ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.smad.2019.150016

 

Potentials and challenges of the itinerant team’s work on drug user care*

 

Potencialidades y límites del trabajo de un equipo itinerante en cuidado a consumidores de drogas

 

 

Adriane Domingues Eslabão^I,II; Leandro Barbosa de Pinho^I; Márcio Wagner Camatta^I; Elitiele Ortiz dos Santos^I; Talita Portela Cassola^I; Vanessa Alvez Mora da Silva^III

^IUniversidade Federal do Rio Grande do Sul, Escola de Enfermagem, Porto Alegre, RS, Brazil
^IISecretaria Municípal de Saúde, Atenção Básica, Capão do Leão, RS, Brazil
^IIIUniversidade Federal do Pampa, Uruguaiana, RS, Brazil

 

 

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ABSTRACT

OBJECTIVE: to identify potentialities and challenges of the work of an itinerant mental health team in the care of drug users.
METHOD: a qualitative study with an itinerant team, from a city in Rio Grande do Sul, Brazil. Data was collected through participant observation and a semi-structured interview with professionals in the year 2015. For the data analysis, the Thematic Content Analysis was used.
RESULTS: among the potentialities, the very creation of this service to act with the judicial sector stands out. With regard to the challenges, the difficulty of discussing hospitalization with the family was highlighted.
CONCLUSION: innovations and challenges are inherent in the psychosocial way in which complex situations involve the territory and the organization of health services.

Descriptors: Mental Health; Health Care Reform; Public Policies; Drug Users.

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RESUMEN

OBJETIVO: identificar potencialidades y limites del trabajo de un equipo itinerante em salud mental para el cuidado a consumidores de drogas.
MÉTODO: estudio cualitativo realizado e nun equipo itinerante de una ciudad del Estado de Rio Grande do Sul, Brasil. Los datos fueran recolectados a partir de observación participante y entrevista semestructurada com los profesionales en 2015. Para el análisis de los datos se utilizo el Análisis de Contenido Temático.
RESULTADOS: entre las potencialidades, se destacaron la propia creación del servicio para actuar com la justicia. Sobre los desafíos se destacaron la internación psiquiátrica.
CONCLUSÃO:   las innovaciones y los desafios son típicos del modo psicosocial, em lo que lãs situaciones complejas envuelven el territorio y la organización de los servicios del salud.

Descriptores: Salud Mental; Reforma de la Atención de Salud; Políticas Públicas; Consumidores de Drogas.

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Introduction

In the care of drug users, itinerant teams have been considered potent in caring for individuals and families. Roaming is a way to operationalize the care in the territory that provides for the displacement of professionals to the user’s living spaces, with the production of care contextualized to human existence and seeks to ensure the break with normative and reductionist hegemonic logics⁽¹⁾.

Itinerant teams play an important role in caring for drug users, homeless people and other vulnerable groups that do not adapt to clinical protocols established in services. These teams provide the guarantee of the right to meet in the territories, with the identification of their social and health needs, listening, dialogue and participation in the construction of network care strategies^(1-2).

The creation of itinerant teams is the result of the ongoing process of Psychiatric Reform in the country. Their advances have promoted the construction of new care practices in the field of mental health that materialize in the daily spaces of users, the territory in which psychic suffering is taken as a complex object of life, of multiple dimensions, and whose perspective of care takes into account the different ways of living⁽³⁾.

In this perspective, the professionals have greater freedom to invest and invent different ways of caring, being able to integrate and articulate territorial and intersectoral actions, such as they have been developed by the itinerant teams. Thus, in 2014, the first Itinerant Mental Health Team of a municipality in the metropolitan region of Porto Alegre, Rio Grande do Sul (RS) was officially established. The formation of this team brings together two major sectors - the health sector and the judiciary.

The judicialization of mental health has gained evidence in recent years of increased abusive use of drugs and compulsory hospitalizations, often used, as a treatment strategy to respond to a critical demand - "putting out a fire." Compulsory hospitalization is provided for in Law 10.2016 / 2001 (Brazilian Psychiatric Reform Law), by deliberation of the Justice, which is also responsible for evaluating the safety conditions of the health establishment in terms of safeguarding the user, other inpatients and institution⁽⁴⁾.

