ABSTRACT

Objective:

Analyze how professionals understood the multi, inter and transprofessionality and how these practices happened in the CAPS (Psychossocial Care Centers) of São Paulo/SP.

Method:

Qualitative, exploratory, descriptive study, and use of Content Analysis. We interviewed 27 professionals from nine CAPS.

Results:

Organized in two categories: definition of multiprofessional, interprofessional and transprofessional work in Mental Health; and specific aspects of professions and Conceptions about multi, inter and transprofessional teamwork in daily life. There were difficulties in conceptualizing modalities of disciplinary integration, little problematization in the reality of workers, and questions of specific practices of each area. The devices have been problematized, in which the distancing of Public Policies happen.

Final considerations:

There is coexistence of the biomedical, of insane asylum and Psychosocial Care paradigms in the discourses and actions of the teams, to compromise the effectiveness of the Psychiatric Reform. The practice was close to the ideas of integration and of auxiliary interdisciplinarity and not of the effective construction of shared therapeutic knowledge and projects.

Descriptors:
Mental Health; Health Policy; Patient Care Team; Interdisciplinary Communication; Community Mental Health Services

RESUMEN

Objetivo:

Analizar cómo profesionales comprendían la multi, inter y transprofesionalidad y cómo estas prácticas ocurrían en los CAPS de São Paulo/SP.

Método:

Estudio cualitativo, exploratorio, descriptivo, uso del Análisis de Contenido. Entrevistados 27 profesionales de nueve CAPS.

Resultados:

Organizados en dos categorías: Definición del trabajo en equipo multiprofesional, interprofesional y transprofesional en Salud Mental y aspectos específicos de las profesiones y Concepciones acerca del trabajo en equipo multi, inter y transprofesional en el cotidiano. Dificultades en conceptualizar modalidades de integración disciplinar; poca problematización en la realidad de los trabajadores; cuestionamientos de las prácticas específicas de cada área. Problematizados dispositivos en que se dan y distanciamiento de las Políticas Públicas.

Consideraciones finales:

Hay coexistencia de los paradigmas biomédico, de manicomio y el de la Atención Psicosocial en los discursos y acciones de los equipos, a comprometer la efectividad de la Reforma Psiquiátrica. La práctica se encontraba cerca de las ideas de integración y de interdisciplinaridad auxiliar y no de la construcción efectiva de saberes y proyectos terapéuticos compartidos.

Descriptores:
Salud Mental; Políticas Públicas de Salud; Grupo de Atención al Paciente; Comunicación Interdisciplinaria; Servicios Comunitarios de Salud Mental

RESUMO

Objetivo:

Analisar como profissionais compreendiam a multi, inter e transprofissionalidade e como essas práticas aconteciam nos CAPS de São Paulo/SP.

Método:

Estudo qualitativo, exploratório, descritivo, e uso da Análise de Conteúdo. Foram entrevistados 27 profissionais de nove CAPS.

Resultados:

Organizados em duas categorias: definição de trabalho em equipe multiprofissional, interprofissional e transprofissional em Saúde Mental; e aspectos específicos das profissões e Concepções sobre o trabalho em equipe multi, inter e transprofissional no cotidiano. Dificuldades em conceituar modalidades de integração disciplinar, pouca problematização na realidade dos trabalhadores e questionamentos das práticas específicas de cada área. Foram problematizados os dispositivos em que se dão o distanciamento das Políticas Públicas.

Considerações finais:

Há coexistência dos paradigmas biomédico, manicomial e da Atenção Psicossocial nos discursos e ações das equipes, a comprometer a efetivação da Reforma Psiquiátrica. A prática se encontrava próxima das ideias de integração e de interdisciplinaridade auxiliar e não da construção efetiva de saberes e projetos terapêuticos compartilhados.

Descritores:
Saúde Mental; Políticas Públicas de Saúde; Equipe de Assistência ao Paciente; Comunicação Interdisciplinar; Serviços Comunitários de Saúde Mental

INTRODUCTION

With the implementation of the Sistema Único de Saúde (Brazilian Unified Health System) in the 1990s, based on Health Reform, the concept of health was expanded in the paradigm of Social Production of Health, requiring interdisciplinarity⁽¹1 Tavares CMM. Interdisciplinarity as requisite for the formation of the psychiatric nurse in the perspective of psycho-social care. Texto Contexto Enferm[Internet]. 2005[cited 2017 Apr 19];14(3):403-10. Available from: http://www.scielo.br/pdf/tce/v14n3/v14n3a12.pdf
http://www.scielo.br/pdf/tce/v14n3/v14n3... ⁾. In the field of Mental Health, the Psychiatric Reform introduced the Psychosocial Attention Paradigm, which seeks to overcome the logic of institutionalization and also evokes disciplinary integration⁽¹1 Tavares CMM. Interdisciplinarity as requisite for the formation of the psychiatric nurse in the perspective of psycho-social care. Texto Contexto Enferm[Internet]. 2005[cited 2017 Apr 19];14(3):403-10. Available from: http://www.scielo.br/pdf/tce/v14n3/v14n3a12.pdf
http://www.scielo.br/pdf/tce/v14n3/v14n3... ⁾. Over the years, the Centros de Atenção Psicossocial (Psychosocial Care Centers-CAPS) have been configured as strategic equipment in the Rede de Atenção Psicossocial (Psychosocial Care Network- RAPS) and in the support of the logic of substitution to insane asylums because they are devices of intensive care, community and life-support providers⁽²2 Milhomem MAGC, Oliveira AGB. O trabalho em equipe nos Centros de Atenção Psicossocial - CAPS. Cogitare Enferm[Internet]. 2007[cited 2017 Apr 19];12(1):101-8. Available from: http://revistas.ufpr.br/cogitare/article/view/8277/5786
http://revistas.ufpr.br/cogitare/article... ⁾.

