The objective of this paper was to describe and analyze the context of trajectories of workers of Psychosocial Care Centers for Children and Adolescents (CAPSis) with the insertion, practice and motivation of workers in this fieldwork. Comparing the context of trajectories of employees according to the managerial nature: Social Health Organization (OSS) and city hall. Narratives-interviews were conducted with 8 workers from 2 Psychosocial Care Centers for Children and Adolescents (one managed by the City and other by Social Health Organizations), São Paulo City, Brazil. The narratives interviews were transcribed and analyzed from Shutze method. The Theoretical Framework was built from different authors and Psychiatric Reform principles. There are important differences between workers of 2 Psychosocial Care Centers for Children and Adolescents regarding professional profile, motivations, type of training and meanings attributed to work. The current trend in the field goes in opposite direction to the proposals of the Psychiatric Reform, lack of opportunities for discussion and empowerment work team of labor, which should be offered by institutions, makes both groups of professionals feel lost and alone.
Mental health; Mental health services; Child and adolescent
The children and adolescents’ mental health, object of interest subsequent to the one awakened by adults’ mental health, was market for the linking to the educational field and for the inherent asymmetry that govern the relations between adults and children.
The concept of childhood appeared after the French revolution and the teenage one after the First World War, so, before it, there were no worries with mental health of children and adolescents that were seen as miniature adults. In Brazil, following a worldwide trend, during many years the mental health of children and adolescents was seen as less important than the mental health of adults and that why it received less investment.
According to Àries11. Ariès P. História Social da Criança e da Família. 2ª ed. Rio de Janeiro: Guanabara Koogan; 1981. and Reis et al.22. Reis AOA, Delfini PSS, Dombi-Barbosa C, Bertolino Neto MM. Breve história da saúde mental infantojuvenil. In: Lauridsen-Ribeiro E, Tanaka OY, organizadores. Atenção em saúde mental para crianças e adolescentes no SUS. São Paulo: Editora Hucitec; 2010. p.109-130. this discrepancy in time corresponds to the place allocated secondary to childhood in western society. The late notions of childhood and teenager in western intellectual universe indicates the unconcern to their mental health. So it is justified the interest and the relevance for us to strive in this study focused in professionals that work with children and adolescents in psychic suffering.
With the awakening of worries for the well of this population, the welcome of these children and adolescents was given, first, in the context of religious institutions by means of charitable and philanthropic treatment offers. After, with the sedimentation of the process of Psychiatric Reform that proposes the Psychosocial Modes of care for mental health, coupled with legal advances of Children and Adolescents’ Statute (ECA-1990), there were significant changes regarding the children population, positioning its members as subjects of rights. The public policy turned to their care focused in the mental health area making substantial changes, starting to define and institute specific devices involving need of differentiated professionals. It is started to require from professionals the subjective involvement with kids and adolescents, just as with their families and relationship network. Thus, the subjective of professionals starts to be a part of the children and teenagers’ mental health treatment, challenging proposal that takes great attention of adults.
Costa-Rosa33. Costa-Rosa A, Luzio CA, Yasui S. Atenção Psicossocial: rumo a um novo paradigma na Saúde Mental Coletiva. In: Amarante P, organizadores.Archivos de Saúde Mental e Atenção Psicossocial. 2ª ed. Rio de Janeiro: Editora Fiocruz; 2003. p. 13-44. indicates that the Psychosocial Mode of mental health care, that involves just children and adolescents as adults, was proposed as perspective of comprehension and actions of processes and phenomena that take place in the mental health field as a counterpoint to the Asylum Mode and to knowledges considered assimilated to it. The Psychosocial Mode intends stablish itself as a new paradigm seated on some basic parameters related to inter-relations of involved authors: a horizontal conception of interinstitutional relations, with costumers and the general population, in a way that there is an interlocution and no more asymmetry between sane and insane; the free traffic or there is not closing; territorialized and integral care; and finally that the actions defaults in therapeutic terms respond to ethic, searching for singling and not adaptation.
