THE PSYCHOSOCI AL CARE CEN TER ON THE USERS POI N T OF VI EW
1Sandr a Regina Rosolen Soar es2 Toy ok o Saek i3
Soar es SRR, Saek i T. Th e Psy ch osocial Car e Cen t er on t h e u ser s poin t of v iew . Rev Lat in o- am En fer m agem 2 0 0 6 n ov em br o- dezem br o; 1 4 ( 6 ) : 9 2 3 - 9 .
Th e p r esen t st u d y h as as it s aim t o d escr ib e t h e d aily w or k of a p sy ch osocial car e cen t er an d t o apr eh en d h ow t h e u ser s car ed by su ch ser v ice ex per ien ce t h e of f er ed t h er apeu t ic pr ocess. Sem i- st r u ct u r ed int er v iew s w er e car r ied out w it h elev en user s of t he Psy chosocial Car e Cent er , locat ed in t he count r y side of São Paulo st at e. The dat a w er e subm it t ed t o Them e Analysis, based on Minayo. The t hem es w hich cam e fr om t he dat a analysis, allow ed t he configur at ion of t hr ee t opics. I n t he fir st one, t he user exper iences t he t r eat m ent on an or ganicist focus of t he car e, assessed by t he m edical pr ofessional value, in t he m edicine- based appr oach and t he sym pt om cont r ol. The second t opic br ings t he per cept ion of t he space in CAPS as a helping scenar io of social ex changes. And t he t hir d t opic is about t he t her apeut ic pr ocess as being t ow ar ds t he daily life of t he user s. Based in t hese dat a, w e could r eflect on t he dir ect ions of t he new facilit ies in m ent al healt h, t he CAPS.
DESCRI PTORS: m ent al healt h; com m unit y m ent al healt h ser v ices; deinst it ut ionalizat ion
EL CEN TRO DE ATEN CI ÓN PSI COSOCI AL SOBRE LA ÓPTI CA DE LOS USUARI OS
El pr esent e est udio t iene por obj et iv o descr ibir el funcionam ient o de un cent r o de at ención psicosocial y apr en der com o los u su ar ios at en didos por est e ser v icio per ciben el pr oceso t er apéu t ico of r ecido. Fu er on r ealizadas ent r ev ist as sem i- est r uct ur adas, con once usuar ios de un Cent r o de At ención Psicosocial, ubicado en el in t er ior pau list a. Los dat os f u er on som et idos a An álisis Tem át ica, segú n Min ay o. Los t em as em er gidos a par t ir del análisis de los dat os, posibilit ar on la configur ación de t r es t em as. En el pr im er o de ellos, el usuar io per cibe el t r at am ien t o sobr e u n en f oqu e or gan icist a del cu idado, r elat ado por m edio de la v alor ización del p r of esion al m éd ico, en el ab or d aj e m ed icam en t oso y el con t r ol d e los sín t om as. El seg u n d o t em a t r ae la per cepción del espacio del “ CAPS” , m ient r as el panor am a pr opiciador de cam bios sociales. Y el t er cer t em a se r ef ier e al p r oceso t er ap éu t ico est ar d ir ig id o a la v id a cot id ian a d e los u su ar ios. Con b ase en est os d at os, podem os ponder ar sobr e los r um bos de los nuev os disposit iv os en salud m ent al, los “ CAPS” .
DESCRI PTORES: salud m ent al; ser v icios com unit ar ios de salud m ent al; desinst it ucionalización
O CEN TRO DE ATEN ÇÃO PSI COSSOCI AL SOB A ÓTI CA DOS USUÁRI OS
O pr esent e est udo t em por obj et iv o descr ev er o funcionam ent o de um cent r o de at enção psicossocial e apr eender com o os usuár ios at endidos por esse ser v iço per cebem o pr ocesso t er apêut ico ofer ecido. For am r ealizadas en t r ev ist as sem i- est r u t u r adas, com on ze u su ár ios de u m Cen t r o de At en ção Psicossocial ( CAPS) , localizado n o in t er ior pau list a. Os dados f or am su bm et idos à An álise Tem át ica, segu n do Min ay o. Os t em as em er gidos, a par t ir da análise dos dados, possibilit ar am a configur ação de t r ês t em as. No pr im eir o deles, o u su ár io per cebe o t r at am en t o, sob u m en foqu e or gan icist a do cu idado, r elat ado por m eio da v alor ização do pr ofissional m édico, na abor dagem m edicam ent osa e o cont r ole dos sint om as. O segundo t em a t r az a per cepção do espaço do CAPS, enquant o cenár io pr opiciador de t r ocas sociais. E o t er ceir o t em a diz r espeit o ao pr ocesso t er apêu t ico est ar v olt ado à v ida cot idian a dos u su ár ios. Com base n esses dados, pôde- se r ef let ir sobr e os r um os dos nov os disposit iv os em saúde m ent al, os CAPS.
DESCRI TORES: saú de m en t al; ser v iços com u n it ár ios de saú de m en t al; desin st it u cion alização
1 Paper ext ract ed from t he Mast er ’s Thesis; 2 RN, Mast er ’s st udent , e- m ail: [email protected] .br; 3 RN, Advisor, Assist ant Professor, e- m ail: m aryt [email protected].
