ORIGINAL ARTICLE

 

Assistance of health professionals to children and adolescents in situations of violence^*

 

 

Rodrigo Jácob Moreira de Freitas^I,II; Natana Abreu de Moura^I,III; Rúbia Mara Maia Feitosa^I,IV; Deivson Wendell da Costa Lima^V,VI; Livia Dayane Sousa Azevedo^VII; Ana Ruth Macêdo Monteiro^I,III

^IUniversidade Estadual do Ceará, Fortaleza, CE, Brazil
^IIUniversidade do Estado do Rio Grande do Norte, Faculdade de Enfermagem, Pau dos Ferros, RN, Brazil
^IIIUniversidade Estadual do Ceará, Faculdade de Enfermagem, Fortaleza, CE, Brazil
^IVUniversidade Potiguar, Departamento de Enfermagem, Mossoró, RN, Brazil
^VUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Centro Colaborador da PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^VIUniversidade do Estado do Rio Grande do Norte, Faculdade de Enfermagem, Mossoró, RN, Brazil
^VIIUniversidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil

Corresponding author

 

 

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ABSTRACT

OBJECTIVE: to understand the assistance provided by health professionals to children and adolescents who experience situations of violence.
METHOD: phenomenological research through semistructured interviews applied in September to December 2015 with nine health professionals from the Child and Adolescent Psychosocial Care Center of the capital of Ceará, Brazil. The transcribed speeches were categorized and analyzed according to Alfred Schütz's theoretical framework of social phenomenology.
RESULTS: the interviewees carried out individual consultations and group activities to explore the feelings, conflicts, perceptions of the victims, in addition they assisted the family and developed actions with professionals of other services in search of resolutions of the social questions of the cases of violence.
CONCLUSION: health professionals need to know the motivations and meanings they attribute to their experiences with victims of violence to support new actions in health services.

Descriptors: Delivery of Health Care; Health Personnel; Violence; Mental Health; Child Health; Adolescent Health.

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Introduction

Violence is considered a public health problem with a broad social dimension, since it has a strong impact on the morbidity and mortality of populations and increases the need for health care for victims. When violence is directed against children and adolescents suffering from psychic suffering, it has repercussions on physical, sexual and emotional trauma that, although not always fatal, are significant potential for suffering, not only at the moment of violence, but during all their life^(1-2).

Psychic suffering includes everything that affects the order of the subject, a set of malaise and difficulties to live with the contradictory multiplicity of meanings of life related to the difficulties of operating plans define the meaning of life or, also, related to the feeling of powerlessness and emptiness⁽³⁾. In this work, the concept will often be used as a synonym for disorder, illness and mental problem.

In this context, health professionals working in the health care network, in addition to caring for people with mental disorders, need to be alert to situations of violence harmful to children and adolescents, identifying the protective factors of violence and promoting interdisciplinary assistance inter-sectoral approach to the victims. Therefore, these victims of violence need to be accepted without prejudice by professionals in the mental health services, being seen as people with unique conditions, and not only reduced to their diagnosis and excessive medicalization⁽⁴⁾.

Assistance to children and adolescents in situations of violence must have broad, comprehensive and network coverage, establishing strategies that take into account the problems of the territory and the situations of violence experienced and their vulnerabilities.

This study aims to contribute to the production of knowledge in the area of mental health and violence, since, in the literature; most research^(5-10) emphasizes the consequences of violence in the lives of these people, without addressing the assistance made by health professionals to the violence of children and adolescents who already present some psychological suffering.

In view of this problem, the objective is to understand the assistance provided by health professionals to children and adolescents who experience situations of violence.

Theoretical-methodological reference

This study is based on the theoretical reference of Alfred Schütz's Social Phenomenology, which is concerned with subjective human experiences, in order to answer the question: "What did he mean by this action in the world of life?" Thus, it allows the researcher to approach the significant experiences of the person⁽¹¹⁾.

