ORIGINAL ARTICLE
DOI:10.11606/issn.1806-6976.v12i3p147-153

 

Therapeutic workshops as expressions of subjectivity¹

 

Oficina terapêutica como expressão da subjetividade

 

Oficina terapéutica como expresión de la subjetividad

 

 

Izamir Duarte de Farias^II; Maira Buss Thofehrn^III; Ana Paula Müller de Andrade^IV; Lisa Antunes Carvalho^V; Helen Nicoletti Fernandes^VI; Adrize Rutz Porto^VII

^IIDoctoral student, Faculdade de Enfermagem, Universidade Federal de Pelotas, Pelotas, RS, Brazil. Therapist, Centro de Atenção Psicossocial Escola, Pelotas, RS, Brazil
^IIIPhD, Adjunct Professor, Universidade Federal de Pelotas, Pelotas, RS, Brazil
^IVPost-doctoral degree, Faculdade de Enfermagem, Universidade Federal de Pelotas, Pelotas, RS, Brazil
^VMSc, Professor, Faculdade Anhanguera, Pelotas, RS, Brazil
^VIDoctoral student, Faculdade de Enfermagem, Universidade Federal de Pelotas, Pelotas, RS, Brazil
^VIIPhD, Assistant Professor, Departamento de Enfermagem, Universidade Federal de Pelotas, Pelotas, RS, Brazil

 

 

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ABSTRACT

OBJECTIVE: Obtain knowledge on the perceptions of professionals with different backgrounds in the health area regarding the therapeutic workshops at CAPS (Centro de Atenção Psicosocial – Psychosocial Care Center) units. The approach of this survey is qualitative, descriptive, and exploratory, grounded in the historic-cultural theory of Vygotsky. Semi-structured interviews were performed, where the participants were twenty-four health professionals from the Psychosocial Care Centers of the city of Pelotas, in the state of Rio Grande do Sul. The therapeutic workshops were identified as spaces that provide patients of mental health services with means of exploring their potentialities, valuing the healthy aspects of life, allowing subjectivity to be expressed through art, craftwork, and collective therapeutic activities.

Descriptors: Mental Health; Mental Health Services; Art Therapy; Nursing.

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RESUMO

OBJETIVO: Conhecer a percepção de profissionais de diferentes formações na área da saúde a respeito do funcionamento das oficinas terapêuticas no CAPS. Pesquisa de abordagem qualitativa, descritiva e exploratória, fundamentada pela teoria Histórico-Cultural de Vygotsky. Foram realizadas entrevistas semiestruturadas, em que participaram vinte e quatro profissionais de saúde dos Centros de Atenção Psicossocial da cidade de Pelotas/RS. As oficinas terapêuticas foram identificadas como espaços que propiciam aos pacientes dos serviços de saúde mental meios de buscar suas potencialidades valorizando os aspectos saudáveis da vida, permitindo a expressão da subjetividade através da arte, do artesanato e das atividades coletivas terapêuticas.

Descritores: Saúde Mental; Serviços de Saúde Mental; Terapia Pela Arte; Enfermagem.

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RESUMEN

OBJETIVO: Conocer la percepción de profesionales de diferentes formaciones en el área de la salud a respeto del funcionamiento de las oficinas terapéuticas en el CAPS. Investigación de abordaje cualitativa, descriptiva y exploratoria, fundamentada por la teoría Histórico-Cultural de Vygotsky. Fueron realizadas entrevistas semiestruturadas, en que participaron veinticuatro profesionales de salud de los Centros de Atención Psicossocial de la ciudad de Pelotas/RS. Las oficinas terapéuticas fueron identificadas como espacios que propician a los pacientes de los servicios de salud mental medios de buscar sus potencialidades valorando los aspectos saludables de la vida, permitiendo la expresión de la subjetividad a través del arte, de la artesanía y de las actividades colectivas terapéuticas.

Descriptores: Salud Mental; Servicios de Salud Mental; Terapia con Arte; Enfermería.