Therefore, it is evident a new professional demand to realize the mental health work in the midst of a new paradigm elapsing then the challenge of qualify professionals to deal with the specific operation of subjects with severe psychic troubles in public and collective environment. To Amarante44. Amarante P. Asilos, alienados e alienistas: uma pequena história da psiquiatria no Brasil. In: Amarante P. Psiquiatria social e Reforma Psiquiátrica. Rio de Janeiro: Editora Fiocruz; 1994. p. 73-84. among the most important consequences of changings that mental health been through is the new generation of technicians and users that have the possibility of creating and inventing new ways of assistance in public mental health services. Thus, Marazina55. Marazina IV. Trabalhador de Saúde Mental. Encruzilhada da loucura. Saúdeloucura 1. São Paulo: Hucitec; 1989. indicates that several professionals of mental health services do not have specific graduation.
In this context, Rotelli66. Rotelli F. Entrevista com Franco Rotelli. In: Delgado J, organizador e tradutor. A loucura na sala de jantar. São Paulo: Resenha; 1990. p. 81-95. adds that the possibility of new generations of mental health professionals to understand the psychosocial proposal of observe the phenomenon of madness depends a lot of general social processes. For the author, hardly the technicians can be agent of innovation and changing in absence of important social, cultural and political movements. Thus, it highlights the relevance for us to consider the context that professionals build their trajectories, for us understand better how the process of insertion, practice and motivation happens in this field.
In this way, the magnitude of the paper of professionals for the directions taken through the years justifies our interest to investigate. We restricted to children and adolescents’ mental health field, considering the discrepancy in this field when compared to the investment made in adults’ mental health, besides radical asymmetry that brand the relationship of the adult professional with users, which subjectivities are still in building process, just as well as the historical depreciation of professionals turned to work with children and teenagers in psychic suffering, that extended till nowadays.
From the larger study77. Muylaert CJ. Formação, Vida Profissional e Subjetividade: narrativas de trabalhadores de Centro de Atenção Psicossocial Infantojuvenil [dissertação]. Faculdade de Saúde Pública da USP; 2013., this study sought describe and analyze the relation between the context of trajectories of workers from Psychosocial Care Centers for Children and Adolescents-(CAPSis) and the process of insertion, practice and motivation of workers in this field. Moreover, it was compared the context of trajectory of professionals of each intitutions investigated, according to the managerial nature: Social Organization of Health (OSS) and city hall.
Narrative/observational search, exploratory, of qualitative nature having as focus the professional narratives of CAPSi managed by the City and the Social Organization of Health (OSS) respectively. For obtaining the pertinent data to study it was used a tool nominated “narrative interview” which consist in initial preparation of a “asks triggering “directed to the subject from the one you hope to obtain the beginning of the speak which flow is held by the relaunch of new questions elaborated in live and extracted of the interviewed’ speak when he notes extended break. The interview ends satisfactorily when the speak becomes redundant according to criterion of saturation. The interviews were recorded in electronic means (portable recorders) and, after, transcribed in its entirety.
For systematization and organization of data it was used the proposal of Shutze88. Jovchelovich S, Bauer MW. Entrevista Narrativa. In: Bauer MW, Gaskell G, organizadores. Pesquisa qualitativa com texto, imagem e som: um manual prático. Petrópolis: Vozes; 2002. p. 90-113.: Full transcription of interviews, and this transcription must involve paralinguistic characteristics – voice of the interviewed, breaks, intonation changes, silent and expressions, so the narratives not heard , that are fundamental in the analysis process which operates not only what is said, but how it is spoken.
- Text division in material: indexed that corresponds to the rational, scientific, concrete content, in other words, who do what, when, where and why, so, it is the content ordered and, consequently, is of collective order. And unindexed material, that goes beyond events and express values, judgements, refers to the life wisdom and, therefore, it is subjective or individual.
- Using the indexed content (collective), ordering up events for each person, which is nominated individual trajectories.
- Group up and compares the individual trajectories.
- The last step is compare and stablish similarities between individual cases allowing the identification of collective trajectories.
To analyze the material the text is gradually reduced, operating with direction condensation and generalization. The content is divided in three columns, in first stays transcription, in second there is the first reduction and in third only key words. So, categories are developed, first for each of the narrative interviews, after they are ordered in a coherent system for all interviews realized in the research, forming nucleus of meaning, being the final product the joint interpretation of relevant aspects of both informants and researcher.
