REVIEW ARTICLE
DOI:10.11606/issn.1806-6976.v12i2p116-136

 

Academic sayings from the past and the present about the Nursing Role in the Process and Routine of Deinstitutionalization

 

Eses Académicos del pasado y del presente sobre el Papel de la Enfermería en el Proceso y Rutina de la Desinstitucionalización

 

 

Viviane Freitas Duarte^I; Gabriel Lavorato Neto^II; Larissa Rodrigues^III; Claudinei José Gomes Campos^IV

^IRN, Hospital de Clínicas da Unicamp, Campinas, SP, Brazil
^IIMaster’s Student, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil. Professor, Faculdade Nazarena do Brasil, Campinas, SP, Brazil
^IIIMaster’s Student, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil
^IVPhD, Professor, Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil

 

 

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ABSTRACT

This Integrative Review aims to explore the Brazilian scientific production of psychiatric nursing about psychosocial rehabilitation from 1992 to 2014. The analysis of the surveyed articles results in five thematic categories: nursing and Psychiatric Reform, tools and strategies that provide psychosocial rehabilitation, family background in psychosocial rehabilitation, Psychosocial Care Centers and other spaces as facilitators of psychosocial rehabilitation and mental health in primary care. According to our conclusions greater investment in the nurses’ professional training is necessary in order to fulfill the demands of care to the people with mental illness presented by the Psychiatric Reform, which has been slowly consolidating with inclusion strategies that seem appropriate, but still insufficient.

Descriptors: Psychiatric Nursing; Deinstitutionalization; Psychiatric Rehabilitation.

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RESUMEN

Esta Revisión de integración objetiva explorar la producción científica nacional de enfermería psiquiátrica sobre la rehabilitación psicossocial en el período de 1992 a 2014. El análisis de los artículos levantados, resulta cinco categorías temáticas: enfermería y la Reforma Psiquiátrica, herramientas y estrategias que posibilitan la rehabilitación psicossocial, el contexto familiar en la rehabilitación psicossocial, CAPS y otros espacios como facilitadores de la rehabilitación psicossocial y salud mental en la atención básica. Nuestras conclusiones consideran la necesidad de una inversión mayor en la capacitación profesional del enfermero para compatibilizar con las demandas de atenciones a los enfermos mentales presentadas por la Reforma Psiquiátrica, que viene consolidándose de manera progresiva con estrategias de inclusión que parecen adecuadas, sin embargo aún insuficientes.

Descriptores: Enfermería Psiquiátrica; Desinstitucionalización; Rehabilitacíon Psiquiátrica.

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Introduction

The idea and understanding of mental disorder have varied with time. Until recently, the crazy person was considered individual devoid of their reason and therefore they should be curtailed from their freedom of choice. Asylums, or madhouses, emerged in that context as a solution to the psychiatric patients’ issue, exclusion – a consequence of therapeutic seclusion (Hospital admission) which was submitted, which prevented its citizens. The object of that model was to return their reason and freedom through a moral treatment so that they become again subjects of right. Thus, this asylum practice became mandatory for all individuals without reason, because they were considered crazy, delusional or hallucinating^(1-2).

Nowadays, seclusion and exclusion of these subjects still exists, with more subtle occurrences, despite efforts to transform it, especially made by the Psychiatric Reform (PR): "By not accepting the exclusion there is the risk of not accepting the difference; this cannot be denied; recognizing and living with it without excluding is necessary, as the great pretension of the Psychiatric Reform"⁽³⁾.

 The Ministry of Health defines the Psychiatric Reform as "the political and social complex process, composed of actors, institutions and powers from different backgrounds, that focuses on different territories, federal, state and municipal governments, universities, market health services, professional councils, associations of people with mental disorders and their families, social movements, and territories of the social imaginary and public opinion. It is understood as a set of transformations of practices, knowledge, cultural and social values, it is in the daily life of the institutions, services and interpersonal relations that the PR process advances, marked by impasses, tensions, conflicts and challenges"⁽⁴⁾.

Currently, in the reflection and search of resource use for treatment in the Psychosocial Care Centers, in the Therapeutic Residences (TRs), and in the proposal to have the subject psychiatrically affected back to the community, lies the real reform proposal that is rapidly developing.