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Introduction

The dimension of subjectivity is not included in a purely rational field, but is related to a chain of meanings, not always perceptible to the individual or to the organization to which they belong. This dimension, in turn, is inserted in the context of interpersonal relations in nursing and is understood as the existence of trust, responsibility, ethics, collaboration, cooperation, engagement, creativity, and initiative. Thus, it should be cultivated for the collective reconstruction of the forms of interaction, communication, and action, to strengthen both the healthcare worker and the patient seeking healthcare services through the reconfiguration of the relational area and professional identities⁽¹⁾.

Although workers are immersed in a universe of norms, rules, and submissions, their manifestations must be permeated by their perceptions and constructions of the human condition which are singular and therefore objective and also subjective.

At the Psychosocial Care Centers (CAPS), the daily routine of caring for people who are suffering or undergoing a mental disorder, with their physical, psychological, and social needs that originate from this pathology, requires from the professionals a set of skills that allow these patients to be viewed in their individuality/singularity, inserted in their historic-social context in the community and family unit they inhabit. Thus, the staff’s reflective critical thinking regarding their work and their knowledge as to the subjectivity of relationships are important, since they influence the professional task and are characterized by committed care, where accepting the other person and understanding them is fundamental⁽²⁾.

When received by a CAPS, patients build their Singular Therapeutic Plan (STP) along with a staff of local professionals, including one or more therapeutic workshops, with the purpose of opening a new door so that, while in the condition of being a user of the service, this individual can regain their perception of health and review their concepts of being sick or healthy, establishing strategies that can contribute to their quality of life.

The Singular Therapeutic Plan consists of a work tool that allows this staff to trace actions that consider the psychosocial dimension, since their main focus is each individual and their social context⁽³⁾. This may help to incite higher or lower concern with their physical or mental condition, making the patient notice matters beyond medicalization and disease.

The therapeutic workshops can comprise an important tool for channeling the thoughts and projections of this patient towards the production of something useful to them and to the collective around them, which may lead them to a more effective process of psychosocial rehabilitation in which they are aware that the goal of CAPS and of the tools available for this process is their rehabilitation.

This study proposed looking into mental healthcare, which for many years was grounded in psychiatry and hospitals, and which is gradually being replaced by the sum of knowledge that results in the constitution of the interdisciplinary staff that provides services at the Psychosocial Care Centers (CAPS). In addition, the purpose of this study was to understand the significance of the therapeutic workshops as a mediating tool to health professionals at CAPS, and obtain knowledge on the perceptions of professionals of different backgrounds in the health sector regarding the functioning of these workshops.

The question that guided this study was: "What is the significance of therapeutic workshops as a mediating tool to health professionals at CAPS?"

 

Material and Methods

The approach of this study was qualitative, descriptive, and exploratory, grounded in the historic-cultural theory of Vygotsky⁽⁴⁾. According to this theory, human beings construct knowledge based on the meanings they conceive through their interactions with the environment in which they are inserted⁽⁵⁾. The goal was to present, through this study, the meanings manifested in the statements of the health professionals that comprise the interdisciplinary teams at CAPS.

This study was performed in the city of Pelotas, in the state of Rio Grande do Sul. The data were collected from April to August 2013 at the six CAPS II that comprise the mental healthcare network of the municipal, after the approval of the project for this study by the Research Ethics Committee at the School of Nursing at UFPEL, under the number 232.387, on March 28^th, 2013.

The data were collected through semi-structured recorded interviews, which were later transcribed. A total of 24 health professionals from the six CAPS II in Pelotas were interviewed, according to their academic training, namely: one doctor, one social worker, one psychologist, and one nurse. The purpose was to represent these professions in this study by including the participation of these four professionals at each CAPS. They were identified by the letter "P" for "professional", followed by the interview number and by acronyms that represent each profession. For doctors and psychiatrists, the acronym was "DOC"; for social workers, "SW", for nurses "NUR", and for psychologists, "PSY". These acronyms were also followed by a number representing the order in which each category of professional was interviewed, each participant being represented as in the following example: P2DOC4.