According to the adopted frame of reference, all action is a human conduct conceived by the actor, based on a preconceived project, and this action contains meaning and can be understood as meaningful when one has a direction and when it is directed to others it becomes social. Thus, one can perceive the behavior of professionals as social actions in the world of life⁽¹¹⁾.

These actions are intentional and motivated by the interests of professionals. When the motive is the objective that one intends to attain with the action, it is reflected in a projected act, and the lived situation is previously imagined, producing a future action, which is constituted in the "motivation with-purpose-of"⁽¹¹⁾.

The "motivation because" refers to past experiences, which lead the person to act as he or she acted, the project being the action itself. These motivations are closely related to the biographical situation of the person and their stock of knowledge at hand, which refers to the actions already performed by the professionals, allowing them to reflect on their own experience^(11-12).

The encounter between the researcher and the professional during the interview allows us to establish face-to-face relationships and favors the real simultaneity of two distinct streams of consciousness, and only then can we perceive the other and know them, capturing his subjectively significant action in the world of life^(11-12).

Thus, the meeting of the interview requires the researcher to position him or herself to be decentralized to intentionally target the researcher's understanding. This position is called phenomenological attitude. The use of epoché, as an attitude of phenomenological reduction of doubt, is fundamental to reach or approach the essence of the experienced phenomenon⁽¹¹⁾.

 

Method

This is a phenomenological research developed at the Child and Adolescent Psychosocial Care Center (CAPSi), from September to December 2015. The research site was chosen for being a pioneer in the public service specialized in assisting the child and adolescent in psychological distress in the capital of Ceará, Brazil. In addition, this research site has relevance for the contribution in the health training process of university students.

Initially, 14 professionals were invited, but two refused to participate in the survey and three did not attend on the days and times scheduled, totaling nine participants. The study sample was for accessibility.

The inclusion criteria for participation in the research were: being a higher-level health professional with six months or more of time in the CAPSi and having performed some care for children and/or adolescents in situations of violence. Those who were away from work due to vacation, health leave or maternity leave were excluded.

The data collection was done through the semi-structured interview that had the following guiding question: how do you provide assistance to children and adolescents in situations of violence?

During the data collection phase, in accordance with the methodological theoretical framework adopted, the data analysis stages were carried out simultaneously⁽¹¹⁾.

After the organization of the material collected, the notes of the rapporteurs and transcription of the speeches, the text of the interviews transcribed individually, in a thorough way, in order to appropriate the material researched. The material was related to the guiding question of the interview and the lines were separated into coding units, that is, the most representative sections, which reveal the most significant results pointed out by the interviewees. Then, after the individual coding of the interviews, the meanings seized from their similarities were organized and grouped, consequently defining the categories⁽¹³⁾.

The evidenced categories were described and discussed, which favored a better understanding about the phenomenon under study. Thus, the discourses were interpreted to arrive at the meaning of the action of the people that were analyzed, using the reference of Alfred Schütz's Social Phenomenology, articulating them with its main concepts⁽¹¹⁾.

The research was submitted to the evaluation and was approved by the Research and Ethics Committee with the opinion 696.813, under CAAE 27056814.0.0000.5534. The combination letter and number, for example, "E1, E2 ..." was designated to preserve the anonymity of the research participants.

 

Results

The participants were female, with a predominant age range of 25 to 30 years, with a mean age of 35 years. They had been working at CAPSi for more than a year, since the last selection that occurred in the municipality. The health professionals were: four psychologists; two occupational therapists; a nurse; a speech therapist and a social worker. Of these, only one professional was attending postgraduate, masters level, and the others had specialization, but not in the area of mental health. None of them carried out courses that dealt with violence.

The assistance of health professionals to children and adolescents in situations of violence were divided into three categories: individual consultations and group activities with victims of violence; assistance to the family of children and adolescents in situations of violence; actions with professionals from other health services and social support network.

Individual consultations and group activities with victims of violence

The professionals pointed out "motivations because" in individual consultations and in group activities, in coping with conflicts and frustrations related to violence with children and adolescents, thought as "purpose-of-purpose" to avoid violent behaviors. For the CAPSi professional, it is important that he not only focus on the mental problem, but on the issues inherent in being a child and adolescent.