The national historical process that led to the change of the psychiatric care model reflected world trends, with the landmarks: the critique to the psychiatric knowledge and the hospital-centered model promoted by the Workers Movement in Mental Health (MTSM, in Portuguese) in 1978; the creation of the Unified Health System (UHS) in 1988, with principles that would be integrated to the PR and the political activity in 1989 when Paulo Delgado proposed in the National Congress the Law of extinction and replacement of the current model. From 1992 arise: Psychosocial Care Centers, Psychosocial Care Centers and Hospital day (HD); and, in 2001, Law 10,216 provides for the rights of people with mental disorders, prohibiting on national territory the construction of new psychiatric hospitals and hiring private beds by the public service for the purpose of psychiatric hospitalization. The treatments, from then, should meet the PR principles, recovering the patients and reinserting them in their social environment^(4-5).

In 1999, there was the vision of rehabilitation described in focus⁽⁶⁾: by the ability to take up residence of the former inmates, exchange feelings and identities; and produce and exchange goods and values. Concerning care administration, two rehabilitation processes⁽⁷⁾ are adopted in the new psychiatric vision: a first listening movement and reception of wishes and needs – which were also detained –; and "then there was the establishment of a link and accountability of the entire network of care in order to produce new and better ways of living"⁽⁷⁾. It also draws attention to the possibility of promoting resocialization and compliance with the PR concepts through theoretical, politics and ethics constitution of the service network^(6-7).

In the context of previous nursing to the PR, the work was based on a normative service, in order to maintain the overall organization of the psychiatric establishment. The nurse was supposed to perform an administrative and bureaucratic role, such as organizing the work schedule of the mid-level professionals under their supervision, clothing conference (of patient, bed, bath), belongings (of patient, ward, hospital), systematic care removal of patient and even control of other professionals, such as medical visits, surveillance during family visits and during the auxiliary activities and other professionals⁽⁸⁾.

In the 80s, there was a paradox in the nursing training process between education and action⁽⁸⁾. In the past the theoretical bases of the North American nursing were transmitted by schools, colleges and high level courses. Therapeutic attitude was privileged as well as its communication skills and interpersonal relationships, psychopathology notions and humanistic influence of care for human beings. However, the nursing action had no focus on the patient and the family, but maintaining the "therapeutic environment" so that the doctor-centered interventions were carried out fully and with greater amplitude. The nursing action was always under the control of medical conduct, which was responsible for requesting medical evaluation, administering the prescribed medication, performing the restraint of patients when necessary and keeping the patient under constant surveillance⁽⁸⁾.

The hospital-centered psychiatric model, by being guided by medical actions, echoed the paradox of training, depriving the nursing from any autonomy for its practice. From a severe and with no alternative context, this pattern was significantly changed by both responsibilities made in the reform process as by the new trends of the models of practice and care adopted by the nursing around the world.

Nowadays, there is a need for interdisciplinary actions within the services articulated in the core network, comprising the interconnected work of social worker, nurse, doctor, psychologist and occupational therapist, among others, which is an innovative issue in the process. Within the team, the nurse is not only playing the role of custodian of the patients, but turning their actions in social and psychological approaches that are little explored to date⁽⁹⁾.

Whereas the nursing role and the nature of their work process, in trigger point, undergo paradigmatic changes that give them autonomy and strengthening of their interdisciplinary links in the therapeutic process of the people with mental illness, the thematic interest that is common to the line of our research group occurred. Thus, we decided to update, extend and discuss the Final Paper of one of the members of our research group, and it was used as a basis for this production. Therefore, we identified academic databases national scientific production psychiatric nursing on psychosocial rehabilitation (first name given to the effects promoted by RP), cataloging their contributions and themes about the progress made. New molds and names of these effects were added, to date, and recorded in scientific production. This fact highlights the procedural status of PR implementation.

 

Objective

Exploring national scientific productions of nursing on the historical process about the deinstitutionalization and psychosocial rehabilitation from the Brazilian PR and evaluate their development process.

Figure 1.