Discipline is a homogeneous area of study, with well-defined boundaries, responding to power relations and forms of control of discourses⁽³3 Japiassu H. Interdisciplinaridade e patologia do saber. Rio de Janeiro: Imago; 1976.⁾. Multidisciplinarity proposes the juxtaposition of several disciplines, without involving joint work and coordination⁽³3 Japiassu H. Interdisciplinaridade e patologia do saber. Rio de Janeiro: Imago; 1976.⁾. Interdisciplinarity requires a common problem, with joint work and mutual learning, and recombination of the elements of each discipline⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾. Transdisciplinarity seeks to go beyond, proposing openness to what goes through and goes beyond all disciplines⁽⁵5 Nicolescu B, Morin E, Freitas L (Comitê de Redação). Carta da Transdisciplinaridade: Artigo 3º. Primeiro Congresso Mundial de Transdisciplinaridade. Convento de Arrábida, Portugal, 1994.⁾.

In fact, the CAPS shows difficulties in the development of multiprofessional practices with the teams, often transformed into a group of workers with parceled practices, still under the influence of the medical authority⁽²2 Milhomem MAGC, Oliveira AGB. O trabalho em equipe nos Centros de Atenção Psicossocial - CAPS. Cogitare Enferm[Internet]. 2007[cited 2017 Apr 19];12(1):101-8. Available from: http://revistas.ufpr.br/cogitare/article/view/8277/5786
http://revistas.ufpr.br/cogitare/article... ⁾. It is also observed the auxiliary interdisciplinarity as a challenge to the practices in a multiprofessional team, seen in Mental Health especially when Psychiatry assumes the role of coordinator of the other areas⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾.

In addition to the challenges directly linked to disciplinary integration, there is the articulation with the territory and the structural lack as other fragilities of the CAPS. Even though the discourses show Psychosocial Care as the predominant conception, there are internal conflicts in the work processes of the teams and questions about the real viability of the execution of the Mental Health Policies, which seem to depend exhaustively on the creativity of the professionals to be executed⁽⁶6 Ramminger T, Brito JC. “Each Caps is a Caps”: a coanalysis of resources, tools and standards available in the activities of mental health work. Psicol Soc[Internet]. 2011[cited 2017 Mar 30];23(N.Spe.):150-60. Available from: http://www.scielo.br/pdf/psoc/v23nspe/a18v23nspe.pdf
http://www.scielo.br/pdf/psoc/v23nspe/a1... ⁾.

OBJECTIVE

To analyze the conceptions of the workers of the CAPS on the different forms of disciplinary integration and as they happened in the reality of the services of the city of São Paulo/SP.

METHOD

Ethical aspects

The research project received a favorable opinion from the Ethics Committee of the Universidade Federal de São Paulo (UNIFESP) on April 23, 2015 and the Research Ethics Committee of the Secretaria Municipal de Saúde (Municipal Health Secretariat) of São Paulo/SP, on May 15, CAPS managers signed letters of authorization and all participants signed the Informed Consent Form.

Type of study

This is an exploratory, descriptive, qualitative approach study.

Methodological procedures

Methodological procedures were according to Content Analysis⁽⁷7 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2016.⁾.

Study setting

It was carried out in nine adult CAPS in the city of São Paulo/SP, one in the Center-West region and two in each of the other administrative regions: South, North, Southeast and East. Data were collected from July to September 2015.

Study participants

The study was composed of professionals of higher level, and members of the multiprofessional team of the CAPS. The study participants were chosen for convenience, and a member of the coordination and two professional care providers were interviewed in each service, belonging to different professional areas. The inclusion criteria were: to be a minimum of one year in the CAPS and to be a public servant without connection with any Social Health Organization (OSS). In two units there were no coordinators who fulfilled this last criterion, due to the shortage of adult CAPS of direct administration of the City Hall of São Paulo/SP in some regions. It was decided to keep these participants to ensure representativeness and considering that they fit the other exclusion criteria.