The training and the creation of the Itinerant Mental Health Team are an innovative proposal that aims to reduce the mental health judicialization in the municipality and qualify the offer of care to the drug user and his family. When receiving the judicial processes, the professionals evaluate each case and carry out the first steps to insert the user into the care network, they respond officially to the judicial sector in relation to the actions taken and, in addition, it is up to this team to strengthen, with the judicial sector and other social spaces, emblematic issues related to drug user care.

Faced with the complexity of the care that these teams face in seeking to build an interface with the territory and innovate the modus operandi of health work, this study aims to: identify the potentialities and challenges of the work of an Itinerant Mental Health team in care to drug users. The results of this study may contribute to the problematization and the transformation of realities similar to this study in the equalization of the processes of judicialization of drug user care.

 

Method

This is a qualitative study oriented by the theoretical framework of the health work process. Qualitative research uses the universe of meanings, aspirations, beliefs, values, attitudes and culture, since it is understood that this set of human phenomena is part of social reality⁽⁵⁾.

And the work process in health occurs in act, in the accomplishment of the action, whose product is inseparable from the process of its formation. The work process is carried out through technologies, the operative knowledge that constitute the theoretical-conceptual instrument that bases the action in health to produce practices aimed at the object, individual or healthy / diseased groups with different needs⁽⁶⁾.

The field of study was to the mental health network of a municipality in the metropolitan region of Porto Alegre in the State of Rio Grande do Sul, Brazil, area of action of the Itinerant Mental Health Team. The study participants were the professionals that comprise this team, three psychologists and a clerk, however, according to the exclusion criteria to participate in the study - being away or on vacation during the period of data collection -, the clerk did not participate in the collection of interviews.

Data collection was performed through a semi-structured interview and participant observation. Participant observation, and documentary analyses were carried out from July to September 2015, totaling 180 hours. Participant observation was accompanied by the team work process in home visits, in the monitoring of users and families, in meetings with mental health services and in other devices of the care network, as well as in the preparation of a technical opinion, to the Public Prosecutor’s Office the demand for evaluation of the need for compulsory hospitalization.

To perform the analysis of the data obtained in the study, the Thematic Content Analysis was used⁽⁵⁾, which is composed of three stages: Pre-Analysis, Exploration of Material and Treatment of Results Inference / Interpretation. In the first stage, the floating and exhaustive reading of all the material was carried out. In the second stage, the data analysis was performed, separating from the text fragments and excerpts that were distributed in topics, identified as information unit, and, then, the units of similar information were approached giving rise to the units of meaning, which, from the approximation and the analytical work of the units of meaning culminated with the analytical categories. Finally, in the third stage, an interpretive synthesis was performed from the treatment of the results obtained, being these subjected to complex or simple operations that allowed to highlight the obtained information⁽⁵⁾.

According to Resolution 466/2012 of the National Health Council, the study contemplated the bioethical prerogatives and obtained the approval from the Research Ethics Committee, in July 2015, through the number of opinions: 1,144,089. The study participants signed the Free and Informed Consent Term and were identified with the letter T of the worker and the number corresponding to the interview, as T01, T02, respecting anonymity. The excerpts from the field diary were represented by the acronym DC. 

 

Results and discussion

Potentials of the Work of the Itinerant Mental Health Team

The itinerant teams, for acting on the street and in the places of production of life, become important technological tools of care, identifying situations of conflict, family breakup, school dropout, violence, among other vulnerable situations that need the look of willing professionals to play its part in health.

The autonomy of creating alternatives that can respond to local health demands, such as the creation of the itinerant team, is one of the characteristics of the modes of organization of the Brazilian health system. This autonomy enables the municipality to think about its real needs, to create care services or strategies, taking responsibility for local decision making.

In this case, the workers point out that the creation of the team was one of the potentialities, not only because there are many lawsuits in mental health, but also because the Itinerant Team is a strategy that can promote care in this field: I think the itinerant is a innovation so you know. I think it’s a breakthrough in care, I think she’s much more likely to be a resolving care than simply complying with a court order [...]. I think that you can think and signal and construct even if it is a case that in fact needs a hospitalization that this is put in a different way for the user will be much more therapeutic than you fully comply with what is there in black and white (T01). I think it’s one more thing that was created thinking about the care and freedom of the user [...] one of the things that come along with this, the creation of the itinerant. I think it was this mental health banking with the legal that not who owns it if that person needs to be hospitalized or is not mental health is not the judge (T03).