Univer sit y of São Paulo at Ribeir ão Pr et o College of Nur sing, WHO Collabor at ing Cent r e for Nur sing Resear ch Developm ent , Br azil
I NTRODUCTI ON
A
ft er t he m ilit ar y coup in 1964, t he official B r a z i l i a n m e n t a l h e a l t h p o l i c y w a s b a s e d o n in v est m en t s t o in cr ease t h e n u m b er of p sy ch iat r ic beds, m ult iplying t he pr ivat ely hir ed net w or k at a t im e w h e n t h e e n t i r e w o r l d w a s m o v i n g t o w a r d s d e h o s p i t a l i z a t i o n . Th u s , c o m m i t m e n t p r a c t i c a l l y con sol i d at ed i t sel f as t h e on l y m en t al h eal t h car e alt er nat ive in t he count r y. This healt h r esour ces w as m ainly adm inist er ed by pr ivat e init iat ive, w it hout any k ind of social cont r ol( 1).At t he end of t he 1970’s, societ y w as looking f o r t e c h n i c a l l y a n d p o l i t i c a l l y m o r e a d e q u a t e alt er n at iv es t o t r eat m en t al pat ien t s, gu ided by t h e pr inciple of deinst it ut ionalizat ion * , in w hich or ganized segm ent s in civ il societ y incor por at ed t he m ov em ent t hat st ar t ed in I t aly and becam e know n as t he Net w or k of Alt ernat ives t o Psychiat ry, seeking w ays t o confront t h e m odel est ablish ed in t h at cou n t r y. I n 1 9 7 9 , t h e I t alian psy chiat r ist Fr anco Basaglia v isit ed Br azil and t he I Nat ional Meet ing of Ment al Healt h Wor ker s was held in São Paulo. These w er e t w o landm ar k s in t he discussion of Ment al Healt h Policies in Br azil.
Th i s scen a r i o g a v e r i se t o t h e Psy ch i a t r i c Re f o r m M o v e m e n t * * . B a s e d o n t h e c o u n t r y ’ s r edem ocr at izat ion pr ocess, t h is m ov em en t cr it icized psychiat r ic know ledge and inst it ut ions, as w ell as t he asy lu m in f r ast r u ct u r e.
I n r e sp o n se , t h e St a t e i n co r p o r a t e d t h i s cr it icism and or ganized t he I Nat ional Ment al Healt h Con fer en ce, in Ju n e 1 9 8 7 , as a con sequ en ce of t h e 8t h Nat ional Healt h Confer ence. I n t he sam e year, t he I I Nat ional Meet ing of Ment al Healt h Workers was held in Baur u ( SP) , w hich r at ified changes in t he et hical-t heor ehical-t ical pr inciples of psy chiahical-t r ic car e and cr eahical-t ed t he Ant i- asylum Fight Movem ent , under t he m ot t o For a societ y w it hout asy lum s.
Fr om t h at p oin t on w ar d s, t h e An t i- asy lu m Fight Movem ent , const it ut ed by differ ent social act or s u s e r s , r e l a t i v e s , w o r k e r s a n d i n t e l l e c t u a l s -a p p o i n t ed t h e n eed f o r -a b r o -a d er p o l i t i c-a l -a ct i o n st rat egy, est ablishing a dialogue w it h t he populat ion a b o u t m a d n e s s a n d i t s a s p e c t s , w i t h a v i e w t o r econst r uct ing t he r elat ions bet w een m ad people and societ y.
I n f l u e n ce d b y t h e I t a l i a n t r a n sf o r m a t i o n m o d el , t h e An t i - asy l u m Fi g h t Mo v em en t i n d i cat ed d ein st it u t ion alizat ion as a f u n d am en t al p r em ise in ser v ice r eor g an izat ion an d m en t al h ealt h p r act ices. Thus, t he guiding issue w as not t he m oder nizat ion of inst it ut ions, but t he creat ion of new spaces, w it h ot her ap p r o ach es.
I n t he legislat ive area, t he m obilizat ion of civil societ y, allied w it h t h e p olit ical societ y, led t o t h e discussion of Law Pr oj ect No 3.657/ 89 in t he Br azilian Nat ional Congr ess, pr oposed by feder al congr essm an Pa u l o D e l g a d o a n d r e l a t e d t o t h e p r o g r e s s i v e ex t inct ion of asy lum s and t heir r eplacem ent by ot her ca r e r eso u r ces ( D a y Ho sp i t a l s, Psy ch o so ci a l Ca r e Gr o u p s a n d Cen t er s - NAPS a n d CAPS, Pr o t ect ed Hom es) . This pr oj ect , sanct ioned and issued as Law No 10.216 in Apr il 2001 on t he basis of a pr ogr essive u n d e r s t a n d i n g o f c a r e , w a s a t o o l u s e d b y t h e organized societ y t o reform psychiat ric legislat ion and co n so l i d at ed t h e d i scu ssi o n p r o cess ab o u t m en t al healt h and psy chiat r ic inst it ut ions.
