version ISSN 0104-1282
Rev. bras. crescimento desenvolv. hum. vol.22 no.1 São Paulo 2012
Thaís Thomé Seni Oliveira PereiraI; Manoel Antônio dos SantosII
IDepartment of Psychology and Psychoanalysis, Universidade Estadual de Londrina - UEL, Londrina, Paraná, Brazil
IIDepartment of Psychology, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
The psychosocial care, the mental health care model applied in Brazil nowadays, has the following principles: democracy, social participation, involvement and shared responsibility, acceptance, listening and polyphonic interaction. This model connect mental health to citizenship and quality of life, aiming the psychosocial rehabilitation, the role and autonomy of users. In this model, the mental health professional is characterized as a caregiver, being the main instrument of his work, through direct and prolonged contact with users and staff. Thus, the mental health work engenders a particular kind of vulnerability, due to the constant emotional involvement with clients and other professionals, requiring affective resources, professional attitudes, skills and competencies that go beyond the limits of formal knowledge. Due to these aspects, several studies indicate the nature and organization of mental health work as generators of overload and stress for mental health professionals. This study aimed to identify the thematics that emerged in an intervention process carried out with two multidisciplinary teams of Psychosocial Care Center (CAPS) in a city in northern Parana, Brazil. Ten weekly meetings of "care groups for mental health staff" were carried out, with experiential activities followed by group discussion. The qualitative analysis of field diary allowed some themes identification such as: "Self-care: taking responsibility in reducing vulnerability," "From individualistic position to the collective project" and "Giving new meanings to teamwork". It was concluded that the intervention resulted in important reflections about daily professional issues that reflected in participants professional practices. It was highlighted that the care groups may constitute useful strategy for professional development in the mental health field.
Key words: mental health; patient care team; inservice training.
The psychiatric reform, movement occurred in Brazil since the 1970s, proposed to replace the paradigm of traditional mental health care prevailing at that time, which was centered in the mental hospital and held, therefore, the hospital-centered model. In the midst of this process, the psychosocial care has emerged as an alternative model to the psychiatric ward design. This paradigm was later adopted as a State public policy in 2001, proposing a decentralized, intersectional and interdisciplinary attention, linking the construct of mental health to concepts of citizenship and quality of life1,2.
Psychosocial Care Centers are strategic services in the context of the current model. These services are substitutes for psychiatric hospitals to hold patients with mental disorders, encourage their social and family integration, strengthen their efforts to search for autonomy and offer medical and psychological support. It must provide clinical care under day care, regulate the entrance of the mental health care network and support mental health care in primary attention.
In the new models of health care, including psychosocial care model, the role of health professionals in several areas, corresponds to a caregiver professional 4, 5.6. In this context, we highlight the essentially relational nature of care, which implies, among other conceptual advances, replacing the word "treat" by the concept of "caring." From this perspective, treating involves a diagnosis, while taking care makes it possible to sustain an enlarged view of the cared person4,5,7.
Generally, we understand that new forms of assistance require development on new professional skills that go beyond the technical success5 and ultimately require changes in health professional training and development. Thus, the mental health teams become essential for the current model success, deserving more attention and improvement 7,8,9,10. According to Lunardi et al.11, caregiver professionals need to be cared for, to exercise its function more efficiently.
The mental health work engenders a particular kind of vulnerability, because of the constant emotional involvement with clients and other professionals, demanding emotional resources, professional attitudes, skills and competencies that go beyond the limits of formal knowledge. Due to these aspects, several studies indicate the nature and organization of mental health work as generators of overload and stress for professionals.
In this context, group interventions directed to mental health professionals have been proposed as an in-service training or professional development strategy in mental health. The objective of this study was to identify emerging issues in two group process with professional teams of two community mental health services from a northern city on Paraná state.
The study included 34 professionals from mental health services teams. There were multidisciplinary teams, comprehending a total of six nurses, five psychologists, two social workers, six physicians, two occupational therapists, two physical education teachers and eleven nursing assistants. Participants' age ranged between 28 and 53 years, and work experience in the mental health field, between three months and 12 years. 27 participants were female and seven were male.
The intervention was conducted in two Psychosocial Care Centers: CAPS III and CAPS Ad, at the northern region of Parana State, Brazil. It is important to mention that the city currently has approximately 500 000 inhabitants and its network of mental health care consists of CAPS III, CAPS Ad, CAPSi, and Outpatient Psychiatric Emergency Room.
The intervention activities were conducted in three distinct stages: at first individual interviews were conducted with the participating professionals, aimed at the characterization of each team and assess their needs, in the second stage was carried out a feedback of the results of qualitative analysis for teams, which was proposed in the development of groups with mental health professionals and, finally, there were group activities, which we call the Care Group.
The Care Group for mental health professionals occurred in 10 weekly meetings, lasting an hour and a half. Fifty percent of team members, on average, participated so as not to impair the operation of services. At each meeting, a couple of psychology interns proposed experiential activity related to a topic, previously planned in supervision.
