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SMAD. Revista eletrônica saúde mental álcool e drogas

On-line version ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.14 no.2 Ribeirão Preto Apr/June 2018

http://dx.doi.org/10.11606/issn.1806-6976.smad.2018.149449 

ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.smad.2018.149449

 

The mental health concept for health professionals: a cross-sectional and qualitative study*

 

El concepto de salud mental para profesionales de salud: un estudio transversal y cualitativo

 

 

Loraine Vivian GainoI; Jacqueline de SouzaI; Cleber Tiago CirineuI; Talissa Daniele TulimoskyII

IUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
IICentro de Atenção Psicossocial de Álcool e outras Drogas, Cordeirópolis, SP, Brazil

 

 


ABSTRACT

OBJECTIVE: this study aims to investigate and compare the concept of mental health for professionals working in different services of the public health network.
METHOD: this is a qualitative study, carried out in 2017. Data collection was carried out through semi-structured interviews with 20 professionals of said services in a city in the interior of São Paulo. To analyze the data, the thematic analysis was undertaken.
RESULTS: two categories were identified - Integral Perspective and Psychiatric Symptoms and Disease. Most of the participants associated this concept with the notion of well-being, integrality of the human being and social determination of the health-disease process. Some interviewees from the specialist services and the Urgency and Emergency Unit referred to the absence of disease and to the psychiatric symptoms to exemplify the term "mental health".
CONCLUSION: these results are related to the health approach adopted by the World Health Organization and by the Brazilian Unified Health System. Strategies to bring professionals from different services together in a network perspective may be essential to broaden this discussion and consolidate a broader perspective of health.

Descriptors: Mental Health; Health Personnel; Health Services; Qualitative Research.


RESUMEN

OBJETIVO: este estudio buscó investigar y comparar el concepto de salud mental para profesionales actuantes en diferentes servicios de la red de salud pública. La recolección de datos se realizó a través de entrevistas semiestructuradas con 20 profesionales de estos servicios en una ciudad del interior de São Paulo. Se trata de un estudio cualitativo, realizado en el año 2017. Para análisis de datos se realizó un análisis temática.
RESULTADOS: se identificó dos categorias: Perspectiva Integral; Los Síntomas Psiquiátricos y Enfermedades. La mayoria de los participantes presentaron un concepto ampliado y integral de la salud mental y el bienestar relacionado, pero algunos de los entrevistados de los servicios y urgencias se refierón a la ausencia de enfermidades y síntomas psiquiátricos para ejemplificar el término.
CONCLUSIÓN: tales resultados están relacionados al abordaje de salud adoptado por la Organización Mundial de la Salud y el Sistema Único de Salud brasileño. Estrategias para acercar a los profesionales de los diferentes servicios desde una perspectiva de red puede ser esencial para ampliar tal discusión y consolidar una perspectiva más ampliada de salud.

Descriptores: Salud Mental; Personal de Salud; Servicios de Salud; Investigación Cualitativa.


 

 

Introduction

Health and mental health are concepts that are complex and historically influenced by socio-political contexts and the evolution of health practices. The last two centuries have seen the rise of a hegemonic discourse that defines these terms as specific to the field of Medicine. However, with the consolidation of multidisciplinary health care, different areas of knowledge have gradually incorporated these concepts(1-3).

According to the World Health Organization (WHO), "Health is a state of complete physical, mental and social well-being, and it does not consist solely in the absence of disease or infirmity"(4). This 1946 definition, was innovative and ambitious, because instead of offering an inappropriate concept of health, it expanded the notion including physical, mental, and social aspects(3,5,6).

Despite the positive intentions assumed by this definition, it has received intense criticism during its 60 years of existence. This is due to the fact, especially, that an unreal meaning is proposed, whose human and environmental limitations would make the condition of "complete well-being" impossible to achieve(3,6).

Due to the criticisms of the WHO concept and to the various political and economic events, a new paradigm emerged: health as a social production. This new vision emerges from the combination of preventive medicine and integrative health approaches, the expansion of the concept of health education and the rejection of the hygienist approach(2,4,7).