I n 1 9 9 2 , t h e I I N a t i o n a l M e n t a l H e a l t h Con f er en ce t ook p lace. Par t icip an t s in clu d ed u ser s, w or k er s an d ou t sou r ced p r of ession als. Discu ssion s i n c l u d e d i s s u e s l i k e c a r e m u n i c i p a l i z a t i o n a n d cit izen sh ip of m en t al p at ien t s an d r at if ied cr it icism against t he hospit al- cent er ed m odel fr om t he et hical, t echn ical an d polit ical per spect iv es.
Law No 10.216/ 01, fr om Apr il 2001, list s t he r ight s of m ent al pat ient s, st r engt hening t hese subj ect s’ social inclusion and r egulat ing a new psychiat r ic car e policy in Br azil.
I n Decem ber 2 0 0 1 , t h e I I I Nat ion al Men t al Healt h Con f er en ce occu r r ed. I n it s f in al r epor t , t h is con f er en ce r eaf f ir m ed t h e con q u est s ach iev ed as a r esult of ear lier confer ences, Law No 10. 216/ 01 and Healt h Min ist r y decr ees t h at r egu lat e m en t al h ealt h ca r e i n Br a zi l . Th i s co n so l i d a t e d t h e co m m u n i t y se r v i ce st r a t e g y ( CAPS) a s p r i o r i t y e q u i p m e n t i n m ent al healt h car e or ganizat ion.
Fu r t h e r m o r e , i n o r d e r t o r e g u l a t e a n d r eo r g an i ze n ew p r act i ces, d ecr ee No 3 3 6 / GM w as issued in Febr uar y 2002. This docum ent dist inguished b e t w e e n t h e CA PS , r a n k i n g t h e m i n t e r m s o f com plex it y and r ange. Thus, t he CAPS w er e defined as st r at egic ser v ices t o r eplace psy chiat r ic hospit als.
* Under st ood as a cr it ical- pr act ical pr ocess t hat r eor ient s inst it ut ions, k now ledge, st r at egies t ow ar ds ex ist ence- suffer ing, or also consider ed as t he const r uct ion, invent ion of a new r ealit y( 2)
H e n c e , o p e n s e r v i c e s e m e r g e d a s a count er point t o closed inst it ut ions and ar e aim ed at “ br eaking w it h t he com m it m ent t endency of t he asylum i d eo l o g y ; k eep i n g u ser s a t t h e i n st i t u t i o n f o r t h e short est t im e possible; st im ulat ing user s’ perm anence in t he fam ily and social nucleus; and m aking viable a life pr oj ect t h at is com pat ible w it h each in div idu al’s pot ent ialit ies”( 4 ).
Ho w ev er, d u r i n g t h i s d ei n st i t u t i o n al i zat i o n m ov em en t , in v iew of t h e im por t an ce of it s ev en t s an d in n ov at ion s, n ew pr oblem s ar ose. On e of t h ese put for w ar d t hat t he fact t hat a ser vice is ext er nal or open does not guar ant ee it s non- asylum char act er ist ic, and t hat t he ser v ice st r uct ur e, pr ofessionals’ act ions in car e f or m en t al p at ien t s sh ou ld b e in v est ig at ed , w it h a v iew t o diagnosing r em nant s of asy lum s( 5).
I n t h is per spect iv e, t h e CAPS Pr of. Lu iz da Ro c h a Ce r q u e i r a i n S ã o Pa u l o Ci t y a n d t h e Psy ch o so ci a l Ca r e Gr o u p i n Sa n t o s st a n d o u t a s for er unner s in t his m ent al healt h car e m odalit y.
N o w a d a y s , a c o m p r e h e n s i v e n e t w o r k o f t h er apeu t ic offer s is fu n ct ion in g, aim ed at r eplacin g t h e h osp it al- cen t er ed m od el, su ch as: p sy ch osocial car e cen t er s, p sy ch iat r ic b ed s in g en er al h osp it als, s o c i a l c e n t e r s , w o r k c o o p e r a t i v e s , t h e r a p e u t i c r esi d en ces, a m o n g o t h er s. I n g en er a l , t h ese n ew ser vices ar e char act er ized by t he use of a br oad and c o m p l e x s e t o f t h e r a p e u t i c t e c h n o l o g i e s a n d psy chosocial pr act ices, aim ed at m aint aining pat ient s in t he com m unit y.
The et hical com m it m ent t o guar ant ee qualit y ca r e t o p a t i en t s w i t h m en t a l d i so r d er s, b a sed o n p r em i ses l i k e si n g u l ar i t y, r i g h t t o h eal t h an d t o a dignified life, has driven innovat ive proj ect s, breaking w it h t he r eclusion m odel. These pr oj ect s include t he Psychosocial Car e Cent er s ( CAPS) . These exper iences under const r uct ion ar e spr ead out acr oss t he count r y now aday s and should const it ut e innov at iv e ser v ices, g u a r a n t e e i n g a “ p r o d u ct i o n sp a ce f o r n e w so ci a l p r act ices t o cop e w it h m ad n ess, m en t al su f f er in g , div er se ex per ien ce; t o con st r u ct n ew con cept s, n ew form s of living, of invent ing life and healt h”( 6).