Methodology

The objective of this study is an integrative review of the literature, a research method that "aims to gather and synthesize results of research on a limited theme or issue in a systematic and orderly manner, contributing to deepening the issue investigated"⁽¹⁰⁾.

We explore new models of psychiatric care due to significant changes prescribed therein regarding the work for which nursing was necessary. The scientific documentation is the clear record of model implementation. It provides conditions to effectuate an assessment of the recommended ideal by the manuals that established the PR, deinstitutionalization and psychosocial rehabilitation, with its progress and the actual conditions of its practice. This type of comparison allows checking both the historical segment of the process and its empirical measurement. Finally, it provides the data that facilitate the innovation of knowledge and adoption of measures that aim to improve the health services involved.

For this review, publications of Brazilian articles were used, from January 1992 to September 2014. The documents were cataloged through systematic searches in: 1) Brazilian Virtual Health Library (VHL); 2) electronic databases LILACS, Medline; 3) Scientific Electronic Library Scielo; and databases in specialized areas (BDEnf – Nursing Database). The following descriptors were used and crossed: nursing, deinstitutionalization, psychosocial rehabilitation. The first two descriptors (Deinstitutionalization and nursing) were defined from a search in the Descriptors in Health Sciences (DeCS, in Portuguese) of the VHL. The third descriptor (Psychosocial rehabilitation) is not part of those descriptors. However, as a result of the discussion of our material in the Research Group, we kept the opinion on the importance of including it as a keyword in the search. We made it clear that to search for articles produced from 1992 to 2004; the keywords "deinstitutionalization" and "nursing" were used. The third descriptor had no results when inserted in the base because it began to be gradually used from 2005 and then became more present in the academic production on the subject.

From the results in databases, the articles that met our theme were selected after reading the abstracts and their descriptors. For sampling the following criteria were established: access to the entire text at its source; relevant discussion on the theme; they were produced between January 1992 and September 2014; correlation with the nursing scenario through the authorial connection to the area (Professor, student or teacher), or by its context on nursing. Into our results 39 articles were included and integrated, in addition to those that contributed for the introduction and discussion of the integrated content.

The articles we read were evaluated thoroughly. From the data set, researchers selected thematic cutouts that provided the elements for the categorical clustering given below, which aims to answer the intrigues on the PR progress in Brazil, and especially how it affects the scientific production in the mental health nursing context in Brazil.

 Results and discussion

After reading and analyzing the articles, they were grouped according to the following thematic categories: 1) Nursing and Psychiatric Reform (11 articles); 2) Tools and Strategies that provide psychosocial rehabilitation (8 articles); 3) Family background in psychosocial rehabilitation (9 articles); 4) Psychosocial Care Centers and other spaces as facilitators of psychosocial rehabilitation (5 articles); and 5) Mental Health in Primary Care (6 articles).

A comparative analysis of the volume of publications can be related as follows: 13 articles produced in 2010-14; 25 articles written between 2000-09; one article produced in 1998 (First indexed reference in VHL of an article on the PR guidelines and its impact on knowledge and nursing practices in Mental Health); As for the design of studies: 25 are qualitative; 2 are quantitative; 1 is quantitative and qualitative; 7 are article reflection or experience reports; 3 are Review articles; one is conceptual.

The increasing production volume, the predominant qualitative spectrum in study designs with a comprehensive evaluation of phenomena in the field, and the nature of discussions with the production of reflections and reviews suggest the interest movement in the research: how the PR concepts, humanization and deinstitutionalization were implemented, and how a philosophical and political preconization affected knowledge and actions in the areas of assistance to the Mental Health and its consequences in the Brazilian society. It is in this sense that the following results of the thematic analysis in which we defined our references are discussed.

Nursing and the Psychiatric Reform

Nursing work faces a challenge in the PR scenario, which is to abandon the old mentality of the asylum custody model, adopting the new mental health policy aiming at social inclusion. Nurses, in addition to their role with the patients and their entire context, must be concerned with the creation of a reformist thinking in their team (assistants and nursing technicians and community health agents) under their supervision.

In 2004, in a qualitative study of nurses in primary care, specifically working in the family health program, it was reported that the understanding of these professionals on patient care with mental disorder was the distribution and control of drugs used by them, psychotropic in most cases, without much thinking about other welfare activities ⁽¹¹⁾.