The model change redirects care to people’s living territory. The proposal to change the health care model was expressed at the VIII National Health Conference in 1986, and was established in the Brazilian scenario with the creation of the Unified Health System, which brought principles such as universality, equity and integrality, guidelines which should reorient the process of health care and broaden the concept of health as a result of social conditions of life⁽³⁾. It is through these model changes that the municipality under study manages to innovate its practices, building new ways of acting in response to the needs and demands of the territory. 

In this sense, considering the "macro-political" context of the process, the municipality has been proposing new modes of care through the deployment of itinerant health teams. The creation of the Itinerant Mental Health Team, in this perspective, is an innovation, because the judicialization of health is a common process in the studied location. In the "micro-political" context, in other words, in the daily functioning of the network and of the team itself in this network, there are other elements involved that facilitate the work of professionals. T02, below, highlights the autonomy of working in this team, in addition to the availability of a car, something not recurrent in other realities of care: We have enough, I do not know if enough, but much more than other services is our possibility of autonomy of work there, of drawing [...] We have a transport available that facilitates a lot, it was not to be, but the people know that there are many colleagues who work without transportation [...]. It is a working condition potentiality (T02).

T02 highlights the autonomy, as a potential of the work of the team, to build networks external to the services. However, it is understood that it is necessary to relativize this autonomy of the worker, because their actions are conditioned by the technical-organizational organization, by the socio-political influences present in the work spaces and by the production of care, that is characterized by a given formation⁽⁷⁾.

The team presents greater conditions to reinvent the work, that is, to think and organize the processes that involve it, designing care alternatives. And this greater degree of autonomy is strengthened when the worker finds, in the service, the very means to favor the performance of his activities, such as having a vehicle available.

Studies point to important difficulties in the articulation between specialized services and the basic network in mental health care^(8-9). Thus, the automobile can collaborate in the organization of work processes centered on the need to know the living areas of users and their families, in articulation with the network services, in the formal and informal networks of care, their common spaces of socialization and speed up response to team demands and actions.

The team also notes advances in the construction of new care and dialogue projects with basic care, even if it still has difficulties to understand its role in relation to mental health care: In the very basic mental health care, as a whole, I think it has been possible to work on this in a very good way so with basic attention through matriciation [...] more so you see a very great difficulties of the people to accept that basic care also has to deal with mental health care in the territory (T03).

In a study carried out with professionals from the Family Health Strategy, interaction between the mental health and primary health care (PHC) fields was identified through the involvement of specialists and general practitioners, through matriciation, providing new relationships and professional interactions. This promotes a new model of public health, which implies care practices in the perspective of integrality⁽¹⁰⁾. In this sense, it is necessary to invest in professional training and practices of mental health training⁽⁸⁾.

Another potential related to the Work of the Itinerant Team was the advance of the joint actions with the Center of Attention Psychosocial Alcohol and other drugs (CAPS AD). Among these actions, the appointment of a reference technician of the specialized service to receive the demands of the Itinerant Team and the increase of the frequency of meetings between the teams, as set forth below: I think the relationship with CAPS AD has improved a lot [...] The people with them have been able to stipulate some things of the technical type of reference of the team that can be more linked thus more responsible for this care with the itinerant, the people has been able to hold meetings, now we have been able to do more then (T03). At 9 am a CAPS AD technician came and invited one of the workers from the Itinerant Team to attend a meeting with CREAS to discuss a case, which is a legal process. T03 questions the reason for the meeting and her colleague from CAPS AD says that CREAS follows the family (mother and child) and that the mother is elderly and the child is not being able to organize to take care of her (DC).

Although CAPS AD is a potent place of care for drug users, it is also evident the need to expand out-of-service actions to better integrate the psychosocial care network and the workers involved. CAPS AD workers feel restricted to intramural spaces, when they should, according to the premises of the Psychosocial Attention model, circulate more through the territory⁽¹¹⁾. Meetings to discuss cases can be part of the strategies that allow interaction between services, expanding the problematization of complex situations and the planning of articulated actions between different services and interlocutors in the attention to users of the services.

Thus, the act of caring for drug users, in community services, demands, from the professionals, a reflexive and creative knowledge, since it is necessary to apprehend with the user’s immediacy, while trying to re-signify the relation established with the use of a certain drug⁽¹²⁾.