Th i s h i st o r i ca l co n t e x t a l so co n t a i n s t h e Psy ch osocial Car e Cen t er ( CAPS) “ Esp aço Viv o” in Bot ucat u, w hich has been act iv e since 2000. One of t he goals of t his service is t o im plem ent t he psychiat ric r ef or m p r in cip les, f ou n d in g it s p r act ices on r esp ect f o r si n g u l a r i t i e s a n d o n t h e d e f e n se o f l i f e . Th e inst it ut ional ax is guiding it s int er v ent ions focuses on t he pr em ises of Psy chosocial Rehabilit at ion, not as a set of t echniques, but as an “ et hical r equir em ent ”( 7).
Thus, t his st udy aim s t o appr ehend how user s at t en d ed at t h e CAPS “ Esp aço Vi v o ” p er cei v e t h e t her apeut ic pr ocess t hat is offer ed.
METHODOLOGY
This st udy w as car r ied out by m eans of t he case st u dy m et h od, becau se it can pr ov ide a m or e det ailed and focused v iew on t he st udy cont ex t and because t he obj ect ive of t his r esear ch appr oach is t o analyze a unit in dept h( 8).
This st udy aim ed t o appr oach m ent al pat ient s’ ex per ience w it h t heir under st anding of t he t r eat m ent offer ed at a m ent al healt h car e ser v ice, in t his case t he CAPS “ Espaço Viv o”, w it h a v iew t o obt aining in-d ep t h k n o w l ein-d g e ab o u t t h e st u in-d y o b j ect , w i t h o u t ignor ing t hat t his appr oach is incom plet e and t hat it s con clu sion s ar e t em por ar y.
H o w e v e r, i n f a v o r i n g k n o w l e d g e a b o u t a delim it ed realit y, t he case st udy perm it s, based on it s r esu l t s, t h e f o r m u l at i o n o f h y p o t h eses f o r f u r t h er r esear ch( 8 ).
Elev en m ale an d f em ale u ser s p ar t icip at ed i n t h i s s t u d y. Th e i r s e l e c t i o n w a s b a s e d o n t h e f ollow in g cr it er ia: 1 . in ser t ion in t h e CAPS “ Esp aço Viv o” and at t ending t he ser v ice in t he sem i- int ensiv e r eg im e at t h e t im e of d at a collect ion ; 2 . ab ilit y t o com m u n icat e an d u n d er st an d t h e r esear ch an d 3 . a g r e e m e n t t o p a r t i c i p a t e , b y u s e r s a n d t h e i r r esponsibles, in accor dance w it h Resolut ion 1 9 9 / 9 6 .
Th i s r esear ch w as ap p r ov ed b y t h e Et h i cs Com m it t ee at t he Facult y of Medicine - UNESP.
Sem ist r u ct u r ed in t er v iew s w er e elab or at ed on t he basis of a scr ipt w it h t he m ain quest ions. We m a d e a n a p p o i n t m e n t w i t h t h e u s e r s a n d t h e r esear cher r ealized t he int er v iew s indiv idually, at t he ser v ice. User s’ nam es w er e om it t ed and r eplaced by t he nam es of t he m ain char act er s in a t heat r e piece per f or m ed by t h e CAPS.
Af t er dat a collect ion , t h e obt ain ed m at er ial w as subm it t ed t o Them at ic Analy sis, w hich “ consist s in discov er ing t he unit s of m eaning t hat m ak e up a com m unicat ion, w hose pr esence or fr equency m eans som et hing t o t he analyt ic obj ect ive t hat is aim ed for ”( 9).
RESULTS AND DI SCUSSI ON
t e s t i m o n i e s : T h e O r g a n i c I n f l u e n c e i n c a r e
d e l i v e r e d b y t h e s e r v i c e ; T h e CA P S a s a
s c e n a r i o t h a t f a v o r s t h e n e t w o r k o f s o c i a l
r e la t ion s; and finally, Th e r a p e u t ic W or k d ir e ct e d
a t u se r s’ d a ily lif e .
Th e fir st t h em e con t ain s cat egor ies lik e t h e v alu at ion of m edical pr ofession als, t h e em ph asis on m e d i c a t i o n t h e r a p y a n d t h e i m p o r t a n c e o f t h e t h er apeu t ic appr oach t o u ser s’ sy m pt om s.
These quest ions allude t o t he discussion about t he evolut ion of psychiat r y. This know ledge’s t raj ect or y w as m ar k ed by con cept u al in f lu en ces, based on an or ganic v iew of t heir et iology, on sign and sy m pt om m anagem ent and on t he pr ognosis of m ent al diseases, w hich m ar k ed it s act ion.
These concept s w er e int r oduced in psychiat r ic pr act ice fr om t he 20t h cent ur y onw ar ds as, dur ing t he pr evious cent ur y, t he det ails of t he hum an body w er e p r act ically u n k n ow n . Th e ad v an cem en t of scien t if ic m edicine m ade it possible t o under st and phy siologic p r ocesses, t h u s at t r act in g at t en t ion t o in cr easin g ly sm aller par t s of t he hum an m achine( 10).
