team can better guide these practices associated with psychosocial rehabilitation23.
Caring upon the user's singularities, recognizing the subjectivity and symbolic dimension of the individual and having an articulated and structured RAPS are ideas defended in a study that portrays the user's perception of psychosocial rehabilitation24, an aspect to be considered in the reflection on care practices in psychosocial rehabilitation. Examples of care challenges are social reintegration and the expression of singularities when implementing rehabilitation practices25.
Strategies such as those adopted by the Solidarity Economy movement can contribute to the effective contractual power of users by providing spaces for socialization, learning and cooperation7. However, professionals need to have better knowledge on psychosocial rehabilitation so that this can be an actual practice committed to the needs of CAPS users.
On the other hand, several types of difficulties hinder the already incipient psychosocial rehabilitation activities within the scope of the services, such as those presented by the professionals, with emphasis on their limitations in carrying out the PTS due to the concentration of care by doctors, which fragments care and makes it impossible to exchange knowledge19,26, in addition to the lack of investment required to purchase supplies aimed at carrying out psychosocial rehabilitation activities, not to mention family impairments derived from social exclusion, making it difficult for the user to understand the therapeutic itinerary27.
Intersectoral experiences involving social inclusion through work, as provided for in Ordinance GM No. 1.169/2005 which provides for incentives offered to municipalities with social inclusion projects, were nonexistent during data production28. The same applies to workshops for income generation and cooperatives as a representation of work with social value29.
The setback in the National Mental Health Policy (Portuguese Acronym: PNSM) that, in 2017, removed component VII (related to psychosocial rehabilitation) from Ordinance No. 3.088/2011, which requires revocation, should also be considered. This action impacted initiatives aimed at generating income and work as well as the social cooperatives of the Ministry of Labor.
These circumstances partly justify the lack of initiatives in the CAPS, which can be considered a limitation of the study. The need to prepare professionals to work with psychosocial rehabilitation was noticeable, exemplified by the difficulties some of them had in understanding the association between work and social inclusion, in addition to their little availability to engage in solidarity projects, incentives for improving care and reflection on the work processes developed in the PNSM29.
CONCLUSION
PCA has proven to be a unique tool for qualifying care practice, given its ability to reconcile the reflection of the health team involved with the promotion of continuing education, integrating research and care. The information about the research, its emancipatory technologies’ framework and the conceptual definition of psychosocial rehabilitation allowed greater participation of professionals in the convergence groups, which initially perceived the user embracement process as a complex and central care practice for psychosocial care.
This study revealed a gap in psychosocial rehabilitation in the context of services and care practices in the RAPS, as well as the urgency for its construction so that other processes can permeate the care provided by the mental health team in the territory.
Mental health service users are citizens who have lost their autonomy and contractual power in terms of work and social networks. They demand resources from intersectoral public policies focused on health, work and income, that guarantee comprehensive and longitudinal care.
That said, the study contributes to the engagement of these policies in favor of people who use mental health services, seeing them as integral individuals capable of approaching the care system in the territory.
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» https://www.gov.br/saude/pt-br/acesso-ainformacao/acoes-e-programas/caps/raps/arquivos/dados-da-rede-de-atencao-psicossocialraps.pdf/
NOTES
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ORIGIN OF THE ARTICLE
Extracted from the thesis - Emancipatory practice in Psychosocial Care Centers using nursing care technologies, presented to the Postgraduate Program in Nursing, Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, 2021.
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FUNDING INFORMATION
FAPERO- Fundação Rondônia de Amparo ao Desenvolvimento das Ações Científicas e Tecnológicas e à Pesquisa do Estado de Rondônia.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Escola de Enfermagem Anna Nery-Hospital Escola São Francisco de Assis, Report No. 2.991.799/2018, Certificate of Presentation for Ethical Consideration No. 00977118.0.0000.5238. Amendment Report No. 3.571.116 and CAEE: 00977118.0.0000.5238.
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TRANSLATED BY
Agência Latintrad - Leonardo Parachú