We seek to work on issues of being a child or adolescent and not just about illness and violence, this is also important. (E1); They speak, in the consultations, of the difficulty of adapting to the school, of having social relations. Our job is not to look like the patient, but to enable him to adapt well to this context. (E4); In group activity with children, we work hard on this issue of the child being frustrated, from the conflicts. She has a chance to talk about the conflict, and we support her at the moment. (E9)

Child and/or adolescent care, whether individually or as a group, concern the work of personality and socialization issues, helping to overcome conflicts in the daily life of these individuals. In this way, professionals will be promoting actions for CAPSi people who have experienced physical, sexual, psychological violence, as well as situations of social exclusion related to the stigma of mental illness that have occurred at home, in the school or in the community itself, not only focusing on the diagnosis of mental health, but also, preventing situations that, instead of being resolved with violence, can be resolved through dialogue and bond building.

It is worth mentioning that the unit did not have specific groups to work on issues of violence experienced by these subjects. Assistance happens in a timely manner as cases are identified.

Assistance to the family of children and adolescents in situations of violence

In this category, the "motivations because" of the care provided by CAPSi health professionals were the visits to the families of children and adolescents in situations of violence. The "motivations with-purpose-of" were for relatives, especially mothers, to vent their anxieties.

Family groups are geared towards this family support that often these people arrive here very lost, very confused, not only with regard to the disease, but how to deal with those children in suffering due to violence. (E1); We realize that this is not only a problem for the child or for the adolescent, but also for the family. The family is going to take care of this child. We always emphasize this in family groups, in groups of mothers; we give the space for them to put the situations they are living. (E2); The group is a welcoming space so they can share their experiences, tell each other, and learn how to deal better with the situation, but also to forget, at the same time, the child's illness and think a little about them too. (E6)

The group activity with families made it possible to confront their problems and to reflect on their postures towards the child and the adolescent, since the relationship between mother and child was weakened by the difficulty of the members in dealing with the mental problem. With this type of relationship, the family does not care for the person in psychological distress, becoming a situation of violence experienced by them. This violence is sometimes expressed by the lack of patience with the child, seeking, in violence, a way of dealing with the situation.

Actions with professionals from the health care and social support networks

The "motivations because" because of coping cited in this category include network care, articulated with professionals from other health services and the social support network, and "motivations with-purpose-of" aim at comprehensive care, articulating no only the mental and the child victim of the various types of violence, but also the physical, social and family.

It's networking that we do. Not only the individual care and the group, but also that this child has the support in CRAS [Center of Reference of Social Assistance], CREAS [Center of Specialized Reference of Social Assistance], in other instances and also in other institutions that we can be partnering. (E3); I, at least, cannot disconnect the mental from the physical, I see other issues, like the social. If the adolescent already has an ability to develop a task that provides a chance in the job market, we seek this strategy, to look at it as a whole. (E8).

CAPSi health professionals are committed to looking at the whole person, building strategies together with the different professionals who work in this context. Although there is this need and the importance of networking is recognized, interviewees point to many difficulties for it to work, as expressed in the speeches.

I heard from a CREAS professional: "Sometimes, a case involving mental health does not know what to do." (E5); It is as if the patient who has a mental disorder is only the disorder or only a victim of violence. It is not considered a person who accesses the health network for other intercurrences than the psychiatric one. It is as if it were restricted; there it is CAPSi; the CAPSi has to solve, and it is not; is a citizen, he has a life that involves the other dimensions. (E5)

This articulation with other professionals has some obstacles. Most other professionals, they also have this difficulty. Material is scarce and they have little motivation. I think sometimes we lack motivation in people too. (E7)

Besides the structural difficulties, the lack of knowledge of the other sectors was pointed out when a person is involved in violence in a psychological suffering. This limited view about the individual restricts the health care network's performance and overloads the CAPSi.