A t t h e e n d o f t h e 1 9 5 0 ’ s , d i f f e r e n t p sy ch o t r o p i c d r u g s w er e i n t r o d u ced i n p sy ch i at r i c t her ap y, including t r icy clic ant idepr essiv e m edicat ion a n d b e n z o d i a z e p i n e s , w h i c h w e r e t h e “ i n d i r e c t r e sp o n si b l e f o r t h e i n t e g r a t i o n o f p sy ch i a t r y i n t o int er nal m edicine”( 11).
Th e s e c o n c e p t s , m a r k e d b y t r a d i t i o n a l pr act ices, st ill in f lu en ce pr of ession al act ion s in n ew m ent al healt h equipm ent lik e t he CAPS( 12).
An d m en t al illn ess, f r om an or g an ic f ocu s, pr oceeds f r om t h e con cept ion t h at “ it is som et h in g t hat occur s ‘w it hin’ t he space of t he body. I ndividuals’ su bj ect iv it y is discar ded, oper at in g a r edu ct ion t h at t r ansfor m s t hem int o dam aged obj ect s”( 13).
Th e r e p o r t b e l o w e x e m p l i f i e s t h e o r g a n i c n a t u r e o f m e n t a l s u f f e r i n g , i n a c c o r d a n c e w i t h lit erat ure findings: So, m edicat ion t r eat m ent is like t hat , it ’s
logical t hat w e have m ent al pr oblem s, but t hese ar e caused by
differ ent m ot iv es, w hich is t he per son’s ow n br ain, t her e’s a
fluid m issing in t he br ain. I can’t explain it ver y w ell, but t hese
dr u gs f igh t t h is def icien cy y ou h av e, t h is disease [ . . . ] Th e
m edicat ion helps t he person t o replace t hat deficiency t hat person
has, at t he level of t he br ain, you know , like, or ganic ( Ner o) .
The above int er view dem onst r at es how a user elaborat es his illness. This report reveals t he influence o f t h e o r g a n i c v i e w p r e s e n t e d h e r e a s a b r a i n deficiency. I n t his case, t his dy sfunct ion is appoint ed as a cause of m ent al pr oblem s.
Consequent ly, t he m edicat ion appr oach is t he m ost indicat ed opt ion in t his sit uat ion, expect ing t hat it w ill solv e t he pr oblem s and equat e t he deficiency. Th a t i s, a cco r d i n g t o h i m , t h e m e n t a l i l l n e ss i s perceived as deficiency, disabilit y and loss. And, t hus, p r o f e ssi o n a l s a n d i n st i t u t i o n s a r e r e sp o n si b l e f o r pr ov iding m eans t o fight t hese sequelae.
Hence, t he r epor t t r anslat es t he im age t hat being ill is essent ially a loss: it m eans losing abilit ies, it m eans losing affect ive bonds; it m eans losing. This d em o n st r a t es t h a t t h e d i sea se i m p l i es a st a t e o f disabilit y, est ablished b y t he event of losing and by t h e n o n - v a l u a t i o n o f r e l a t i o n s a n d i n t e r r e l a t i o n s bet w een t he indiv idual and societ y.
I t i s r e m a r k a b l e t h a t , e v e n t o d a y, t h i s d i s c o u r s e i s r o o t e d i n a n d p e r m e a t e s u s e r s ’ s t a t e m e n t s , a l t h o u g h t h e y a r e i n s e r t e d i n n e w se r v i ce s, i n i n n o v a t i v e i n st i t u t i o n a l d e v i ce s a n d , t heor et ically, const it ut ed by new pr act ices.
Th u s, t h e m e n t a l d i se a se , se t t l i n g i n t h e d am ag ed b r ain , ex p ect s t h at t h e t r eat m en t of f er ed w ill be guided by t his organic focus. According t o t his per spect ive, pat ient s associat e t he t r eat m ent w it h t he p r o f essi o n al t h ey co n si d er m o st ad eq u at e f o r t h e ex p ect ed t h er ap eu t ic act ion s, seek in g solu t ion s f or t he m ent al illness.
I n t h is case, ph y sician s w er e pr of ession ally m o s t v a l u e d t o h a n d l e t h e t r e a t m e n t a n d t h e m edicat ion appr oach and, fr om t his focus, t o handle t he t r eat m ent offer ed by t he CAPS.
Fr o m t h e o r g a n i c a p p r o a c h , t h e s e p r of essi on al s ar e v al u ed b ecau se, on l y t h e d oct or k now s w hat ’s im por t ant for t he per son’s healt h, and only he can do any t hing about it , because all healt h k n o w l e d g e i s r a t i o n a l , s c i e n t i f i c , b a s e d o n t h e obj ect iv e obser v at ion of clinical dat a”( 14).
A n o t h e r u s e r i l l u s t r a t e s t h i s s i t u a t i o n , r epor t ing t hat : [ ...] And t her e’s also t he psychiat r ist w e t alk t o at t he CAPS and our head m oves back in place, you know
( Mário) .
I n t his st at em ent , t he em phasis on t he organic nat ure of care also st ands out , w hich is very present in user s’ discour se. How ev er, t his issue needs t o be problem at ized bet t er, as t his type of t reat m ent should be par t of t he t her apeut ic pr ocess offer ed by m ent al healt h equipm ent s. However, for users in t his research, t h e a p p r o a ch d e scr i b e d h e r e i s m o r e i m p o r t a n t , referring t o a m ore t radit ional view of psychiat ry.