When following the proposals to reform the Brazilian health system, the concept of health was formally revisited and influenced by international experiences involving health policies, as discussed mainly in the 8th. National Health Conference in 1986. At that time, it was suggested that health should include factors such as diet, education, work, housing, income and access to health services(1,8).

As a result, the Brazilian concept of health began to be understood in a more complex way, considering the principles of universality, completeness and equity in health care. These principles, however, coexist with approaches clearly linked to the old view(8).

The term well-being, as defined by WHO, is a component of the concept of both health and mental health, and is understood as a construct of a subjective nature, strongly influenced by culture(3,9). The WHO defines mental health as "a state of well-being in which an individual perceives their own abilities, can cope with everyday stresses, can work productively, and is able to contribute to their community"(10-11).

Definitions of mental health are objects of various knowledge, however, a psychiatric discourse prevails, which understands this as opposed to madness, denoting that people with diagnoses of mental disorders can not have any degree of mental health, well-being or quality of life, as if their seizures or symptoms were continuous(12-13).

In the 1960s, the Italian psychiatrist Franco Basaglia proposed a reformulation of the concept of madness, changing the focus of the disease and expanding it with issues of citizenship and social inclusion (14). The reformulation gained adherents and ignited a movement that influenced the concept of mental health in Brazil and resulted in the subsequent Brazilian Psychiatric Reform(15-16).

In view of the above, it is understood that there are two main paradigms the discussion of the concept of health and mental health, that is, the biomedical paradigm and the social health production. In the first, the focus is exclusively on disease and its manifestations, and madness is essentially the object of study of Psychiatry. In the second, health is more complex than disease manifestations and includes social, economic, cultural and environmental aspects. In this paradigm, madness is much more than a psychiatric diagnosis, since patients with a psychiatric disorder can have quality of life, participate in the community, work and develop their potential.

The Brazilian Unified Health System adopts an expanded concept of health and includes, mental health care in its priorities(1,8). However, this study presupposes that such perspective is not introjected by the health professionals that integrate this system, still prevailing the biomedical paradigm. Thus, this study aims to address the term mental health from the perspective of health professionals of the public health network.

 

Objective

This study aims to investigate and compare the concept of mental health for professionals working in different services of the public health network.

 

Method

Location and study design

This is a cross-sectional and qualitative study conducted in nine health services in a city in the interior of São Paulo.

The services included a Psychosocial Care Center (PCC), a Mental Health Outpatient Clinic (MHOC), five Family Health Strategy Teams (FHS) and an Urgency and Emergency Unit that also met psychiatric and the mental health demands.

The choice for these services was due to the fact that they developed mental health actions. It was also chosen to cover the primary and secondary health care services in order to capture possible differences in the concept in question. The municipality studied also has other services, such as the Center for Medical Specialties, the Center for Physical Therapy, Pharmacy, Central Ambulances and Dental Center, which do not develop specific actions of mental health and therefore were not included in the research.

At the time of data collection, the PCC had eight professionals; the MHOC, with seven professionals; the FHS’s, with 84 professionals and the Emergency and Emergency Unit, with 21 professionals. These services had professionals from the most varied areas, such as psychologists, nurses, among others.

Sample and recruitment of participants

In order to obtain a representative sample in terms of professional diversity, at least one participant from each professional category of each service group was included, i.e. covering all professional categories. The inclusion of a variety of participants makes it possible to obtain different points of view and is recommended for qualitative research(17).

The first step in the selection of participants from each group was to obtain a list of the workers in those services, to separate them into professional categories, and to classify them in terms of those who worked closest to mental health care activities and those with a longer time working in health networks. On-call workers were excluded, with less than one year of on-call service and on vacation during the time of collection. The professionals were invited by the researchers personally during their working hours. There were no denials of participation and 20 professionals accepted to participate.

Another important aspect related to the selection of participants in qualitative studies is data saturation(18). So the need for insertion of more individuals was assessed throughout the collection process, preliminary analysis and validation of data with the interviewees.