It is important to stress the need for new activities in nursing practice involving "the welcoming, the humanization of relations between the subjects involved with the mental health care and the involvement of family members with the service"⁽¹²⁾.

Subjectivity of nursing workers refers to the daily exposure of a difficult routine with various stressors. Therefore, the nursing must be helped to create spaces for reflection on the quality of services so that they can move forward, involving the group of professionals, patients and family, aiming at the reconstruction of life and redirecting the focus of the disease attention for the individual in distress⁽¹³⁾. One of the conditions to minimize these stressors is the humanization of work, which is seen as one of the instruments that can offer a better care condition to the mental health caregiver⁽¹⁴⁾, just as is the focus of reformist action, as the National Humanization Policy (NHP) understands humanization as inclusion⁽¹⁵⁾.

In these spaces to rethink the assistance, which can be supervision or reflection groups, it is possible for the nursing staff externalizing dimensions relating to care, leading to maturation of professionals, allowing also understand the environmental influence in the care of psychiatric nursing⁽¹⁶⁾.

The characteristics of nursing work with the psychotic people, developed in a Psychosocial Care Centers and TR services, "are marked by the construction of unclear connections between the purpose, object and tools of work due to the multiplicity of knowledge and subject and clinic concepts that support different work process technologies, coexisting in the same institutional space"⁽¹⁷⁾. Thus, the need to organize the ways of working in these spaces is perceived, for the care of individuals to be more specific, and the therapeutic plan has more success.

Now, with respect to nursing education in the mental health area, the curriculum subjects, while emphasizing the PR, continue to carry out their academic internships in the area of mental health in psychiatric hospitals, contributing to the maintenance of the asylum model⁽¹²⁾. There are reports of some exceptions in which the student started seeing the patient as a subject of rights, which should have access to their autonomy and citizenship (in case this has been denied). Thus, professionals in training use their practices to the transformation of psychiatric care in the nursing field, thus changing the way the person with mental disorder is assisted and referred⁽¹⁶⁾. The first published study that considered the experience of this curriculum subject change in mental health comes from the northeast, indicating the possibility of exploring the prospect of deinstitutionalization in psychiatry, thinking of the guarantee of citizenship right for patients and families who use the mental health services. The curriculum has been modified since 1996; in 2001 the authors point out the existence of social resistance to this kind of reasoning, and observe the importance of discussions in class about the deinstitutionalization experiments that began to be disseminated in the country, as today is theme for reflection in study environments and nursing practice. The difficulties encountered in PR implementation should not be an alibi for omission, but an incentive to search for new paths. Education focused on the conditions of life and work in the collectivity and particularity of each individual was significant for the institution, permeating philosophical and pedagogical discussions and solidifying this idea in students⁽¹⁸⁾.

Transformations of a ward in a therapeutic space also appear as influential in nursing practice. Creating this environment is a function of all the people who deal and interact with the patient. Opening the doors creates a new configuration of this space that was once used to segregate these patients. Therefore, nursing must adapt to seek agreement with the PR, meeting the needs and rights of these individuals⁽¹⁶⁾.

Nurses should expand their professional roles in mental health, improve their notions of acceptance, listening therapy, and interdisciplinary work. The new methodologies adopted in services and education can promote the establishment of new practices and knowledge in this context⁽¹⁹⁾.

The professional should act as a facilitator so that the individual is able to reorganize their personal lives and social relationships from before the disease, because the patient must seek new forms of autonomy and thus again be independent of care from health professionals⁽¹⁹⁾.

Amid the change process, mental health professionals are challenged to an adaptation to a new field of knowledge, and (re)build new health practices, choosing mental health and new treatment services (substitutes) as practical care spaces aimed at mental health-disease process of the patient and family⁽¹⁹⁾. The interpretation of the guidelines of the National Mental Health Policy may suffer multiple influences, such as the asylum model, which can restrict the actions of substitutive spaces, as one that allies the National Mental Health Policy.

The person with mental disorder needs network construction, where health professionals, patients, families, managers and community are inserted, actors and performers of the guidelines, framed in different scenarios that influence the effectiveness of existing reform measures⁽¹⁹⁾.