Th e se co n d ca t e g o r y - ‘ T h e CA P S a s a
r e la t ion s’ - w as st r uct ur ed on t he basis of how user s
h av e p er ceiv ed an d u sed t h e CAPS sp ace an d h ow t his sit e has adapt ed it self t o t her apeut ic act ions, in t h e u ser / ser v ice an d u ser / p r of ession al r elat ion s as w ell as in bonding.
Open m ent al healt h services, in t his case t he CA PS , o r i g i n a t e d f r o m i n n o v a t i v e p r o j e c t s t h a t at t em pt ed t o br eak w it h t h e asy lu m m odel in daily pr act ice. Am ong t hese pr oj ect s, em er ged at t he end of 1 9 8 0 , t h e CAPS Pr of. Lu iz da Roch a Cer qu eir a in São Pau lo, t h e NAPS in San t os - SP an d t h e CAPS “ Nossa Casa” in São Lour enço do Sul - RS st and out . Thus, t he w or k dev eloped in inst it ut ions lik e t he CAPS pr esupposes m or e com pet ence, av ailabilit y and cr eat iv it y in t he t eam t han w hat happens in t he t r ad it ion al p sy ch iat r ic m od el, in w h ich t h er ap eu t ic act ions ar e pr edet er m ined and cr y st allized. And, t he psychosocial care service m ust be a “ pr oduct ion space for new social pract ices t o cope w it h m adness, m ent al s u f f e r i n g , d i v e r s e e x p e r i e n c e ; t o c o n s t r u c t n e w con cept s, n ew f or m s of liv in g, of in v en t in g lif e an d healt h”( 6).
Th e CAPS “ Esp aço Viv o” also con st it u t es a scenario for cont radict ions, conflict s, uncert aint ies and negot iat ions bet w een user s and t he t eam . Reflect ions and debat es about doing and k now - how ar e pr esent on a daily basis.
Th e r ep or t b elow , b y Cam ar g o, sh ow s t h e st ill cu r r en t d iscu ssion ab ou t p sy ch iat r y, it s r ole in social organizat ion and, m ainly, about psychiat r ic car e inst it ut ions. This CAPS user ’s discour se m ay also be shar ed by m any ot her user s, r elat iv es and w or k er s, w h o a r e a c t o r s i n a n o n g o i n g p r o c e s s . I n t h i s p e r sp e ct i v e , a cco r d i n g t o Ca m a r g o : Th e CAPS i s a
dehospit alizat ion pr oposal, you know . Out side societ y, nobody
sur vives, because t he hum an being, he needs ot her people t o
survive. So t he CAPS, it would be nice if we had a CAPS I I I here as
w ell, if t he places w er e canceled, if t he psychiat r ic hospit al w er e
closed, you know . Because t he psychiat r ic hospit al w as useful in
ot her t im es, in gover nm ent r egim es w it h anot her m ent alit y, but
in t his dem ocr at ic m ent alit y, anot her CAPS w ould be needed t o
at t end t o t he dem and, you know ( Cam argo) .
Mor eov er, accor ding t o t he r epor t , t he CAPS appears as a count erpoint t o t he hospit al, as a ser vice w or k ing t ow ar ds dehospit alizat ion. I n fact , t he CAPS e m e r g e d a s i n t e r m e d i a r y se r v i ce s o r, b e t t e r, a s inst it ut ions w hose com plex it y int er m ediat ed bet w een p sy ch iat r ic h osp it als an d t h e com m u n it y, d eliv er in g car e t o p at i en t s w h en t h ey w er e d i sch ar g ed f r o m hospit als, w it h a view t o t heir passage t o com m unit y
l i f e o r a v o i d i n g c o m m i t m e n t . Th e CA PS p r o j e c t accept s, even if t em porar ily, t he psychiat r ic hospit al. Wit h r esp ect t o p r of ession als’ act ion s, t h e i n t er v i ew ees p er cei v e an at t i t u d e o f l i st en i n g an d w elcom in g of su f f er in g in t h e w or k er s. Th is r ole is v alued as an inst r um ent in t he t her apeut ic pr ocess. The int erview s offered several report s in t his respect :
That I needed t o giv e v ent t o m y t ensions som et im es and I
couldn’t , you know . Alt hough I r eleased pr essur e a lot w it h ot her
people, but it w asn’t t he sam e t hing as a pr ofessional, you know
( Adelaide) ; Your suppor t t o m e w hen I needed it m ost , it w as
good at t hat t im e. I ’m m uch bet t er now ( Loucur a) ; I t helped in
t he care t hey give m e, everyt hing t hey give m e [ ...] Ah, t he care,
I felt alone [ ...] I needed t o be w it h som e people, because I
w asn’t w it h m y sist er anym or e ( Michele) .
User s r epor t t hat t hey feel suppor t , car e and list ening and use t he m eet ings w it h t he pr ofessionals as oppor t unit ies t o r elease pr essur e, t o get r elief.