Collection and data organization

The interviews were conducted from guiding questions, with audio recording and verbatim transcription for processing and data analysis. The data collection instrument was developed by the researchers, with data from the participant and the guiding questions: “Describe what you understand by working in a multiprofessional, interdisciplinary and transdisciplinary teamwork in Mental Health.”; “How does multiprofessional teamwork in the service in which it operates?”; “What factors influence the presence/absence of multiprofessional work?”; “Do you consider that multiprofessional teamwork interferes with the service provided to the user? How?” The excerpts from interview responses are identified by the letter P (acronym for participant) followed by the number corresponding to the order of interview.

Data analysis

Two categories of analysis were elaborated with two thematic units in each: 1. Definition of multiprofessional, interprofessional and transprofessional teamwork in Mental Health and specific aspects of the professions (Thematic Units 1.1 Definitions of multi, inter and transprofessional work in Mental Health, and 1.2 Professional specificity and multi, inter and transprofessional work); and 2. Conceptions about multi, inter and transprofessional teamwork in the daily life (Thematic Units) 2.1 Perceptions about multi, inter and transprofessional teamwork in the daily life of CAPS, and 2.2 Interventions and devices that support multi, inter and transprofessional teamwork in CAPS.

RESULTS

Twenty-seven professionals from nine CAPS Adult were interviewed from the five regions of the city of São Paulo/SP. Of the total of services participating, eight equipment were CAPS II and one, CAPS III. Seven nurses, two psychiatrists, one pharmacist, two occupational therapists, six social workers and nine psychologists participated. There were three male and twenty-four female respondents. The participants’ ages ranged from 28 to 64 years, with an average of 45 years and a standard deviation of 10.78 years. Working time in the unit ranged from 1 to 19 years, with an average of 10 years and a standard deviation of 7.03 years. Regarding the graduation time of the professionals, there was variation from 4 to 35 years, mean of 18 years and standard deviation of 8.8 years.

The categories and respective thematic units are presented below.

Category 1 – Definition of multiprofessional, interprofessional and transprofessional teamwork in Mental Health and specific aspects of the professions

When answering about how they understood the modalities of disciplinary integration, sixteen participants approached the concepts of multiprofessional teamwork and eighteen of the interprofessional work; only six knew the transdisciplinary proposal; and twenty-six interviewees believed they knew what the three modalities were about without approaching the concepts in the answers, when the three thematic units were observed. Professional specificities of each area and contradictions experienced in practice between these and the integration proposals were also commented on.

1.1 Definitions of multi, inter and transprofessional work in Mental Health

Among the participants whose answers approached the ideas of multiprofessional work in Mental Health, the main points were the maintenance of disciplinary aspects and the absence of common exchanges and objectives between the areas, focusing on problem solving:

Interviewees who addressed the concept of interprofessional work in Mental Health highlighted the occurrence of “exchange” and “integration”, as well as the perspective of widening the gaze, and the clinic, observing affinity with the notion of integrality of care:

Only six participants addressed definitions of trans-occupational work in Mental Health, which still presents challenges:

1.2 Professional specificity and multi, inter and transprofessional work

The disciplinarity was considered necessary in some moments of the practice, especially as possibility of technical improvement and expansion of knowledge:

Category 2 – Conceptions about multi, inter and transprofessional teamwork in the daily life of Psychosocial Care Centers

2.1 Perceptions about multi, inter and transprofessional teamwork in the daily life of Psychosocial Care Centers

When questioned about the practices of disciplinary integration in the daily life of their services, the participants listened to some multi, inter and transprofessional moments in the CAPS, which were also approximated to ambulatory practices in some situations. The shared groups, the team meetings, the elaboration of the Projeto Terapêutico Singular (freely translated as Unique Therapeutic Project) and the host were listed as examples of disciplinary integration in the CAPS, being verified that they cannot by themselves be considered multi, inter or transprofessional practices, ranging between each service or even in the different situations of the same equipment. In general, teamwork was considered a condition for the approximation of care advocated in Public Policies and the broadening of the user-oriented approach:

2.2 Interventions and devices that support multi, inter and transprofessional teamwork in Psychosocial Care Centers

In commenting on the reception devices, ambience, Projeto Terapêutico Singular (freely translated as Unique Therapeutic Project) and Technical Reference (TR), therapeutic groups and workshops, clinical-institutional supervision and networking and their articulations with the multi, inter and transprofessional proposals in the reality of the services, draws attention to the distance between the theory and documents of the Ministry of Health and the practice in the CAPS. It can be verified, in the speech of the participants, the impoverishment of these resources in front of scattered and overburdened teams and the difficulty of approaching Psychosocial Attention. As main examples of this subunit, one can consider the reality of PTS and TR devices, therapeutic groups and workshops and ambience:

DISCUSSION

Category 1 – Definition of multiprofessional, interprofessional and transprofessional teamwork in Mental Health and specific aspects of the professions

11 Definições de trabalho em equipe multi, inter e transprofissional em Saúde Mental

In the proposal of interprofessional work, the team meetings were valued, especially when the porosity between the professional boundaries and the specific aspects of each area was problematized, the importance of work organization and the reduction of the hierarchies between management and worker and these and the users.