The discharge process was a movement of differentiation between the identity of the patient and the institution. This movement occurred within the thoughts, feelings and attitude, making all paths for this mental health care to go through the therapeutic relationship: the relationship between two people guided by professional strategies to help each other. Thus, the professional nurse preparation, as the entire multidisciplinary team, should consider the relationship⁽²⁰⁾.

Mental health knowledge during the PR movement should be open and complex in order to stimulate the search, reflection and intuition. From that point, the nurse must relearn how to learn, so it is necessary to propose well-defined projects that allow scientific experimentation and transformation, and practice starting with critical thinking, continuous self-criticism on the dynamic of paradigm change⁽²¹⁾.

Tools and Strategies that provide psychosocial rehabilitation

Start practicing care and promotion of mental health in primary care requires redirection of focus and instrumentalization to the health team. Nurses should build and use these resources for patient rehabilitation with mental disorders in the community, thus respecting the principle of integrality presupposed in the Unified Health System⁽²²⁾.

With the PR development several types of resources emerged, which were intended to deinstitutionalization and consequently psychosocial rehabilitation focused on the autonomy of the citizen. Nowadays, to recover this autonomy we talk about individual therapeutic project (ITP), an instrument characterized by setting objectives and planning activities within the mental health areas, so that the individual under care can achieve these objectives⁽²³⁾.

At first we describe the use of Therapeutic Accompaniment (TA), which is the practice of a companion that provides to the person affected by mental disorder exits to the city in daily activities, with the aim of developing the same social integration skills. A process that always happen according to the execution of the individual therapeutic project (ITP), aiming at the psychosocial rehabilitation process of the subject assisted⁽²³⁾. In this practice, the therapeutic companion does not have a particular profession, but has a specific training to practice, with interdisciplinary feature⁽²⁴⁾.

Another resource used as a reform tool to community integration, of broad-spectrum, between the person with mental disorder and society was the Inclusion Cup, highlighting the sport, which is a futsal championship between workshops and other spaces, for participation of all. The event organizers are from diverse areas: psychiatrists, nurses, psychologists and physical trainers. This event, which is a partnership between university entities and substitutive equipment, involves patients, workers, families and community members. Given one of the fundamental requirements of reintegration, the project promotes the patients, their family and the society surrounding them; it is a living articulation in addition to causing a "reduction of madness stigma", as evidenced by the approach of the community during sports activities⁽²⁵⁾.

 Therapeutic workshops are important tools that allow during the work and the realization of artistic practices, socialization and social interaction of patients and professionals; consequently, social reintegration. In them, the subject deals with fears, insecurities, and also exchanges experiences. Professionals help the individual in crisis to integrate to the activities, bringing them back to the social life⁽²⁶⁾. Monitoring by professionals from various fields - nursing, psychology, occupational therapy, physical education, etc.- is considered beneficial since it "contributes to the production of new ways to intervene in mental distress"⁽²⁶⁾. The workshop leadership is fundamental for reflection that keeps the therapeutic function, which requires the training of these professionals⁽²⁶⁾.

Music is also used to facilitate bonding, dialogue, raising self-esteem and causing self-care among participants of care therapy workshop with the body in Psychosocial Care Centers. It is the means of stimulating the way of perceiving and desire to take care of themselves, since it has the power to change the state of mind, and to acquire individual meanings when combined with the experiences of life. The use of this medium resulted in increased motivation of patients to participate in these workshops and to be cleaner and tidier, showing that their identities were being reintegrated⁽²³⁾.

At this point, case management has been documented as a working strategy for psychiatric nursing practitioners, considering the psychosocial aspect and reintegration of patients into society: "the basic idea is that it should combine and coordinate different services for psychiatric patients living in community, promoting a monitoring of these people and enabling their better ‘practical’ functioning in the community"⁽²⁷⁾. It is a nursing practice that also requires a clearer and objective concept, but it has been shown that community psychiatric nurses who use case management have a better ability to assess patients and define the goals to be achieved by them. These patients have improved their state of the mind, quality of life and consequently there was a decrease of admissions. ^(28-29).