The meetings themes were related to professionals issues, including their individual careers and constitution of the team itself, subjective experiences of the professional role, individual and collective projects. Later, the groups expressed needs to work on issues relating to the group itself, such as communication, the prescribed and informal roles of each professional, as well as the professionals' difficulties and satisfactions at work.
The themes were worked through expressive activities and recreation, such as games, directed relaxation, collages, drawing, painting and theatre. The activities were followed by a reflection / discussion group.
Each group meeting was registered immediately after the meeting in a descriptive way and highlighting the significant speeches of the participants. Thus, this study data provides from the researchers' field diary, which formed the research corpus.
Data were analyzed by content analysis in a thematic form 12 according to the model proposed by Biasoli-Alves and Dias da Silva13. This model aims to foster links with reality, intending to offer professional reflections on the practice from research indicatives, through some core themes.
The study followed the ethical considerations involving human research, and participants signed an Informed Consent Term.
The analysis identified three themes: "Self-care: taking responsibility in reducing vulnerability", "From individual position to collective project" and "New meanings for teamwork".
Self-care: taking responsibility in reducing vulnerability
This core theme includes reports of field diaries referring the issue of self-care assumed by health professionals as a strategy to reduce vulnerability to daily work stressors. The Care Group provided a source of reflection-mediated activities, aimed at promoting experiences and reflections on the importance of self-care11.
Participants expressed surprise on the experience of feeling cared, suggesting some difficulty in let themselves being cared.
Funny that, at first, I was feeling strange, a strange feeling that someone was taking care of me, it seems that I only know taking care. (Participant 14)
The speech points out the professional´s surprise when realized that he was occupying an especially designed care space. It suggests that he´s used to caregiver role and see himself like the subject of care is a potentially troubling experience, when it displaces the usual. Therefore, the Group Care required subjective involvement from participants, in which they could realize their singularity and needs, which are often obscured by the mechanical compliance of automated tasks on a routine filled with obligations and daily activities.
Professionals also perceived themselves as under pressure workers, overload and complained of lack of time to look at themselves.
Because that´s the way. The routine swallows you. It is such a great hurry, so many suffering people, and they depend on you, right? Depend on the team. And we go making, making, watching, helping ... and we always getting behind. (Participant 6)
If you think, is crazy, right? We take care, but just not taking care of us. And who takes care of us? (Participant 15)
Participants mentioned the responsibility of health professionals in pursuit self-care. Discussions at the Care Groups took the issue from an individual quest for a collective responsibility, which should be discussed at the work environment.
Professionals have to update and take care of themselves, right? We must do study groups, psychotherapy... The problem is finding time and money for all this [laughs]. (Participant 8)
With Care Group experience, participants pointed out as one of the ways to overcome the lack of time and space to engage in self-care, the inclusion of such activities in their own work, perceiving this alternative as opportunity to evaluate their expectations and work performance.
Wow! How we need that. and we don´t have it. I think a lot of overload comes from that feeling, you know? [...] It must have a space like this at work It would be a working tool for us. (Participant 21)
Through activities, participants could reflect about importance of caring for themselves, even as a form they can take better care of each other. It seems to happen in two ways: providing motivation for the exercise of their role and providing technical resources to use in their daily practice.
These moments are very important because I feel I open myself to understand the patient, to empathize with him, and also take some technical instruments, as these dynamics we experienced and we know how it will work with them. (Participant 21)
From individualistic position to collective project
This core theme comprises the movement that each participant undertook in his career, articulating individual dimensions to collective demands , as well the pursuit of common welfare and interdisciplinary work effectiveness.
Participants reflected about their individual professional careers, personal and professional goals, and speculated about the goals of teamwork. Group Care activities provided new meanings about work and the caregiver role, through individual stories of career paths and meanings constructed by each professional throughout his career until the present moment - the work in CAPS. This process allowed group members recognition and possibly a "re-identification" of the assistance task, which led to a new articulation of meanings. They transformed the scope eminently individual to the group scope, the knowledge and information sharing, the resizing of the boundaries between the various practices and areas, the collective work as a palliative to difficulties faced by the team in daily work, strengthening the role of each in construction of shared resources to face the challenges.
Sometimes I ask myself, what am I doing here in CAPS? I felt kind of falling parachute. But looking back I see my career as I was building a path itself, which allowed me to leave the office comfort, seeking more than the individual clinic, to live the wealth of teamwork. (Participant 3)
Here we're always solving emergent problems, always going, coming, helping and we do not stop to look at the results of the work, nor to celebrate the successes. We do not stop to see what we're doing here, looking at us, look at the team, to the collective result. (Participant 6)
Becoming aware of strengthening each other in Care Group, professionals perceived their limits and possibilities more clearly. They could realize inertia as an inhibitor of effective awareness and use of their own resources, which was difficulting the development of their potential. They tended to reproduce a team working pattern focused in deficits and problems from adverse events of daily work. This position is the extreme opposite of empowerment, since it discourages search for creative solutions, which explain, for example, the lack of positive results celebration.