Mi ch el e accr ed i t s h er i m p r o v em en t t o t h e con t in u ou s su p p or t b y t h e ser v ice w h ile h er social net w or k w as not st r engt hened. At t hat t im e, she felt alone and used t he CAPS as a space for m eet ing and hav ing cont act w it h ot her people.
I n t h eir d iscou r se, t h e in t er v iew ees d o n ot define in w hat act ivit ies or ‘places’ t hese ‘encount ers’ h a p p e n , w h e r e t h e e x ch a n g e s a n d n e t w o r k s a r e e s t a b l i s h e d . Th u s , t h e s p a c e s m a y h a v e b e e n p er m eab le an d m ay h av e of f er ed su p p or t t o u ser s’ n eed s.
Th ese t est im on ies sh ow t h at p at ien t s h av e u sed t h e ser v ice as a f ir st ap p r oach an d t h at t h e est ablished relat ion cont inues at t he level of care and s u p p o r t . H o w e v e r, t h i s a p p r o a c h h a s o c c u r r e d gradually. Thr oughout t he r esear ch, w e found r epor t s dem onst r at ing t hat t he t her apeut ic pr ocess has m oved for w ar d t o at t end user s’ needs.
I n s u m m a r y, t h e CA PS c o n s t i t u t e s a n oppor t unit y t o act in t he w or ld again. For t hese user s, w i t h d r a w n f r o m p r o d u ct i o n p r o ce sse s a n d f a ci n g decr eased or ev en absent social bonds, par t icipat ing in t h e ser v ice an d en t er in g a n et w or k of solid ar it y and suppor t allow s t hem t o r ecover social bonds in a sit uat ion w her e t hese bonds ar e even m or e necessar y. Th e l a st ca t e g o r y - ‘ T h e r a p e u t i c W o r k
d i r e ct e d a t u se r s’ d a i l y l i f e ’ - ad d r essed u ser s’
of m ult iple relat ions. Daily realit y is not a rout ine, it is n ot t h e sim ple m ech an ical r epet it ion of act ion s t h at lead t o doing for t he sak e of doing. D a ily r e a lit y is
t h e p l a ce w h e r e w e a t t e m p t t o ca r r y o u t o u r
p r a ct ica l t r a n sf o r m in g a ct iv it y , it is t h e so cia l;
it is t h e con t e x t w e liv e in ”( 15) ( our it alics) . Th e d a i l y c o n t e x t g i v e s r i s e t o c o n f l i c t sit u at ion s, f ear s, d if f icu lt ies, ab ilit ies an d con cr et e si t u a t i o n s o f l i f e i n ca r e. An d i t i s t h r o u g h t h ese sit u at ion s t h at t h e w ir es of t h e t h er apeu t ic pr ocess ar e w ov en. Thus, user and ser v ice w or k t oget her in t he search for act ual needs and desires in t he m eaning of t r eat m ent .
The discour se of user s at CAPS “ Espaço Vivo” discloses sit uat ions and ev ent s t hey liv ed and coped w it h, for w hich t hey r eceived suppor t fr om t he ser vice. Th r ou gh t h e in t er v iew s, r epor t s em er ged t h at poin t t ow ar ds t her apeut ic pr act ices t hat hav e helped user s t o face difficult ies in daily life.
Th e t w o t e s t i m o n i e s b e l o w p r e s e n t t h e i m p o r t a n c e o f t h i s t h e m e t o s u p p o r t u s e r s ’ i m p r o v e m e n t , t o t a k e co n t r o l o f t h e m se l v e s, t o m anage t heir lives: [ ...] Ranging fr om t he sim plest t hings, cl ean i n g , d o i n g ev er y d ay t h i n g s, t o b u si n ess. Ob l i g at i o n ,
appoint m ent , t im e, it helps a lot . Because I was having difficult ies
like, w it h t im es, I had sw it ched day and night , I couldn’t m anage
t o do w hat I do her e and, for t en m ont hs now , I alr eady m anage.
I t ’s not from one day t o t he ot her. But I already m anage t o t ake a
bur den off m y daught er , a v er y heav y r esponsibilit y for her .
( Adelaide) and Today I m anage t o go t o t he cit y, buy what I want ,
I ... if t her e’s a bill I go t her e and pay it [ ...] Now , at hom e, if
t her e’s a kit chen, I go t her e and clean t he kit chen, I alr eady help
m y daught er m ore, you know, clean a house, like... what I ’m able
t o I ’m doing. I t hink t his has already helped m e a lot . ( Dem ent ina)
These st at em ent s show t hat t her apeut ic w or k st ar t s w it h t he difficult ies est ablished in and r elat ed t o t he perform ance of daily act ivit ies. The r epor t s also reveal t hat t he t herapeut ic process - w hich st ar t s w it h body car e aspect s - t hen incr eases t he com plexit y of int ervent ions, focusing on daily act ivit ies, but st ill in a pr ot ect ed space, t he CAPS in t his case. Lat er, t hese a ct i v i t i es a r e t r a n sf er r ed t o t h e r esp ect i v e a ct u a l spaces, in each pat ient ’s daily cont ex t .
Th e i n t e r v i e w e d u s e r s p e r c e i v e t h e per for m ance of dom est ic chor es as t he achiev em ent of higher levels of aut onom y, and also as im por t ant act iv it ies w it h r espect t o r elat iv es.