Data collection

Data collection was carried out using a semi-structured interview. Interviewers followed a guide with guiding ideas to conduct the interviews, to know "Tell me what is mental health to you" and "Give me some examples of your practice to illustrate this concept".

The interviews were conducted and recorded in private rooms at the interviewees’ own services by a psychologist (master’s degree) and a Psychology student who had received previous training for the activity. Each interview lasted about 40 minutes. Data collection was terminated as soon as the data saturation criterion was reached. Data was collected between June 2013 and May 2014.

It is important to emphasize that the importance in the publication of data that was collected in the year 2014 is due to the relevance of the theme in the contemporary context and the lack of publication about the perception of health professionals and mental health (Family Health Strategy, Urgency and Emergency Unit and Specialized Mental Health Services) about the concept of mental health, a fact that directly implies effective actions and practices for the process of citizenship and social inclusion.

Data analysis

The data analysis was based on the inductive method, since the knowledge emerged from the empirical data, based on the observation and experience in the field about the researched reality. In this way, the use of the Thematic Analysis principles for the analysis in question was considered more appropriate(17). According to this technique, it is emphasized that there are five phases for analyzing qualitative data: compilation; disassembly; reassembly; interpretation; and conclusion.

In the first stage, named as a compilation, the data corresponds to the organization of information in a systematic way in a database. In this way, the interviews were transcribed constituting a corpus of information about the participants’ perception about the concepts of health and mental health.

Then, in the disassembly phase of the analysis, the information corpus was divided into units of meaning, that is, segmented into sentences words, or paragraphs that contained aspects related to each other through their content and context. As there were no pre-established categories for analysis of this corpus, the researchers performed floating reading in order to discriminate the terms in evidence. Therefore, successive re-readings of sentences containing these terms were made for the construction of a first level of codes.

From this first level of code, the researchers involved (psychologist, occupational therapist and nurse) intersected groupings into categories by creating specific themes from the convergences of discourses and creating the units of meaning. In this sense, this phase is related to the third stage of analysis proposed by Yin(17), known as Reassembly. These codes were then regrouped to form two categories: "Full Perspective" and "Psychiatric Symptoms and Diseases", at which point the discrepancies in the categories were discussed and marked among the three researchers.

After the complete construction of the categories, the interpretation of these contents was carried out, taking, as a parameter, the concepts of health and mental health, based on the WHO definitions, by Almeida Filho(5), Foucault(13), Amarante(12).

Finally, the fifth phase of the process of analysis, also described by Yin(17), called the conclusion, was elaborated, in which one seeks to broaden the concepts studied by suggesting proposals and calling for new studies.

It is emphasized that the study was approved by the Ethics Committee of the School of Nursing of Ribeirão Preto - University of São Paulo (CAAE 10341212.0.0000.5393) and complied with all ethical principles established for research involving human beings.

 

Results

The participants were mostly female, had a mean age of 34 years (minimum age of 24 and maximum of 54) and average time of the last training of eight years (minimum of one year and maximum of 30 years). The average working time in the current health services was three years (minimum time of one year and maximum nine years).

From the analysis, two categories were found: "Integral perspective" and "Psychiatric symptoms and diseases", which will be described below with an example of the speeches of the participants, according to their respective services.

It is important to highlight that the most significant speech fragments were selected, which originated the categories and became important for the writing of this article.

Category 1: Integral perspective

In this category, it is important to highlight how the professionals of the public health network services understand the concept of mental health.

To that end, it is worth mentioning that most of the participants in the services investigated described the concept of mental health in order to signal a more generic and integral conception of the term "mental health". There was not much distinction between the speech fragments of the professionals interviewed and presented below.

Specifically in the Specialized Mental Health Services, professionals spoke about their perceptions of how they understand mental health, giving rise to the following statements: Mental health involves everything, general health, physical well-being, happiness and nourishment (Social Worker, PCC); [Mental health] is the person being able to have good living conditions, work, have children (Psychiatrist, PCC); [Health] is a combination of physical, mental, financial and emotional well-being (Nursing Technique, PCC); [Health] is feeling good inside, having a good diet and doing physical exercises. (Receptionist, PCC).