The ethical principles for studies of human beings were respected, as stated in Resolution number 466/2012 of the National Health Council of the Ministry of Health⁽⁶⁾.

The data were analyzed using the operative proposal of Minayo⁽⁷⁾, which recommends a guided analysis in basically three steps: ordering and classification of the data through a horizontal and comprehensive reading of the texts; transversal reading and construction of the thematic categories; and final analysis of the results of the study in light of the theoretical framework.

 

Results and Discussion

Based on an analysis of the data, the results of the study were organized into three thematic units, as follows:

Therapeutic Workshops as Valorization of Healthy Aspects

Interventions by the interdisciplinary staff are indispensible; however, as a higher common goal for this team, the different therapeutic spaces should enable an amplified evaluation of the patients so that they can be accessed as a whole, thus perceiving their manifestations in the collective. Some professionals referred to the therapeutic workshops as spaces that provide participants of mental healthcare services with means to seek their potentialities, valuing the healthy aspects of life:

The workshops help us have a more complete evaluation of the life of the person as a whole. I think that in the individual appointments the matter of disease ends up being a focal point. (P10DOC2)

I think that the role of the service’s workshop is important to decentralize healthcare and demystify that idea that healthcare is done by professionals such as psychologists and psychiatrists, [...] when other professionals can provide care focused on health and on the potentialities of the individual, valuing their healthy aspects and manifestations and not offering a service focused on the disease. (P211PSY5)

By observing the proportions and characteristics of each one of these spaces, the workshops – through their proposal of working focused on a goal – promote actions that stimulate the expressiveness, learning, and the production potential of each patient.

Therapeutic workshops must be inserted in a dynamic process so as to avoid institutional inertia and the adoption of solidified stances that do little to reform. These spaces are tools for the production of life and must be continuously problematized together with the patients. By doing so, CAPS contributes to bring the patient nearer to the day-to-day activities of life, constituting a complete service of opportunities and social inclusion⁽⁸⁾.

Therapeutic Workshops as Valorization of Abilities

In the statements below, based on the proposal of each workshop, the patient can seek in socialization means of valuing their abilities:

During appointments, I think it is important to give back to the person, to show that they are not sick all the time, but spend much more time healthy than sick. (P10DOC2)

In general, what users demonstrate most of the time during the workshop is their healthy side, because it interacts, it expresses itself, it creates [...]. (P21PSY5)

The transformation of the patients and the qualitative leap in their lives occur when they manage to perceive themselves as humans larger than their own diseases, and that, aside from the manifestation of symptoms, they can discover or rediscover their potential to overcome suffering, and even learn from it. In addition, people with mental disorders, in the condition of being a person with all the applicable attributes, by the logic of psychosocial rehabilitation, can overcome their suffering and return to being productive to society, be it through their work or by demonstrating their abilities⁽⁹⁾.  

The therapeutic workshops with their work proposals allow the person to create, as stated in the testimony of one of the participants:

This ability to create, the creative act, is what makes you develop your attention to the healthy aspects of the person - in the ability to create something. That is being in touch with health. We don’t look at the sick subject, we see the person, with what they bring through health. (P23SW6)

Thus, the creative act and enabling of this creativity are seen as synonyms of health. In addition, the importance of building the valorization of the healthy aspects that surround the individual, so as to divert focus from the mental disorder, is cited as a potentiality of the therapeutic workshops:

During the workshop, people share the space with others, learn to share, and quit the obsessive thought pattern they have regarding the disease [...]. They learn that there are other things to which they can pay attention and which can be more useful than thinking only about the disease and suffering because of it. Many times, users see that, together with others, they can do wonderful things and feel good or much better about their illness. (P8NUR3)

The sharing of the workshop spaces or creative production spaces is one of the potentialities of this tool for allowing the healthy aspects of the person to be valued, which, consequently, we may consider as a production of health itself.

The moments guided by the psychosocial care model and experienced in the workshops, with the certainty of liberation from psychological and social ties that tormented the patient for years, become a possibility for creation, for experience, and for the patient to be what they are, liberating their monsters and fears, deconstructing the concept of insane people being dangerous and opening the invisible cells so that they can, in fact, be sociable beings, without the stigma of insanity.