 The similarity between the TA and the case management is to treat the individual in mental distress in the community and their culture. Features such as workshops and the Inclusion Cup bring the community into spaces where the patient is undergoing treatment. Thus, in one way or another, the important thing is that the person with mental disorder comes back to society and feels integrated with reality.

More recently the strategy of Therapeutic Residences occurred, bringing a breakthrough in mental health policy in the context of deinstitutionalization, creating the possibility of decent housing and monitoring the development of daily activities, aiming to rescue the individuals’ autonomy, just as the reintegration in social environment. Thus, out of asylums, individuals still have tutors guided and inserted in a closed group consisting of patients in mental health treatment⁽³⁰⁾, but with greater community life.

The nursing professional acts on all reported resources, since the professional’s playing field is very broad and not fully exploited, in order to improve care to the people with mental illness and their social reintegration.

Current spaces reflect a decrease of burden and family stress for those involved in psychiatric treatment. Psychosocial Care Center, a great example of this phenomenon, promotes family harmony and greater understanding of mental health problems; however, in the social imagination there is correlation of these spaces with the old model. For example, Psychosocial Care Center and psychiatric hospital may be confused by the community speech due to lack of knowledge about the nature of the service, which hinders adherence to treatment⁽²⁷⁾.

Again, nursing, through its strong health education action, intervenes in the imaginary scenario to create ties with the patients and their families and promote therapeutic appropriateness, the generation of the family-ill-health team agreement. This performance is a demonstration of the influence of this category in promoting inclusion^(27).

Family background in psychosocial rehabilitation

The family has interpretations about the behavior of the mental disorder patient according to their knowledge previously accumulated, with strange connotation towards the actions taken by the patient, especially in times of crisis, and translates the impact brought to the family homeostasis in this context⁽³¹⁾. Reflecting on the greater the knowledge of the family the better their understanding and facilitating the routine with the patient brings to the nurses and the team the need for family education to mental health.

Family is a particular common approach in articles raised from 2005 to 2014. This is a very important part in the lives of affected individuals who are members of a family structure, therefore essential to the rehabilitation subject. The experience of a Psychosocial Care Center in the state of Rio Grande do Sul on the introduction of the family member in the treatment environment as a service philosophy shows the institution requirement instead of a concession to individuals with mental disorder. PR has the basic assumption the inclusion and active participation of the family, thus allowing a joint work, preventing the patient abandonment and helping therapeutic projects⁽³²⁾.

The out-of-hospital services are given to families. Thus, "it provides assistance to families to clarify the symptoms of the disease and make them allies and collaborators in the treatment, keeping the deinstitutionalized individual to be understood in their uniqueness"⁽³²⁾ is a very important issue to support this family structure. The result is the change in family stereotype as responsible for mental disorder, for a family responsible for treatment and the rehabilitation of their affected member⁽³³⁾.

The importance of interdisciplinary care also appears as a benefit to customers and workers, since the issues surrounding mental health and the subject’s family are complex and need specific knowledge. Professors are seen as responsible for preparing students for interdisciplinary work involving families and basically "foster the growth of professional and discipline as a science"; and also "improve care conditions offered to the clientele, increasing the likelihood of improvement in quality of life and offering a more comprehensive care"⁽³⁴⁾. However, there is still the challenge of achieving an interdisciplinary work to obtain proper care of the family and the person with mental disorder in this deinstitutionalization model⁽³⁴⁾.

The lack of hope for a better future diminishes the positive perspectives; paradoxically, the family uses the belief of improvement to deal more satisfactorily with their suffering towards mental disorder. The family does not believe that the psychiatric hospital is an environment that cares efficiently of its family member, due to the patient loss of singularities. Home is seen as a space that contributes to the patient rehabilitation. However, the way to provide care to the individual can be both an "efficient care," which will enable them to deal with their life, as a "dependent care", making them unable to assume their true abilities⁽³⁵⁾.

Some assumptions in relation to family background involving the nursing role are: "the nurse’s philosophical baggage helps the patient and their family to find meaning in illness experience" and "the nurse is responsible for helping the patient and the family to find meaning in suffering and disease"⁽³⁶⁾. Thus, nursing and family work together with a common objective, which is the recovery of the family member⁽³⁶⁾.