As a result of the trans-professional work, the interviewees considered it as a possibility to go “beyond” the other modalities, from the production of something “new”, not belonging to any of the fields per se, with the user’s needs as the main goal of the actions. It was possible to verify, both in the answers that went away and in those that approached this proposal, that the notion of transdisciplinarity referred the interviewees to a distance between literature and practice, being considered unreachable and sometimes non-existent in the current reality of CAPS.

1.2 Definitions of multi, inter and transprofessional work in Mental Health

In this unit, the interviewees observed the importance of maintaining the disciplinary knowledge, and the contradictions between the specific aspects of each area and the proposals of disciplinary integration; the lack of clarity of the teams and users of the CAPS (cited by professionals interviewed) on the different professional roles; the disputes between knowledge and power; and the importance of dialogue among workers. One can think of the confrontations between the proposals of disciplinary integration and the formal and bureaucratic aspects, like the Professional Councils, marked by the disciplinary logic and control of the speeches, and the Registro das Ações Ambulatoriais de Saúde (Registry of Ambulatory Health Care Actions- RAAS) (fundamental for indication of service productivity), which does not allow placing two professionals coordinating the same group, for example.

The notion of discipline is related to the Cartesian Method, which defends the fragmentation of the object and the specialization of the researcher, proposing strict boundaries between knowledge⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾. Although fundamental to the development of several existing technologies, this paradigm has as its difficulty the apprehension of objects that are not subordinated to only explanatory approximations, but which cannot but be part of the field of science⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾. Concerned with the multiplicity of the real, Morin⁽⁸8 Morin E. Ciência com consciência. Rio de Janeiro: Beertrand Brasil; 2014.⁾ presents the concept of complex objects, which seeks to account for the articulations between different disciplines and the different dimensions of the events that present themselves. In this context, health can also be understood in an expanded way, from Public Health to Collective Health, a field marked by epistemological innovation, with the inclusion of new dimensions and understood as transdisciplinary in health-disease-care integrals⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾.

Based on the definitions of multi, inter and transdisciplinarity, Almeida Filho⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾ observes that these modes of understanding disciplinary integration do not consider the practical difficulty of different fields, which start from different assumptions, to be able to communicate effectively and propose some redefinitions in the idea of transdisciplinarity. It suggests that disciplinary fields are understood as praxis rather than structures, composed of intraparadigmatic elements (symbolic, ethical, political, pragmatic) and knowledge is an institutional network operated by concrete and pragmatic historical agents, which are linked to the socio-political context⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾.

Therefore, transdisciplinarity would occur from the communication between the agents of each disciplinary field and not between the fields⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾. It would be the “transit of the subjects of the speeches” that would guarantee the different accesses to particular facets of the complex object⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾. In each field there would be “agents of scientific practice”, moving between at least two disciplinary fields and “experts”, who remain in their own fields and the syntheses could take place in the paradigmatic bias in each disciplinary field, with the enrichment of each and transdisciplinar, from the practice of the agents, with the reach of provisional totalizations of the complex objects⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾.

In the various conceptions of disciplinary integration, it is worth emphasizing that the forms of disciplinary, multi, inter and transprofessional work do not cancel out, which would retreat to the idea that there would be a unique form of response to the multiplicity of life, but can be thought of as four arrows of the same bow⁽⁹9 Nicolescu B. O manifesto da transdisciplinaridade. São Paulo: Triom; 1999.⁾. It is observed the importance, rather than the attachment to the different forms of work, that care is centered on the demand of the user and that knowledge can be produced from the idea of democracy⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ^,1010 Domingues I. Multi, Inter e Transdisciplinaridade: onde estamos e para onde vamos? Pesq Educ Amb[Internet]. 2012[cited 2017 Mar 30];7(2):11-26. Available from: http://www.revistas.usp.br/pea/article/view/55959/59341
http://www.revistas.usp.br/pea/article/v... ⁾.

Category 2 – Conceptions about multi, inter and transprofessional teamwork in the daily life of Psychosocial Care Centers

2.1 Perceptions about multi, inter and transprofessional teamwork in the daily life of Psychosocial Care Centers

In this thematic unit, we highlight the perceived differences between the definitions of the disciplinary integration modalities of each interviewee and the practices of the different equipment, such as services in which there is a glimpse of transprofessional actions and others still mostly ambulatory.

The problematization between the ideal discourse in contrast to the possible practice was also highlighted, especially when considering the overload to which the professionals are submitted, often approaching ambulatory practices. Ramminger and Brito⁽⁶6 Ramminger T, Brito JC. “Each Caps is a Caps”: a coanalysis of resources, tools and standards available in the activities of mental health work. Psicol Soc[Internet]. 2011[cited 2017 Mar 30];23(N.Spe.):150-60. Available from: http://www.scielo.br/pdf/psoc/v23nspe/a18v23nspe.pdf
http://www.scielo.br/pdf/psoc/v23nspe/a1... ⁾ will relate this to the “anticipated unforeseen events”, daily events that have no forecast in the team’s schedule and the attendance of users who could be in other levels of attention of the network in the CAPS.