For professionals of the Family Health Strategy, the concept of mental health approached those cited by the PCC professionals: As we work in the health area, we hear enough that it is not only absence of the disease, but a quality of life (Community Health Agent 1, FHS).

The understanding of mental health for the professionals of the Urgency and Emergency Unit was also discussed with previous ones: I understand much more than the absence of disease. You have to evaluate the biopsychosocial aspect. Getting stuck in absence of disease is too restrictive (Nurse, Urgency and Emergency Unit).

In addition to this more general perspective of the concept of mental health, some professionals mentioned sociocultural aspects and resources that individuals have at their fingertips.

In the meantime, the professionals of the Specialized Mental Health Services reported: I think it is very relative, the definition leads to normality patterns of society in general. This has to do with the values and education that each person has (Psychologist, PCC); [Health] not only the absence of disease [...]. Mental health is to be able to reconcile desires and difficulties, to have faith in the future, despite adversities [...] And seek help when not feeling well (Occupational Therapist, PCC); Mental health is you having a social bond with friends, family, being able to express what you feel, feel good about yourself (Psychologist, Mental Health Outpatient Clinic).

The professionals of the Family Health Strategy, complemented that: Mental health is the patient being well with himself. Aware of your situation and your living condition. The mental health for me today is knowing how to conduct problems the way they see them and try to solve them in the best possible way (Nurse, FHS); Mental health encompasses the well-being in the person’s daily life, how she feels. Not only the physical part [...] as it is seen in society and in the family environment (Community Health Agent 2, FHS); [...] it is not only physical, but also mental, spiritual, social, economic (Family Health Doctor 2, FHS).

However, the professionals of the Urgency and Emergency Unit did not verbalize significant statements related to the sociocultural aspects and the strategies and to the resources used by individuals in this area of coping with psychic suffering.

Category 2: Psychiatric symptoms and diseases

In this category, it was opted to discuss the importance of the impact of psychiatric symptoms and diagnosis on the concept of mental health.

In this sense, with the exception of FHS professionals, the interviewees referred to "absence of diseases" and / or psychiatric symptoms as auxiliary ideas to exemplify how they conceptualized the term mental health.

Therefore, according to the professionals of the Specialized Mental Health Services, the following fragments appeared: [...] during the anamneses,s it was clear that she had a mental health problem. She was very confused, delirious, with irrational mystical delusions (Nurse, PCC); The patient had abnormal behavior. When she arrived, we realized she was not in her normal state [...] She wanted to demolish one house to build another, completely out of the blue. She was saying that she did not want to take any medication to feel better. And she spoke frantically (Nursing technician, PCC); I would define more by denial, not having psychic suffering (Psychologist, Mental Health Outpatient Clinic).

From the perspective of the professionals of the Urgency and Emergency Unit, it was possible to highlight the following statements: Health is the absence of disease (Nurse, Urgency and Emergency Unit); One of the factors you can already identify is people’s behavior. The patient arrives in a hospital already with a change of behavior, that you know that a person who is in good conscience would not do (Nursing Technician, Urgency and Emergency Unit).

 

Discussion

The professionals participating in this study were, mostly, female and with a mean age of 34 years corresponding to the predominant professional profile - women between 30 and 40 years old - found in other researches with both health professionals in general(19-21), and with professionals working in mental health services(22).

Regarding the categories found in the thematic analysis, in the first, the perspective of the professionals of the public health network services of a municipality in the interior of the State of São Paulo, denote notions of individuality and well-being when asked about the concept of mental health.

However, most participants in the services involved in the study presented conceptions, strongly influenced by the WHO definition of health: the most widespread in academic teaching materials.

When observing the fragments of the professionals of the Specialized Services of Mental Health and the Unit of Urgency and Emergency, it is noticed that the speech is constructed from real experience with the people who present any type of psychic suffering. These professionals verbalize the concept - emphasizing well-being - with more ownership and empowerment, while the professionals of the Family Health Strategy, emphasize about it in a more timid and implicit way, referring to what others say to this respect.