It is also important to remember that each family has its own peculiarities, even if the problem between them is the same, it is necessary to conduct the actions individually taking into account the reality of each family⁽³⁶⁾.

There are phenomenological records on family caregivers of people with mental illness and how they consider the medication important, bringing the disease and its context with common sense, and even with difficulties, and trying to understand the pathology and the patient’s behavior⁽³⁷⁾; other quantitative basis authors evaluate and escalate dimensions of family life by: A) Assistance in everyday life; B) Supervision to problematic behaviors; C) Financial expenses; D) Impact on daily routine and E) Concern for the patient. In these latest studies, most families are overburden in everyday routines. When there are strategies for caregivers’ participation in family support programs, where they can express feelings and doubts about the pathology, and the possibility to exchange experiences about the disease, there is a significant decrease in the burden felt by the caregiver^(38-39). Here, the findings on different methodologies are noteworthy, perhaps because in general there is family adaptation regarding living and care, but it is elementary that in several sectors of family life there are stressors, and therefore psychological defenses acting in members of this family.

As for the inclusion of family therapy group in the routine of mental health services, it aims to involve the responsibility the family member and make it both suitable and healthy coexistence between the family and the affected person. The groups are organized and become an entity with own specific laws and mechanisms, in which all members are gathered around a task and a common objective. "The group size cannot exceed the limit that jeopardizes the essential preservation of communication." It also takes into account "the space preservation (days and right location of meetings), time (schedules, duration of meetings, vacation plan, among others) and the combination of rules and other variables that delimit and normalize the proposed group activity"⁽⁴⁰⁾.

Psychosocial Care Center and other spaces as facilitators of psychosocial rehabilitation

Throughout history a infrastructure consolidation was observed in the mental disorder treatment in the conception and madness stigma, maintaining relationship with society and political determinations⁽⁴¹⁾, setting the great difficulty of transformation of care and attention to the psychiatric patient for PR models, not only theorizing of the actions but also the physical spaces of this attention.

The National Mental Health Policy is dedicated to the objective of reducing the number of inpatient beds in psychiatric hospitals, aiming to expand alternative services, such as Psychosocial Care Center, therapeutic residences, mental health services in primary care, and beds in general hospitals.

The definition of territory where there is mental health care portrays a place beyond the physical space, but the site that provides "exchange of experiences and that builds a new way of conceiving the individual with mental disorders"⁽⁴²⁾. The categorical outcome of autonomy supports the functionality of the territory as a space in which the interaction between patients and staff provides a role of subjectivity, in the same way they are responsible for managing life and business, money. Finally, the space is no longer a place for housing/residence and becomes a property housing site, both physical location and interactional space, as is the case of households⁽⁴²⁾.

The National Hospital System Assessment Program (PNASH, in Portuguese)/Psychiatry was an instrument created to compare current legislation for mental health with the reality of the assessed psychiatric hospitals. When assessing 16 hospitals in six different states, the care precariousness is what draws more attention. Often the minimum requirements of the Ministry of Health are not met. Hospitals that were assessed as bad (14%) did not even have a therapeutic project, demonstrating a lack of concern for social reintegration⁽⁴³⁾.

In contrast to this aforementioned fact, Psychosocial Care Centers are opposed to this conception of patients isolation and consider them as "people who live in a given territory, establishing social relations, which is part of a particular family and that carry a severe and persistent disorder that has repercussions on different aspects of their life"⁽⁴⁴⁾, but are seeking to redeem their capabilities, relationships and bonds that may have been lost due to mental disorder. The Psychosocial Care Centers’ focus of attention is on the patient and the family in order to provide comprehensive care to the individual affected, involving their mental disorder and psychosocial rehabilitation⁽⁴²⁾. Psychosocial Care Center is a substitute of the manifestation of "major conflicts and challenges", as the phenomenon of crisis is experienced in this place⁽⁴⁵⁾.

There is still the dichotomy between spaces for psychosocial rehabilitation. This can be explained by the PR process still being under construction and being relatively recent, still demonstrating features of the old asylums practices along with new individual recovery concepts in their social context. The important thing is that these spaces continue to be studied and evaluated so that the fundamental objective of the mental disorder rehabilitation is treated.