Some respondents note the way in which “non-conventional” professionals (not directly related to the health area or even without a higher education level) appear in the care of the users: although one wishes to speak of a valuation of different forms of knowledge, present in the ideal of disciplinary integration⁽⁹9 Nicolescu B. O manifesto da transdisciplinaridade. São Paulo: Triom; 1999.⁾, in practice it is verified that, in addition to legal difficulties, such as deviation of function, secrecy, etc., they still occupy the role of informants of the technical team. Ramminger and Brito⁽⁶6 Ramminger T, Brito JC. “Each Caps is a Caps”: a coanalysis of resources, tools and standards available in the activities of mental health work. Psicol Soc[Internet]. 2011[cited 2017 Mar 30];23(N.Spe.):150-60. Available from: http://www.scielo.br/pdf/psoc/v23nspe/a18v23nspe.pdf
http://www.scielo.br/pdf/psoc/v23nspe/a1... ⁾ point out, in contrast to the answers to the guiding questions, that the work in the CAPS ends up maintaining social divisions and other characteristics of the practice in psychiatric hospitals, so that the professionals seem to have recourse to the model they intend to overcome.

At this meeting, in several responses of this study it was possible to verify the coexistence in the CAPS of the Psychosocial Care Paradigm and the insane asylum mentality, seized for example in language (users still as patients without voice) and few allusions to participation and to the social control of users, an important way for the effective place of citizens, as well as the prevalence of auxiliary interdisciplinarity⁽⁴4 Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cienc Saúde Colet[Internet]. 1997[cited 2017 Apr 1];II(1/2):5-20. Available from: http://www.scielo.br/pdf/csc/v2n1-2/1413-8123-csc-02-1-2-0005.pdf
http://www.scielo.br/pdf/csc/v2n1-2/1413... ⁾. Despite the advances made by the Psychiatric Reform, CAPS are still understood as a place for “patient treatment”⁽⁶6 Ramminger T, Brito JC. “Each Caps is a Caps”: a coanalysis of resources, tools and standards available in the activities of mental health work. Psicol Soc[Internet]. 2011[cited 2017 Mar 30];23(N.Spe.):150-60. Available from: http://www.scielo.br/pdf/psoc/v23nspe/a18v23nspe.pdf
http://www.scielo.br/pdf/psoc/v23nspe/a1... ⁾ and many discourses still seem empty, repeaters of ideals with no resonance in everyday life. In this respect, Mattos⁽¹¹11 Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, (Org.). Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ, IMS: ABRASCO; 2006. p. 43-67.⁾ points to the loss of political power due to the “banalization of use”⁽¹¹11 Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, (Org.). Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ, IMS: ABRASCO; 2006. p. 43-67.⁾, especially regarding the use of terms with empty sense, which draws even more attention when considering that the Psychiatric Reform is process that demands constant construction.

2.2 Interventions and devices that support multi, inter and transprofessional teamwork in Psychosocial Care Centers

When approaching the reality of TRs in the CAPS, it is verified that, faced with the daily overload of care and tasks, these end up distancing themselves from effectively therapeutic proposals and the production of contractuality. They are able, at most, to manage the care of the user, knowing, for example, the facts of their daily lives and their follow-up in the health service or in other spheres of the network. The same happens with PTS, which ends up being reduced to “what activities the user is inserted” or even “on what days it comes to the CAPS”. In the worst case scenarios, the participants emphasized the presence of users only in medical consultations, valuing medication care to the detriment of others.

The PTS faces as limitations to its practice the difficulties of teamwork, centered on the biomedical model and with reduced knowledge sharing; the removal of the theoretical bases in the daily life; the overload due to the high demand of the services; the lack of discussion of the PTS with the user and the family; the fragmentation of the PTS implementation in the different levels of attention and the restricted understanding of the PTS only as an administrative tool⁽¹²12 Silva EP, Melo FABP, Sousa MM, Gouveia RA, Tenório AA, Cabral AFF, et al. Projeto Terapêutico Singular como Estratégia de Prática da Multiprofissionalidade nas Ações de Saúde. Rev Bras Ciênc Saúde[Internet]. 2013[cited 2017 Mar 27];17(2):197-202. Available from: http://www.revistas.usp.br/rto/article/view/14124/15942
http://www.revistas.usp.br/rto/article/v... ⁾.