It is inferred that this may be linked to the educational level of training, and that the Family Health Strategy professional has a lower degree when compared to the others; by contact and / or (con) living with the person in psychological distress; or even by implication and direct involvement in your work process. This questioning is something that deserves more detailed and in-depth studies on this subject.

From this point of view, it is of great relevance to think that the mental health system must have, the person in psychic suffering as a protagonist, so that it can exercise its autonomy in society, building affective bonds and (re) signifying the attainment of its own autonomy, even though he did not have the complete remission of the symptomatology resulting from his diagnosis(15-16).

Based on the observation in this category, WHO cites the inclusion of psychological aspects as part of health and the idea of social health production, which reaffirms that physical and mental well-being depends on good living conditions involving food, housing, employment situation among others(3,6). This innovative idea, at the time of its dissemination, encouraged countries around the world to rethink their health policies while trying to relieve post-war depression, inspired by the WHO concept of health(5).

However, the WHO concept has been criticized for limiting health only to a complete state of well-being(6). Another weakness of this definition is related to chronic diseases, which were not, at the time, such an obvious health problem, but are now one of the main problems in most countries. In addition, advances in biomedical technology have made it possible to increase longevity, even with an established diagnosis. This new epidemiological profile renders the definition of WHO obsolete and results in greater health spending because if health is a complete state of well-being, a person with a chronic illness means that he is ill and in constant need of medical care(6).

Still on the concept of the WHO, an Australian study with doctors and patients of an Integrative Medical Clinic found the difficulty of explaining the phrase "health is more than just the absence of disease". The authors found that it was easier to define disease and the explanations were based more on comparisons with negative aspects of health. However, in relation to the concept of well-being, participants indicated that they are beyond feeling good mentally, having happiness and satisfaction with life, also involving social aspects, optimized physical and cognitive abilities, spirituality and vitality(3).

In addition to the word wellness, the participants of the research mentioned, used the words "mental" and "physical" to explain the concept of mental health. These contrasting terms appeared mainly in the study of madness in Ancient Greece, as can be seen, for example, in the writings of the philosopher Galen. This division weakened during the Middle Ages when madness, like other diseases, was only considered as a demonic manifestation. The vision of a fragmented human returned with force in the middle of the seventeenth century with the emergence of the biomedical paradigm, which punctuated psychiatric diseases as the simple opposite of mental health(12-13).

In practical terms, still with respect to the first category, professionals cited the importance of socio-cultural aspects and the resources that individuals with psychic suffering are used. In this regard, the professionals of the Specialized Mental Health Services and the Family Health Strategy, referred to the influence that the person in psychic suffering has on the environment, context, family, friends, economic situation, spirituality, the help you receive from other people, your own desires and expectations. For the professionals of the Urgency and Emergency Unit, there were no significant speeches for this issue.

In this sense, it is also noted that some participants seem to understand concepts as socially determined, corroborating a health paradigm as a social product(5,7,12). In this category, the interviewees pointed out individuals’ personal resources in the face of adversity as part of mental health, agreeing with what is proposed by WHO(4).

In the second category, the manifestations of the disease (symptoms) were essential elements to explain what mental health means, suggesting that mental health is the opposite of psychiatric illnesses, despite the current discussions about the importance of extending this concept including aspects related to the well- being, quality of life and social conditions of life(5,12,15). In addition, classifying the person as ill can lead to a decrease in their autonomy and their ability to feel healthy, even with their limitations(23).

However, it was observed, in this category, the importance given to psychiatric symptoms and the diagnosis to obtain the concept of mental health.

The prevalence of the biomedical paradigm in the conception of mental health was found in a study carried out with nurses from Zona da Mata, Minas Gerais. The authors point out that few professionals present an expanded conception of mental health, considering subjectivity. It is also discussed, how in relation to the stigma, the lack of professional knowledge and the prevalence of actions directed only at the disease(24).