Thus, Adelaide r epor t s t hat her im pr ovem ent also br ought about a decr ease in t he “ r esponsibilit y ” she w as delegat ing t o her daught er.
Dem ent ina, on t he ot her hand, per ceives t hat h er im p r ov em en t m ad e h er sh ar e h ou sew or k w it h h er dau gh t er.
The t her apeut ic w or k focused on user s’ daily act iv it ies is also v alu ed as on e of t h e p sy ch osocial r eh ab ilit at ion t ools. Th e cen t r alit y of t h is q u est ion t ur ns t he ser v ice int o an im por t ant innov at iv e dev ice in m en t al h ealt h car e an d “ d aily p r act ices, in t h is cont ex t , ar e consider ed as essent ial com ponent s for u ser s’ psy ch osocial r eh abilit at ion . An d, t h r ou gh t h is r e h a b i l i t a t i o n , t h e c o n s e q u e n t a c h i e v e m e n t o f ci t i ze n sh i p . Th e d i f f e r e n t i a t i o n b e t w e e n t r e a t i n g p e o p l e w i t h t h e i r o w n n e e d s , t h e i r s u b j e c t i v i t y ap p ear s as an im p or t an t d if f er en t ial in com p ar ison w i t h t h e c e n t r a l i z a t i o n i n t h e t r e a t m e n t o f t h e d isease”( 1 6 ).
The analysis of t hese findings show s t hat t he ser v ice h as f ocu sed daily pr act ices in it s w or k . Th e t h er ap eu t i c p r o cess i s b ased o n r esp o n si b l e car e, v aluing t he subj ect s’ abilit ies, difficult ies and needs. Th e u se r s p e r ce i v e t h e r e su l t o f t h e t h e r a p e u t i c con t r act as an im p r ov em en t in t h eir q u alit y of lif e an d au t on om y. To t h e ex t en t t h at t h ese issu es ar e v alued and addr essed, t he ser v ice get s closer t o t he p r e m i s e s o f r e h a b i l i t a t i o n . H o w e v e r, o r g a n i c ap p r o ach es l i k e t h e o n es an al y zed ab o v e ar e st i l l p r esen t . Th is con t r ad ict ion m ay b e in h er en t in t h e daily const r uct ion pr ocess of new ser v ices, ent ailing, ev er y d ay, d ilem m as an d con f r on t at ion s in d ealin g w it h m ent al suffer ing.
FI NAL CONSI DERATI ONS
Th is qu alit at iv e st u dy aim ed t o iden t ify an d an aly ze t h e t r eat m en t of f er ed at t h e Psy ch osocial Car e Cen t er “ Esp aço Viv o” f r om t h e p er sp ect iv e of user s at t ended by t he ser vice. Based on t he collect ed dat a, w e could appr ehend t hat t he car e em phasized fr om t he or ganic v iew point appear s as t he st r ongest p o i n t i n t h e ser v i ce’s t h er ap eu t i c p r o cess. I n t h i s per spect ive, t he physician occupies a pr ivileged place in t he ser v ice, det er m ined by psy chiat r ic k now ledge. Th u s, t h e in t er v iew ed u ser s p er ceiv e t h e f ollow in g inst r um ent s needed t o per for m t his w or k : t he use of p sy ch o t r o p i c d r u g s t o r e l i e v e sy m p t o m s a n d t h e doct or ’s appoin t m en t .
I n t h e in t er v iew ees’ st at em en t s, t h e w elcom in g an d list en in g at t it u d e f r eq u en t ly ap p ear s as p r esen t in ser v ice w or k er s. This char act er ist ic is ident ified as a cur r ent st yle of w or k and pr act ice at t he ser vice: t he h u m an r elat ion , w elcom in g , r esp ect , af f ect ion an d su ppor t t h e u ser s ar e t r eat ed w it h . Th ese pr em ises support ing t he inst it ut ion’s act ions are in line w it h t he Psy ch iat r ic Ref or m .
User s per ceive t hat t alking and being list ened t o r eliev es t h eir su ffer in g, an d t h e est ablish m en t of t his relat ion is a form of help.
A n o t h e r i m p o r t a n t a s p e c t i n t h e u s e r ’ s r e l a t i o n s w i t h t h e s e r v i c e w a s b o n d i n g . Th e
in t er v iew ees in d icat ed t h at t h e p r of ession als h av e at t em pt ed t o “ look” at t he pat ient s’ life cont ext , even w hen t r eat m ent is discont inued. Tr eat m ent fr equency and cont inuit y ar e also consider ed as w ays of bonding, st r engt hening t he t r ust and help r elat ion.
We b e l i e v e t h a t t h e r e a l i z a t i o n o f d a i l y act ivit ies should be insert ed as one of first obj ect ives in care cont ract s and, in a w ider sense, in psychosocial r eh abilit at ion pr oj ect s.
How ev er, once t hese im m ediat e needs hav e b een o v er co m e, t h e f o cu s n eed s t o w i d en t o t h e co m p l e x i t y o f su b j e ct s i n su f f e r i n g , r e a ch i n g t h e concr et eness of t heir liv es and r elat ions.
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