Mental Health in Primary Care

In 2004 it was defined that the nurse’s work should be focused on primary care to promote mental health and reveal to the patient and family the meaning of mental disorder. Thus, nursing practice should be based on perception and observation, making valid interpretations in the work process, emphasizing the therapeutic relationship, considering as basis of the profession the dynamics, which is subject to change⁽⁴⁶⁾.

The Brazilian Family Health Strategy (FHS) is a specific place to preventive actions and early detection of mental disorders due to the bonds between professionals and the community. The FHS acts following the deinstitutionalization logic, because it prioritizes care to individuals in their own health unit and at home. Thus, it constitutes a good way to work with mental health in primary care⁽⁴⁷⁾.

Regarding the training of nursing in primary care focused on Mental Health, the need for improvement was found. This would be aimed at promoting social reintegration through nursing practices to execute joint actions with other professionals, aiming to family support and group activities^(47–49), interventions that would ensure political and anti-asylum practices.

Within the Psychosocial Care Center, the construction of basic network, the strategy adopted for integration of the individual in society is focused on the individual therapeutic project (ITP), which is a work in multidisciplinary team proposing targets established in accordance to the potential of each patient⁽⁴⁹⁾. These objectives are reviewed in short, medium and long term, and take the individual to the recovery work in groups within the Psychosocial Care Center, moving, in their time, for individual activities in daily life. A clear example of ITP’s objective is to return to work. In some situations the Psychosocial Care Center itself is an intermediate between patients and companies that provide activities for which the individual has skills. Regarding the professionals and the ITP, authors state that: Professionals face the challenges of building another type of care from the individual therapeutic projects, considering aspects beyond the disease, often not taught and valued in the courses and universities⁽⁴⁹⁾.

Regarding the attitudes of professionals in the Psychosocial Care Centers and the mental health patients, in the pursuit of social reintegration, it is shown that the ideal would be leaving the Psychosocial Care Center to the community working with the resources that they have to offer and thus, taking these patients to expand their relations⁽⁵⁰⁾. 

Within primary care, individuals recognize the Psychosocial Care Centers as a significant dimension of their daily lives and report feeling safe, that the assistance at the Psychosocial Care Center is good⁽⁵¹⁾, so in this place a vital step towards the autonomy of the affected person occurred, which enjoys quality of life and productivity within the primary care unit.

 

Final remarks

The scientific production of psychiatric nursing in the psychosocial rehabilitation context in the national literature, in the studied period, is wide and varied, covering the individual affected by mental disorder, their families, the resources used for social inclusion of patients from mental health services, the basic health services, spaces for psychological and social rehabilitation and nursing professionals themselves as a facilitator of mental recovery.

Nursing care should holistically see the human being, as there is still the consideration of mental disorder as a purely biological process, with treatment based only on drugs and social isolation.

The continuing education of nursing professionals aiming to change in reorienting the thinking practices in greater harmony with the existing mental health policies is a good resource for new care habits, as well as the constant evaluation of services that provide the mental health care. The quality of services of many psychiatric hospitals and the Psychosocial Care Centers must be monitored to ensure that the patient has a therapeutic plan that aims at their social reintegration.

In relation to the psychiatric patient context, working together with their family is important so that the individual does not lose or recover their social identity. Therefore, nursing should be able to guide families to take care of their patients in order to seek independence and inclusion of these individuals.

Mental health in primary care is also an issue that needs to be further discussed and studied so that the care is effective. Multidisciplinary actions can increase family support and provide other activities to patients, thereby facilitating psychosocial rehabilitation in these health care tools.

Although the studies cover areas related to mental health, the constant renewal of knowledge in this area is needed due to the great complexity of the human being and mental disorder, especially when dealing with relations to effective care.

 

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Received: Feb 26^th 2015
Accepted: Dec. 21^th 2015

Correspondência:
Gabriel Lavorato Neto
Universidade Estadual de Campinas
Rua Tessália Vieira de Camargo, 126
Cidade Universitária Zeferino Vaz
CEP 13083-887, Campinas, São Paulo, Brasil
E-mail: lavorato.neto@gmail.com