 

Discussion

Mental health policies govern the assistance of professionals to people in psychological distress, among them, children and adolescents, including those in situations of violence. This assistance, through individual consultations and group activities, assumes a social function, which has to go beyond doing the merely technical, including the reception and listening in order to "give voice" to the people involved in the violence⁽¹⁴⁾.

By "giving voice" to the people involved in violence, it is possible to contribute to the implementation of effective actions in face of this phenomenon, since it affects the greater participation of the person in suffering in the treatment, stigma facing and improvement of the quality of life. By talking about themselves and identifying themselves with their own stories, children and adolescents see possibilities for finding new meanings and new ways of insertion in society and in the family⁽¹⁴⁾.

Listening is a therapeutic instrument used in individual consultation and group activities, which guides the You in the face-to-face relationship and thus effectively the relationship of the Us in a movement of motivational reciprocity. This reciprocal relationship generates a series of changes in the subjective meanings constructed in the intersubjective world⁽¹¹⁾.

The face-to-face relationship is the orientation to the You, when another person is within reach of the direct experience of another person, sharing a time and a space in common. By being present in person, the person is aware of the other person as himself, flowing their experience side by side and participating in the relationship of the intentionally conscious Us that have taken an orientation towards the You⁽¹¹⁾.

In this scenario, the performance of the health professionals in the groups is fundamental for the conviviality with the diversity of people who share similar experiences. Thus, group activities, if well thought out, in their purpose, structure and clinical management, allow a powerful and rich exchange of experiences and subjective transformations that would not be achievable in a single individualized service. This is due precisely to the diversity of knowledge and the plurality of its members⁽¹⁵⁾.

It is in interaction with others in group activities that self recognizes the existence of another similar self, both having a similar consciousness, in which this self realizes that both are part of an outer world, the world of life, recognizing itself as a social being, because he experiences this world with other similar beings. This interaction is considered in group activities as an intermediary of the relation person and society in which the person happens to recognize themselves as participant, producer and produced by these relations with the collective⁽¹¹⁾.

Institutional support to victims of violence and their families, integrating the family group with therapeutic follow-up practices, has also been pointed out as a pertinent perspective in the health care of these people⁽¹⁶⁾.

The family is characterized as an existential group that shares with the individual its system of typifications and relevance. It is a basic model of socialization that establishes a network of relations with rules, customs, values and beliefs. Changes in the family structure may be directly related to society⁽¹¹⁾.

Family disintegration contributes to the aggravation of the suffering of children and adolescents. This suffering of the family reflects on the behavior of the child and the adolescent, which needs to be worked through the construction of a bond with the institution, because it is in her that the family seeks the support to take care of their families in treatment. It is taking care of the family that the CAPSi health professional will be taking care of the person in psychological suffering.

The sharing of experiences among family members in group activities, organized in the form of a support web, is possible through a good relationship with health professionals, which creates a support of difficulties and an arsenal of facilities, with the perception of alternatives of clinical management and self-recognition in the other⁽¹¹⁾.

Rarely, professionals direct assistance to the families of suffering children and adolescents in the CAPSi. In general, the focus is on the individual being treated and /or individual members, for example, the mothers, thus fragmenting the family support actions. The existence of assistance to all relatives helps in the perception about the psychological suffering of children and adolescents in situations of violence and, therefore, in the search for resolution based on resources available by the family itself^(16-17).

Schütz's phenomenology can contribute to the professional having an attitude of phenomenological reduction (epoché), describing the world as presented in consciousness, moving towards the essence of the phenomenon. The understanding of this concept is fundamental to a professional action without judgments and discrimination with families, children and adolescents in psychological distress⁽¹¹⁾.

Another highlight was the actions of the CAPSi professionals with professionals from the network of health care and social support in cases of violence. The actions in the network power a more comprehensive and multidisciplinary action of a set of actors from several institutions. The integration of the institutions involved in the problem of violence allows sharing of knowledge and experiences, broadening information and resolutions⁽¹⁸⁾.