In this sense, the presence of “expected contingencies”⁽⁶6 Ramminger T, Brito JC. “Each Caps is a Caps”: a coanalysis of resources, tools and standards available in the activities of mental health work. Psicol Soc[Internet]. 2011[cited 2017 Mar 30];23(N.Spe.):150-60. Available from: http://www.scielo.br/pdf/psoc/v23nspe/a18v23nspe.pdf
http://www.scielo.br/pdf/psoc/v23nspe/a1... ⁾ in the daily life of the CAPS teams and the attendance of users of other levels of care are also observed in these services, either because of the difficulty of articulation with Primary Care or even by the presence of the “chronic-beauty”⁽⁶6 Ramminger T, Brito JC. “Each Caps is a Caps”: a coanalysis of resources, tools and standards available in the activities of mental health work. Psicol Soc[Internet]. 2011[cited 2017 Mar 30];23(N.Spe.):150-60. Available from: http://www.scielo.br/pdf/psoc/v23nspe/a18v23nspe.pdf
http://www.scielo.br/pdf/psoc/v23nspe/a1... ⁾, users who no longer need CAPS, but there they attend because they are not inserted in other spaces. Dedicated to the figure of TR, Miranda and Onocko-Campos⁽¹³13 Miranda L, Onocko- Campos R. Funções clínicas do trabalho de referência junto a pacientes psicóticos: uma leitura winnicottiana. Estud Psicol[Internet]. 2012[cited 2017 Mar 27];29(4):519-29. Available from: http://www.scielo.br/pdf/estpsi/v29n4/v29n4a07.pdf
http://www.scielo.br/pdf/estpsi/v29n4/v2... ⁾ observe that this device supports a permanent paradox, involving the delicate relationship between giving support to the user and taking care that it does not become “pathological identification”, not producing autonomy.

Regarding therapeutic groups and workshops, it is worth mentioning the disconnection of these with the theory, which become “recreational” and are little problematized, as if the simple occurrence guaranteed an approximation with the presuppositions of Psychosocial Care. It was possible to verify, in the participants’ speech, the occurrence of shared groups, being able to alternate between multi, inter or transprofessional proposals, depending both on the interviewee’s understanding of these modalities and on the reality of the service. The professionals highlighted the need for integration between the CAPS workshops, observing greater power when these spaces talk, and recycling aligned with the users’ PTS and equipment mission. In some responses, there was a devaluation of the “doing” of groups to the detriment of those who use speech, in a simplified view of these actions, which can be equally therapeutic if appropriate.

Cedraz and Dimenstein⁽¹⁴14 Cedraz A, Dimenstein M. Oficinas terapêuticas no cenário da Reforma Psiquiátrica: modalidades desinstitucionalizantes ou não? Rev Mal-Estar Subj[Internet]. 2005[cited 2017 Mar 30];V(2):300-27. Available from: http://pepsic.bvsalud.org/pdf/malestar/v5n2/06.pdf
http://pepsic.bvsalud.org/pdf/malestar/v... ⁾ have critically devoted themselves to understanding whether the groups and workshops in the CAPS actually deal with deinstitutionalizing modalities and could point out how they can be used in favor of insane asylum logic, of “morality treatment” or even simple occupation. They pointed to the presence of consumer bias in these spaces, with users as “consumers” of the products that the team proposes, with little participation in the construction and production of their meaning⁽¹⁴14 Cedraz A, Dimenstein M. Oficinas terapêuticas no cenário da Reforma Psiquiátrica: modalidades desinstitucionalizantes ou não? Rev Mal-Estar Subj[Internet]. 2005[cited 2017 Mar 30];V(2):300-27. Available from: http://pepsic.bvsalud.org/pdf/malestar/v5n2/06.pdf
http://pepsic.bvsalud.org/pdf/malestar/v... ⁾.

Also from a critical perspective, Thomé⁽¹⁵15 Thomé AM. Os Centros de Atenção Psicossocial como dispositivos de atenção à crise: em defesa de certa (in)felicidade inventiva. In: II Colóquio Internacional do NUPSI: Construções de Felicidade. 21 de setembro de 2013; São Paulo, SP.[Internet]. 2013[cited 2017 Jan 2]. Available from: http://nupsi.org/wp-content/uploads/2013/08/Ana_Maria_Thome-O_centro_de_atencao_psicossocial_como_dispositivo_de_atencao_a_crise.pdf
http://nupsi.org/wp-content/uploads/2013... ⁾ opposes the idea of a “schedule of activities”, widely disseminated in the CAPS, observing that this organization seems to respond to the need for productivity of services and not to care in Mental Health and ends up avoiding the direct contact of the team with the users, when promoting mediated and stiff attention. As a proposal, considers the urgency of approaching the team with psychosis, through “disagreeing care” and the willingness to take care of the user as and when they can present themselves, thus enhancing the ambience. Such management would bring the service closer to a “psychotic” and not “neurotic” functioning, favoring the care of the crisis in the CAPS⁽¹⁵15 Thomé AM. Os Centros de Atenção Psicossocial como dispositivos de atenção à crise: em defesa de certa (in)felicidade inventiva. In: II Colóquio Internacional do NUPSI: Construções de Felicidade. 21 de setembro de 2013; São Paulo, SP.[Internet]. 2013[cited 2017 Jan 2]. Available from: http://nupsi.org/wp-content/uploads/2013/08/Ana_Maria_Thome-O_centro_de_atencao_psicossocial_como_dispositivo_de_atencao_a_crise.pdf
http://nupsi.org/wp-content/uploads/2013... ⁾.