In this case, health services should organize themselves to meet the needs of the user, involving not only the technical knowledge about the substance, but, also, the reality lived by the subject, their way of life, their space and their relationships.

Challenges of the Work of the Itinerant Team

The Itinerant team’s preserved characteristic of being a more territorially oriented service allows it to organize itself to understand that life abroad has much more unique nuances and that health services are not always accustomed to working. Once the subject lives in a living territory, that is, circulates through it, organizes its projects and their relations. So, it is possible to perceive that the teams encounter difficulties located in this field of relations.

T02 highlights that one of the team’s challenges is the difficulty in finding the person in the residence: I think a big challenge that is sometimes to find the user we receive the process and have to organize and within our working hours, schedule that has car, and such sometimes with other services together is a whole joint to go until the residence and sometimes this user is not [...] (T02). They went to the address provided by the young man’s grandmother an itinerant team professional and a CAPS Infantojuvenil professional, but they did not find the house, got out of the car and walked down the street asking the locals, but no one knew the boy or his mother (DC).

Because of this nature "outside the walls", which confers interesting contours related to the autonomy of doing, the team also faces the peculiarities that exist in each territory in which it operates. In this case, what corresponds to a difficulty for them, not to find the user at home, it is understood that this is related to the functioning of the people in their living space, where they organize their schedules and establish their priorities. This characteristic is a great challenge for the work in mental health, because it is the recognition of this territory as something "dynamic" that runs away from the aseptic lines of the services and their institutionalized modes of organization⁽¹³⁾.

Thus, in any home visit, it is possible to not find the person in the residence, it is necessary to reinvent other ways of meeting such as, for example, in a soccer field, school, a friend’s house, and roaming is to constitute greater traffic in these user circulation locations.

However, when talking about drug users, other elements are incorporated into this process. Some studies have already been discussing that the operation of drug users and their families is affected by situations such as aggression, violence, the issue of trafficking and social rejection of the user, placing him at the margins of society^(11,14-16).  Another difficulty is the question of violence of aggression that is sometimes difficult to deal with the family, the issue of territory that involves trafficking [...] The police that perform a super complicated performance and hence generate fear, generate anger and revolt and sometimes even because of lack of knowledge the users relate a lot of police to the public power, then there is a rejection of any service ... and they suffer violence, they are much more marginalized, they are excluded, they go through all the questions of moralism [...].(T02).

In studies with crack users, it has been demonstrated that family relationships are fragile and conflict-ridden, since the drug mainly acts, in the rupture of affective bonds between family members. The use of drugs such as crack produces higher levels of conflict than other drugs, which may be related to the changes that the substance causes in the body of the person ^(11,14).

The way of care proposed by public policies is what enables this meeting between health professionals and families, in their life context, revealing the complexity of the relationships, life histories and the mental suffering of the user and the family. This new way of acting demands new ways of taking care of, dealing with the unforeseen, of rebuilding in front of the need of each person and, therefore, is challenging and demands more of mental health workers.

Another challenge faced by drug users is their relationship with society. The drug user is, constantly, affected by the stigmatization process that generates social restraint, low self-esteem and limited prospects of recovery that negatively interfere, with treatment. Media action, that transmits misinformation, coupled with the lack of clarification about psychic suffering, generates a perception of the drug user as being unable to recover and many are viewed as feared. In this way, they suffer from prejudice and criminalization, with distrust and stereotypes⁽¹⁷⁾.

In this same strand, it is emphasized that the media, through television, mainly, relates symbolic modes on the use of drugs, producing an individualization effect that produces and / or maintains a social imaginary of the user of drugs as ill or delinquent. In both cases, the destination of the drug user is punishment, sometimes through hospitalization, sometimes through imprisonment⁽¹⁸⁾.

Thus, leaving the walls of the CAPS and meeting the unknown represents a valuable mental health care tool that enables new forms of attention to drug users. The family conflicts experienced due to the use of drugs cause the worker to encounter one of the reasons that lead them to seek hospitalization as a refuge. The T03 fragment highlights this issue: [...] the family asks for a lot of the direct hospitalization so I think that it has a general way in society so a fantasy that you interning the person you will take it there with your hand ... of course the family is already tired and already can not take it many more times ... It often happens that there is an imminent risk to the family and that is what you have to be able to evaluate [...] you can put to that family that maybe the expectation that it has will not be exactly met, that this is also part of mental health care [...] (T03).