The therapeutic workshops are spaces for the production of subjectivity, where there is dialog, interaction, reciprocity, and ties that allow an exchange between professionals and patients, permeated by respect for choices. It is this movement towards autonomy that allows us to understand that CAPS is a production space for patients who are free to come and go. This view is understood as compatible with the psychosocial model of producing mental health⁽⁸⁾.

Therapeutic Workshops as an Expression of Subjectivity

Non-verbal human expressivity is extremely subjective from the perspective of linguistics, as there are many distinct possibilities for a person to communicate and manifest their feelings and perceptions regarding the world in which they are inserted.

When it comes to healthcare, the perception of the professional and the amplitude of their knowledge of this skill are greatly important for the needs of the patient to be effectively understood. Absorbed in the daily work routine and by the tasks they are engrossed in, as social beings, these professionals end up losing the ability to read the other person beyond their words, not reading between the lines and perceiving the most diverse human manifestations.

The competency applied to communication aligns with the need for technical and human preparation, the importance of listening and the accurate perception of the other person, as well as the possibility of using this learning as an investment in self-knowledge and respect for others, revealing that this communication, when directed to the patient, should occur in a way that is responsible, solidary, humanized, ethical, and also therapeutic⁽¹⁰⁾.

Effective communication is considered a fundamental tool for comprehensive and humanized care because through it the needs of the patient can be recognized and received empathetically. When health professionals use this tool verbally and non-verbally, they allow the patient to participate in the specific choices and care measures related to their disease, with the purpose of obtaining proper treatment⁽¹¹⁾. In this process, there is a relationship and exchange of ideas and knowledge, which generate a new conscience capable of producing changes in the person and in the world⁽¹²⁾.

Since non-verbal communication has been indicated as a valuable tool for interaction with and comprehensive humanized care for patients of mental healthcare services, therapeutic workshops can be considered a mediating tool in the process of communication between the subjects.

Therapeutic workshops play an important role in allowing patients to be more fully understood in the context of CAPS, since the proposals for expressive activities provide the opportunity for verbal manifestation and non-verbal communication^(13-14).

[...] the expression workshop allows the user to place the things that many times they have difficulty expressing, even through other ways, such as talking, sitting, conversing. There are patients that will manage to do this through more bodily means. For this reason, I think that the workshops of physical education and dance work well, including the music workshops. I think they allow the patients to express their feelings, express what they have not been able to do for a long time. (P9DOC1)

The therapeutic activities in these spaces can be expressive, physical, linguistic […] of free art, which should allow and amplify the means of treatment and rehabilitation of patients, since they stimulate motor skills, cognition, affection, self-esteem, and group interaction, providing better quality of life and use of collective spaces in society⁽¹⁵⁾.

With art and craftwork, the workshops consist of a means of inserting the patient in society⁽¹⁶⁾, permitting their mental organization, and making it possible for them to communicate with other people and discover new alternatives for spending their time.

Workshops can allow users to discover tastes and interests that many times they did not have the opportunity to experiment with in life – certain activities which bring pleasure and which are also artistic. (P7PSY1).

It is pertinent for us to consider workshops as opportune spaces    for learning and experimenting with actions that, most of the time, people in their daily lives as productive citizens to not commit to or allow themselves to try. Only when they need to withdraw from these daily activities due to mental disease and seek treatment at a CAPS do they find in the workshops proposals that they can learn and teach, undertaking an exchange and construction of knowledge based on the relationships that are established in this space.

Art represents an important instrument for re-socialization and insertion of individuals in groups, as it proposes work based on collective acting and thinking, respecting the diversity and abilities of each patient.¹⁷ According to the socio-historic theory of Vygotsky, it is in this relational space that individuals build their meanings and construct themselves as people in their completeness, through the mediations that allow experiences to be internalized⁽⁴⁾.