Although this perspective has a great theoretical power, it is questioned, from the interviewees’ statements, how this happens in the practice of services, considering the routine of the teams and the difficulty of significant ownership of the CAPS devices. Thomé⁽¹⁵15 Thomé AM. Os Centros de Atenção Psicossocial como dispositivos de atenção à crise: em defesa de certa (in)felicidade inventiva. In: II Colóquio Internacional do NUPSI: Construções de Felicidade. 21 de setembro de 2013; São Paulo, SP.[Internet]. 2013[cited 2017 Jan 2]. Available from: http://nupsi.org/wp-content/uploads/2013/08/Ana_Maria_Thome-O_centro_de_atencao_psicossocial_como_dispositivo_de_atencao_a_crise.pdf
http://nupsi.org/wp-content/uploads/2013... ⁾ points out that the unmediated contact with madness can affect the worker, which seems even more worrying in teams without clinical-institutional supervision, something brought by some participants of this study.

The ambience also seems to be an odd device as a scenario of the distance between theory and practice. When it is problematized as “watching television” (P14) or even “all spaces of the CAPS” (P20), it ends up moving away from the possibility of qualification of space and relations, fundamentally promoted by the team. According to Willrich, Bielemann, Chiavagatti, Kantorski and Borges⁽¹⁶16 Willrich JQ, Bielemann VL, Chiavagatti FG, Kantorski LP, Borges LR. Ambiência de um Centro de Atenção Psicossocial: fator estruturante do processo terapêutico. Rev Enferm UFSM[Internet]. 2013[cited 2017 Mar 23];3(2):248-58. Available from: https://periodicos.ufsm.br/reufsm/article/view/7977/pdf
https://periodicos.ufsm.br/reufsm/articl... ⁾, this device allows interactivity and integration between professionals and users, production of meaning and redemption of citizenship in daily demands. One can think of the possible autonomy of each subject in a place, from the appropriation of the spaces and the coexistence, therapeutic bond and individualized look⁽¹⁶16 Willrich JQ, Bielemann VL, Chiavagatti FG, Kantorski LP, Borges LR. Ambiência de um Centro de Atenção Psicossocial: fator estruturante do processo terapêutico. Rev Enferm UFSM[Internet]. 2013[cited 2017 Mar 23];3(2):248-58. Available from: https://periodicos.ufsm.br/reufsm/article/view/7977/pdf
https://periodicos.ufsm.br/reufsm/articl... ⁾.

This is also valued as a possibility to move in the face of the diversity of strategies used by CAPS based on the varied needs of users⁽¹⁶16 Willrich JQ, Bielemann VL, Chiavagatti FG, Kantorski LP, Borges LR. Ambiência de um Centro de Atenção Psicossocial: fator estruturante do processo terapêutico. Rev Enferm UFSM[Internet]. 2013[cited 2017 Mar 23];3(2):248-58. Available from: https://periodicos.ufsm.br/reufsm/article/view/7977/pdf
https://periodicos.ufsm.br/reufsm/articl... ⁾. In practice, it turns out that this intervention ends up being mostly in charge of Nursing technicians, given the routine of TRs and the “doctor’s armor” (P22), which also does not participate in this space. In this way, it turns out to be only space for coexistence and the accomplishment of daily tasks, entertainment or self-care.

Returning to the ideas of Thomé⁽¹⁵15 Thomé AM. Os Centros de Atenção Psicossocial como dispositivos de atenção à crise: em defesa de certa (in)felicidade inventiva. In: II Colóquio Internacional do NUPSI: Construções de Felicidade. 21 de setembro de 2013; São Paulo, SP.[Internet]. 2013[cited 2017 Jan 2]. Available from: http://nupsi.org/wp-content/uploads/2013/08/Ana_Maria_Thome-O_centro_de_atencao_psicossocial_como_dispositivo_de_atencao_a_crise.pdf
http://nupsi.org/wp-content/uploads/2013... ⁾, the question is again whether the reduction in the supply of groups can actually be signified in the CAPS, nowadays, as a plastic possibility and of greater contact with the users or if it ends up becoming empty the services, and load the routine of the TRs of scheduled care of “ambulatory” users. It is felt that this change, by itself, would not be enough to guarantee the care of the crisis, which is more related to the possibilities of qualification of attention, effective work in network and increase of the investment in these services.