It is relevant to point out that working with individual projects have promoted the group collective projects articulation, related to assistance practices, work organization and team professional roles, besides the creation of meeting spaces outside the work environment.
And I think that is rich, huh? For me at least it is. I can tell my story, I can hear stories and see how much I find myself in them, and how we are building the history together. (Participant 3)
New meanings for teamwork
This core theme included professionals' speeches of redesigning and reframing the health team work. The meetings have provided satisfaction sharing - not just CAPS working difficulties - as well as a distinction of roles and functions of each team member.
Participants underlined their satisfaction at working in mental health area and being able to deal with human diversity, learning how to overcome prejudices and preconceptions, accepting differences and dealing with potential and limits of each other, both professionals and patients.
At the first moment, everybody wrote about the functions they were performing at the service. In continuation of this task, participants reported on the functions of a colleague, which was defined by raffle. The consequences of this activity were surprising because the interviews indicated the team as not integrated. However, during the activity, all participants discoursed very easily on the colleagues' roles and responsibilities of colleagues. They remembered, also, many informal roles performed, which showed how they were "in tune" with each other. (Field Diary - 8th meeting - CAPS III)
Another interesting result was the gradual revaluation of participants about themselves, expressing satisfaction with interdisciplinary team work, since the main decisions are taken collectively, which provides responsibility sharing for decisions. This movement allowed the team joining and lowering barriers that have blocked communication processes, leading to a knowledge expansion that team members have from each other, resulting in job enrichment.
Guys, I'm surprised to see how much we know each other. They spoke absolutely right about what do I do. (Participant 8)
I feel I am not alone to make a decision. When you're in a team you are not alone, we share cases, decisions and responsibilities. (Participant 15)
During the first meetings, team was perceived by participants as a multidisciplinary, not interdisciplinary or transdisciplinary team, since, despite having several professionals from different categories, it was not noted as a work based on the exchange of knowledge and practices. However, in the group process, members could share meanings about team work, discuss their professional functions and how they perceived their fellow team members, showing respect and consideration for colleagues' work, recognizing contribution of each professional category in service actions.
The Brazilian psychiatric reform process has made relevant progress in last decades, with notable investments in equipment, human resources and public policies14. One of the challenges nowadays is to enhance skills and promote cohesion of health teams. Therefore, the purpose of this paper was present health professionals to working demands, through a group that has provided a space for mental health care of the formal caregiver.
Participants speeches pointed out that the difficulty of leaving work issues makes them, frequently at the end of an exhausting work journey, take home tensions experienced during the performance of care tasks. This behavior is indicative of overload, produced when daily work tensions are not suitably processed. When the exposure to overload is continuous and prolonged, may enhance the susceptibility of professional psychological pain.
Reflecting on their need to care for themselves, professionals showed that they were sensitive to their own responsibility in seeking resources to promote self care. This reflection is also related to competencies and skills required of mental health professionals for the psychosocial care model effectiveness, overcoming technical success5, requiring changes in teaching and training strategies, both in education and in further professional development.
During the group work, there was also a progressive revaluation of itself, perceiving them working in an interdisciplinary team. The new meaning of interdisciplinary team work is pointed out by Costa8, which mentions that interdisciplinarity is defined by an integration degree between disciplines and intensity of established exchanges among experts, and, from this interactive process, all disciplines should get enriched.
Regarding professional development in health or in-service training interventions, historically referenced is the continuing education, based on the idea that knowledge defines practices. In this logic, educational activities are proposed focused on descending and splitted upgrading skills and specific knowledge 15, 16. Despite of advances in political and educational paradigms, health institutions still reproduce more traditional educational practices. Therefore, it is proposed to change the current continuing education to permanent education17, which includes teaching strategies and active methods in order to promote the development of professional skills.
It must consider that changes in care depend on new technology arrangements, tools, knowledge and relationships involved in caring, considered in conjunction with the other work components. Therefore, assistance innovations engender, among other things, construction / reconstruction of the work meanings as a whole5, 15, and this is where a consistent and permanent work with health professionals has strategic importance.
This paper presented the importance of looking at how CAPS equipment operates and not only intervenes in patients' lives, but also in professionals'. The creation of Care Group for mental health professionals proved to be a valuable in-service training and health professional development strategy. The group is a multi-learning space, where not only the intellectual dimension should be encouraged, but also the creativity applied to daily work, improved by sharing and constructing with one another. Thus, this strategy can work as a way for professional empowerment, which is exposed to everyday situations of suffering from work with human frailty.
Finally, results obtained suggest that the strategy sets a privileged space for subjectivities production, providing opening for reflections that facilitate reconstruction of personal and collective sense of professional roles and functions on the multidisciplinary team and mental health work vicissitudes, resulting in benefits to participants' everyday professional practices.
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Manuscript submitted Aug 02 2011
Accepted for publication Dec 20 2011.
This paper comes from the study presented at III Brazilian Congress of Psychology: Science and Profession, in São Paulo, Brazil, 3 to 7 September 2010. The authors thank the group of psychology interns from State University of Londrina - UEL. The professional internship experience was supervised by the first author