The team has the challenge of deconstructing with the family the social imaginary that the hospitalization will solve the health demands of its relative. And, in addition, to build with the family the means of caring for oneself and the user, because there is a family overload that also needs to be taken care of by the health teams.

The concern with the use of hospitalization is due to the historical fact of being used as a tool of social isolation, mistreatment and punishment. That is, hospitalization was used secularly as the main option; however, it was an isolation device, with no other modes of care at liberty. Currently, hospitalization is a technology of care, among other therapeutic modalities that should be used when there is a need for this intervention, ensuring access to psychiatric beds in general hospitals and monitoring of the case by the teams in the territory.

Study of the evaluation of the insertion of people with intellectual disabilities in the Psychosocial Care Network identified itineraries marked by institutionalization, with an important access barrier in the CAPS and the use of hospitalization as the first option⁽⁹⁾. Thus, it is necessary to reassess the way hospitalizations are being used and to propose methods that value the use of substitutive mental health services such as the follow-up of the youth in CAPS, and in other care network services.

Another challenge of the work of the Itinerant Team is in the resignification of the worker’s gaze, which, often, perpetuates the moralizing and exclusionary view of the society that belongs to. [...] we manage to schedule meetings with the extended network, thus getting in touch with the other services, with the other devices, but it is always very difficult to do so, especially when it involves the use of drugs and much, perhaps, also for this, for this imaginary social relation to drug use you know and even with professionals and colleagues from other sectors you find a certain prejudice (T03).

In this logic, the professionals who make up the care services are also influenced by the existing moralism in society. The Itinerant Team should continue to weave the nets of care, and, in these, they should promote dialogues that deconstruct demeaning and stigmatizing social imaginaries towards the drug users. 

It is necessary that health professionals identify their own prejudices regarding drug use and all the issues that exist in this phenomenon of use. Non-reflexive attitude and a biased look generate great suffering, especially, to the user, who already faces the physical, psychological and social problems related to drug use⁽¹⁶⁾.

The municipality can invest in permanent education programs that include the theme of "drugs" in their agendas, with a view to deconstructing stigmas, reducing prejudice and reorienting services to address the complex problems generated by drug abuse. It can help with more closeness, of families and users, services and professionals, recognizing them as partners and co-responsible for their treatment.

In this way, the innovations that permeate the Work of the Itinerant Team also coexist daily, with the challenges imposed by a way of working closer to people than to services. This dialectic of caring, which is not regular, is typical of the psychosocial way, as a possibility capable of bringing originality and more diversity to the practice of mental health, although also, new challenges for the process.

 

Conclusion

Regarding the potential of the work of the Itinerant Mental Health Team, the creation of the service itself was highlighted, to work with the judicial sector and to reduce the judicialization of health. In addition, autonomy to carry out the activities, designing new forms of care, and the fact of having a vehicle to favor and expedite the fulfillment of service tasks. Other potential of the service were the advances in the construction of bridges of dialogues and shared care with CAPS AD and basic care. Therefore, the potential of the team implies, beyond its most resolute and therapeutic proposal, the way in which the workers organize themselves for it, reaffirming the innovation and the possibility of a different doing, provided by itinerant care in the territory.

Regarding the challenges of the Itinerant Mental Health Team, the participants brought the peculiar situations of the work in the territory, such as not finding the user in their residence, managing the conflicts between the user and the family, and the issues of violence, trafficking and the prejudice of society with the user of drugs. In addition to these hindrances, it is a challenge to deconstruct, with the family, that hospitalization is only one of the therapeutic modalities of a broad menu of options that may or may not meet the needs of users and networking.

Finally, it is hoped that the study will provide new insights into the care of drug users and the judicialization of mental health. And that the potential and challenges of this itinerant team, as innovative processes in the health area, can contribute to the creation of new care devices.

 

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Received: Apr 19^th 2017
Accepted: Oct 5^th 2018

Corresponding author:
E-mail: adrianeeslabao@hotmail.com
 https://orcid.org/0000-0003-1262-6521

 

 

* Paper extracted from master’s thesis "The care for the drug user:an analysis of the technologies present in the daily life in the work of an itinerant team", presented to Escola de Enfermagem, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.