Finally, although certain CAPS devices support substitutive practices, the change of logic in Mental Health care does not occur automatically, as do the multi, inter and trans-professional proposals, which do not depend only on the coexistence of areas in these services. They can be leveraged by investing in the training of Mental Health professionals⁽¹⁷17 Jafelice GT, Marcolan JF. Perception of mental health professionals about the multiprofessional work with residentes. Rev Enferm UFPE[Internet]. 2017[cited 2017 Apr 17];11(2):542-50. Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/9597/pdf_2508
http://www.revista.ufpe.br/revistaenferm... ^-1818 Fávero FM, Fávero DC, Guedes AC, Silva Filho CC, Brum CN. Atuação de equipes em rede de atenção à saúde: fragilidades e potencialidades das equipes que compõem a rede de atenção psicossocial no município de Chapecó-SC. In: VI Jornada de Iniciação Científica e Tecnológica: Ciência e tecnologia transformando a sociedade[Internet]. 17 e 18 de outubro de 2016[cited 2017 Apr 17]; Chapecó, SC. Available from: https://periodicos.uffs.edu.br/index.php/JORNADA/article/view/4697[Cited 2017 Jan 4]
https://periodicos.uffs.edu.br/index.php... ⁾ and by enhancing the service/matrix support network⁽¹⁸18 Fávero FM, Fávero DC, Guedes AC, Silva Filho CC, Brum CN. Atuação de equipes em rede de atenção à saúde: fragilidades e potencialidades das equipes que compõem a rede de atenção psicossocial no município de Chapecó-SC. In: VI Jornada de Iniciação Científica e Tecnológica: Ciência e tecnologia transformando a sociedade[Internet]. 17 e 18 de outubro de 2016[cited 2017 Apr 17]; Chapecó, SC. Available from: https://periodicos.uffs.edu.br/index.php/JORNADA/article/view/4697[Cited 2017 Jan 4]
https://periodicos.uffs.edu.br/index.php... ^-1919 Jafelice GT, Lima CA, Pinto AC. Considerações sobre a implantação do Matriciamento em Saúde Mental em Jundiaí - SP. In: Anais da 14ª Jornada Apoiar - Saúde Mental e Interdisciplinaridade: Propostas e Pesquisas. São Paulo: Instituto de Psicologia da Universidade de São Paulo; 2016. p.945-53.⁾ in order to ensure that changes in care are no longer linked to spaces, being able to reach changes in mentalities⁽²⁰20 Marcolan JF, Mazzaia MC, Vieira MN. Modelo híbrido de assistência psiquiátrica. Psique, Ciência e Vida. 2014;103:36-37⁾. It is also observed the importance of political decisions in the direction of the Psychiatric Reform and the effective implementation of RAPS, since the CAPS equipment is not enough to overcome the psychiatric paradigm⁽²¹21 Vieira MN. Modelo de assistência em Saúde Mental. Psique, Ciência e Vida. 2014;103:46-49.⁾.

Study limitations

Participation of two managers linked to OSS in order to maintain the coverage of all the regions of the municipality. The use of the interview method, which allows respondent’ “desirable” responses, and bias in qualitative research, possibly due to the researcher and participants being agents of the process. As a strategy to reduce these losses, the importance of trained researchers, who can reduce the impact of “familiarity/strangeness” of the participants, is considered. Multiprofessional teams should have knowledge about multi, inter and transdisciplinary work to try to develop them.

Contribution to the areas of Nursing, Health or Public Policy

Deepening of the discussion and listening of the professionals on the modalities of disciplinary integration, condition to implement the Psychiatric Reform. Approximation of the reality of the CAPS of São Paulo/SP, a municipality whose SUS implantation occurs in a peculiar way, due to the extension and political history not always aligned with the Ministry of Health, and still lacking in publications. It criticizes the coexistence of the insane asylum model in substitutive services, and reinforcement of the need to change mentalities for the implementation of the Psychosocial Care and Psychiatric Reform Paradigm, also exemplary of the national reality.

FINAL CONSIDERATIONS

By listening, it was possible to perceive that the proposals of disciplinary integration are still little problematized in the reality of the services. Although they are valued in the interviewees’ discourses and in the literature, they show concepts about which there is no clarity or there are simplified appropriations, usually in the bias of dialogue and integration between different knowledge, but little problematized as the production of democracy and horizontal relations . We also highlight the prevalence of auxiliary interdisciplinarity and the contradictions experienced by professionals between what they consider to be specific to their training, or even what is advocated by professional councils, and the proposals for disciplinary integration.

There were differences between the interviewees’ perceptions about the CAPS in which they worked, and some services were considered primarily ambulatory, with incipient disciplinary integration, while in others there were references to transdisciplinary practices.

The challenges pointed out do not seem to be exclusive to the service surveyed, which justifies the importance of dialogue with the difficulties experienced throughout the country in the implementation of substitutive equipment. The expansion of research and the daily approach of the teams that work in the multi, inter and transdisciplinary perspectives are fundamental tools for the implementation of the SUS and the values of the Psychiatric Reform, as well as the political action and necessary investments in the area.

REFERENCES

Publication Dates

History