In this regard, artistic undertaking involves the practices and use of techniques for the exercise of expressing ideas and feelings that cannot always be manifested through words. This group of mediums consists of an alternative for non-verbal expression⁽¹⁸⁾, which is a mediating tool in the view of Vygotsky⁽⁴⁾. The colors, sounds, movements, and other materials that may be used allow dimensions of human consciousness or subconscious that could not be accessed through verbalization to be manifested, or even create opportunities for the externalization of ideas, as the following professionals report:

The therapeutic workshops allow people to express themselves, to have a voice. (P7PSY1)

The therapeutic process of the workshop makes all the difference, because you are always searching for new activities to do and new things to help the users, to allow them to be able to express themselves and be understood. (P8NUR3).

The therapeutic space creates a device that contributes in a peculiar way to the reflection on what is essential to therapeutic workshops – articulations with the social space. Thus, the activities and methods proposed should be directed towards what is external to the institution. The therapeutic workshops are devices that should make deinstitutionalization possible; for this reason, they are valuable as a practice that articulates with what is outside the walls of the institution. It is important to remember that it is not just about bringing what is outside within, but also leaving the institution for the public space, for the city, and for the world. In this regard, a workshop should not exist to better organize the operation of an institution, simply entertaining patients and keeping them occupied with a passtime⁽¹⁹⁾.

I think it is in the therapeutic workshops that people actually appear as they really are [...]. It ends up being that in the therapeutic workshop, in the more severe cases, we have a more positive response [...] because the person is there, free from any expectations of others, as they really are. (P6PSY2)

The workshop makes other forms of expression possible to the user that go beyond the dialogue in the individual appointment room. I think that this has an extremely important role within CAPS, to see the user as they really are. (P10DOC2)

The reports show a manifestation of knowledge that corresponds to what was recommended at the beginnings of the reformist vanguard of psychiatry – in other words, betting on therapeutic workshops as a tool that allows the person to reveal themselves –, making it an extraordinary technology of care and attention to the patient. The workshop allows the patient to be effectively understood in their completeness, including the most complex mental dimensions of human beings.  

The therapeutic aspect of workshops arises right away from the very convenience they establish, through the relationship that forms between the participants and patients, and mainly among the patients themselves. Many mental disorders include the tendency towards isolation, by the difficulty to establish emotional and social bonds, which means that, even if this isolation persists in the patient’s day-to-day outside of CAPS, the moment of cohabitation in the workshops is vitally important⁽¹⁹⁾.

In this aspect, the value of the workshop refers directly to its potential to transcend the dimension of rationality, of words, and of that which can be verbalized, providing the patients with the possibility to manifest themselves through all expressions possible, leading them to greater self-perception and awareness.

 

Final Remarks

It can be noted that the professionals at CAPS recognize the importance of the therapeutic workshops for the expression of subjectivity by the patients of the Psychosocial Care Centers, as they are recognized as spaces that promote potentialities and abilities, allowing the patients involved to actively participate in their process of psychological and social rehabilitation.

It is known that subjectivity transcends what is seen and palpable; thus, it is necessary to reflect how these workshops require investment and comprehension regarding their objective, not only serving as an environment for entertainment or leisure, as understood by common sense, but as a collective therapeutic space where the professionals of the Psychosocial Care Centers also promote the individual and comprehensive care of their patients.

This study aims to contribute to observations made by the multidisciplinary staff regarding the real significance of the therapeutic workshops and their intervention in the subjectivity of the patients cared for in this space, with the purpose of offering individualized care in a healthy therapeutic environment.

 

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Received: 08. 05. 2015
Accepted: 17. 02. 2016

Corresponding Author:
Helen Nicoletti Fernandes
Universidade Federal de Pelotas, Faculdade de Enfermagem
Rua Gomes Carneiro, 01
Bairro: Porto
CEP: 96010-610, Pelotas, RS, Brasil
E-mail: helyfern@hotmail.com

 

 

1 Paper extracted from Master’s Thesis "Oficinas terapêuticas: significado para profissionais de saúde do CAPS", presented to Universidade Federal de Pelotas, Pelotas, RS, Brazil