Similar results emphasizing the issue of stigma in mental health were found in a survey conducted with professionals and users of Centers for Psychosocial Attention and Family Health Strategy in Fortaleza-CE. The results indicated that the word madness is still understood as synonymous with mental illness and is related to suffering and prejudice(16).

These two studies corroborate what was raised in a systematic review of world literature that aimed to verify the beliefs and perceptions about mental health issues prevalent in different populations and cultures. Even with some differences between contexts, mental health is still explained from emotional (behavioral) symptoms, although the causes presented for mental health problems involve psychosocial, environmental, spiritual, biomedical and genetic aspects(25).

In this study, based on the speeches of the professionals of the Specialized Services of Mental Health and of the Urgency and Emergency Unit of the municipality, the symptomatology resulting from a psychic suffering, based on behaviors unsuitable for social interaction such as confusion of thought and the delusions (regardless of its origin), can lead to a previous analysis to induce a standardization about the concept of mental health. It is worth mentioning that the professionals of the Family Health Strategy were those who did not denote a concept of mental health linked to symptomatology in the discourses that were analyzed for this research.

The meaning and meaning of illness should be carefully and uniquely analyzed, understanding the concrete implications of psychic suffering in their daily lives. In this way, attention is needed to the real abilities of individuals, so that the symptoms and / or the symptoms resulting from psychic suffering are not used as forms of guardianship or to provide advantages in certain situations(26).

It is of extreme relevance to emphasize that the similarity in the understanding of the professionals about the concept of mental health is due to the fact that the investigation was carried out in a small municipality, where the contact between the professionals of the specialized services of mental health with others services is facilitated, approaching the premises of a more articulated work aimed at the integral assistance of the individual.

However, this result highlights the importance of Amarante’s propositions(12) that, a few years ago, "working with mental health" meant addressing patients with mental illness within the scope of psychiatric institutions. However, discussing mental health in modern times means addressing a complex and extensive area that goes beyond the treatment of people diagnosed with mental disorders. In addition, the term mental health refers to the field of knowledge, technical work and public health policies, and it is difficult to establish limits for its definition due to its wide scope and because it is based on different types of knowledge such as Psychiatry, Neurology, Psychology, Philosophy, Physiology, Sociology, and even Geography.

 

Conclusion

The objective of this study was to investigate and compare the concept of mental health for professionals in the Family Health Strategy, Urgency and Emergency Unit and specialized mental health services.

Some professionals from the specialized services and emergency and emergency unit mentioned psychiatric symptoms and the idea of absence of illness as an accessory to exemplify how they conceive of mental health. However, most participants associated this concept with the notion of well-being, integrality of the human being and social determination of the health-disease process.

It is understood that these results are related to the health approach adopted by the World Health Organization and Brazilian Unified Health System and that the organization of the work process of the teams, the specificity of the daily demands and the therapeutic project of the services themselves can also be influencing such conceptions.

Fostering discussions about the concept of mental health and implementing strategies to bring professionals from different services into a network perspective may be essential to broaden this discussion and consolidate a broader perspective of health in different care settings and in the community itself.

Regarding future studies, it would be important to identify if the concepts described by professionals are reflected in professional practice or if only reproduces the discourses absorbed from official documents and academic discussions. That is, automatically repeated responses do not necessarily guarantee the internalization of the concept. Thus, additional studies that use the technique of observing the work processes and behaviors adopted by professionals in the day-to-day life of a person with mental disorders would be essential to deepen such discussions.

As limitations of the study, the use of only one technique of data collection, stands out. In addition, the very presence of health interviewers may have influenced participants to present an expected speech. Further studies are suggested that broaden this discussion, including users of the services and their perceptions about health and mental health.

 

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Received: Aug 28th 2018
Accepted: Sep 5th 2018

Corresponding author:
Loraine Vivian Gaino
E-mail: lorainegaino@gmail.com
 https://orcid.org/0000-0002-2074-909X

 

 

* Paper extracted from master’s thesis "Mental health in the health care network of an inner city of São Paulo", presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

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