Contact with other peers is necessary and it means experiencing interactive engagements with many people in complex networks of social relationships. From intersubjective encounters there is the intrinsic construction of the biographical situation of each one, of what one is today, was yesterday and tomorrow, as well as references to social action⁽¹¹⁾.

Knowing the network of health care and available social support can contribute to the care of the family and children and adolescents, as it is possible to expand strategies to relieve tensions and share responsibilities⁽¹⁰⁾.

The assistance of the network professionals means sharing responsibilities, promoting the follow-up of the case until its inclusion and its attendance in another service, very different from an administrative and bureaucratic procedure of filling only one referral guide for another service⁽⁶⁾.

The network professionals' assistance is also understood as a political articulation between peers that, in order to establish itself, demands: to recognize that the other exists; know what the other does; collaborate, provide help when needed; cooperate, share knowledge, actions and powers and associate, share goals and projects. These preliminary conditions result, respectively, in autonomy, will, dynamism, multi-leadership, information and multiple levels of operationalization⁽¹⁹⁾.

The report of the lack of communication between these network institutions, in the study presented here, represents a denunciation by the professionals. It is necessary to be clear that an effective network does not represent a set of institutions and professionals acting in isolation, but rather institutions and professionals that recognize themselves, being aware of the purpose and the role of each institution, so that the work horizontal and decentralized, in order to improve the quality of information and follow-ups.

 

Conclusion

This study points out the need for the health professional to be aware of his motivations and the meanings he attributes to his experiences in assisting children and adolescents in situations of violence.

Assistance to the child and adolescent in a situation of violence permeates the subjectivity of the professional and how the phenomenon of violence is signified by them. In the speeches of the research people, the ways of coping with this issue are recognized through the importance given to group work, care beyond mental illness, family support, networking, but there is also a lack of specific and specific institutional arrangements to better guide professional action in the face of cases of violence affecting the patients of the service.

This study made it possible for health professionals to reflect on their assistance to children and adolescents in situations of violence who are often unable to visualize their "reasons why" during their work in the workplace. Only when the assistance was questioned to the professional did it become an act, since it rescued the actions already carried out, as an observer of it, and evaluated what circumstances were determined for him to do what he did, with a view to modifying their future action. An attitude in epoché can help the professional, freeing him from judgments and preconceptions about children and adolescents and their families in situations of violence.

As a limitation of the research, it has been the fact that the collection was performed in a single mental health service and, in this sense, it is recommended that more research in this perspective be performed due to the scarcity of published articles and, more than that: that these researches can serve as "motivations with-purpose-of" motivations, underpinning management actions and translating effectively into actions in health services and social support, contributing to the confrontation of violence.

 

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Corresponding author:
Rodrigo Jácob Moreira de Freitas
E-mail: rojmflegal@hotmail.com

Received: Jan 25^th 2019
Accepted: May 24^th 2019

 

 

Authors' Contribution: Research conception and design: Rodrigo Jácob Moreira de Freitas, Rubia Mara Maia Feitosa, Ana Ruth Macêdo Monteiro. Data collection: Rodrigo Jácob Moreira de Freitas, Natana Abreu de Moura, Rubia Mara Maia Feitosa. Data analysis and interpretation: Rodrigo Jácob Moreira de Freitas, Rubia Mara Maia Feitosa. Manuscript writing: Rodrigo Jácob Moreira de Freitas, Natana Abreu de Moura, Rubia Mara Maia Feitosa, Deivson Wendell da Costa Lima, Lívia Dayane Sousa Azevedo. Critical revision of the manuscript: Rodrigo Jácob Moreira de Freitas, Rubia Mara Maia Feitosa, Deivson Wendell da Costa Lima, Lívia Dayane Sousa Azevedo, Ana Ruth Macêdo Monteiro.
All authors approved the final version of the text.
Conflict of interest: The authors have stated that there are no conflicts of interest.
* Paper extracted from master's thesis "Práticas violentas vivenciadas por crianças e adolescentes em sofrimento psíquico: significados atribuídos pelos profissionais de saúde", presented to Universidade Estadual do Ceará, Fortaleza, CE, Brazil.