For the establishment of categories and consequent categorizations it was used both procedure of coding based on data and coding based on concepts, so, the previous Reading of available literature that focuses on the theme as well as the focus of research interest provided the previous definition of a few categories, on the other hand, with the obtained material in field it is possible to build new categories. In the present study the nucleus and explored categories are in accordance with Chart 1.
Nucleus and categories of analyze from the narrative interviews realized.
The study universe had 8 workers, from different professional categories (doctor, psychologist, occupational therapist, nurse and nursing assistant) of both sex, crowded in 2 CAPSis in city of São Paulo, Brazil, where there are 62 of 132 CAPSis existing in Brazil (47%). The choice criteria of unities was the insertion of these institutions in the process of Psychiatric Reform, determinate both by its historical position and by its proximity to the emanated principles from the Mode of Psychosocial Care. So we seek one CAPSis managed directly by the City and one managed by OSS. Despite the legal difference of employment contracts existing between professionals of the two CAPSis (City hall and OSS), it is taken that both are turned to attendance of similar public and their activities guided by principles that govern the public policy ordering activities of equipment of collective mental health. In choice of professionals there was the care of contemplate the biggest diversity of professional categories, ignoring different epistemological perspectives adopted.
The discussion of trajectories according to managerial nature of CAPSis did not constitute object of initial interest, however, in the course of obtaining data and its analysis were being evident strong indications concerning to existence of important differences related to motivations to work, to trajectories and formation according to the subjects interviewed belonging to CAPSi managed by City oR by OSS. However, not to abandon our original idea and, still, in function of an emerging situation of the investigative process, we considered that would be more suitable and real organize data and proceed the analysis having as perspective the comparison of two blocks, to know, trajectories of professionals workers from CAPSi of City and OSS.
The research was approved by Ethics Committee of the Public Health School o São Paulo, USP, had the confidence and the voluntary participation of subjects guaranteed by TCLE.
Analysis and discussion
1; The context of trajectories of workers from Children and Adolescents’ Psychosocial Attention Centers: City Hall and Social Organization of Health
The choice and the sense of work for professionals from CAPSis through the children and adolescents’ mental health field are marked by the context in which it was formed. The professionals from OSS, younger (from 29 to 32 years old) than professionals from the City (from 41 to 49 years old), were inserted in the labor market around year 2000, moment that work relations were strongly marked by competitiveness and individualism appreciation, while workers from CAPSi from City made their professional choices and provided competition around year 1980, beginning of process of implementation of Health Unic System, time that public service was more appreciated:
The area of public service is very bad, it became, but when I got in everybody wanted it [...] it was a nice career[...] We do not have competition in a very long time and when there is the vacancies are not filled, exactly because there is not a better career and there is no competitive salary[...] And things got worst a lot, there is this outsourcing of health, of health field and we do not realize that job rotation in these unities that are with management of social organizations is worst, they change every year, all the team gets out and there is no bond even with us. subject 6
I think we live in a hard moment of divestment of public administration, of a political, ideological commitment and commitment with job and I think that by one side we are a few favorable job conditions, mas I think that nowadays there is an entire movement to not invest in rights, and outsourcing, not investing founds and not giving necessary subsidies, by consequence, you will dismantling services[...] comparing to other moments I realize the difference. subject 8
These reports of professionals illustrate their dissatisfaction with outsourcing in health area, according to Bresser Pereira99. Bresser Pereira LC. A Reforma do Estado dos anos 90: Lógica e Mecanismos de Controle. Cadernos MERE da Reforma do Estado. Brasília: Ministério da Administração Federal e Reforma do Estado; 1997. Caderno 1. this process began around 80’s, when, as a result of changes in world economy, the State got in tax crisis, lost public credit and decreased the capacity to generate savings. Consequently, the intervention capacity decreased drastically. So, there was a decreasing in the paper and “size’ of State that generated changings in the value given, respectively, to instances of public and private in society and, because of changings, there was a new configuration in job world.
This context of macro economic affected the mental health professionals, once that the job Market began to be marked by a Strong competitive component and the services were gradually suffering a process of precariousness. In this sense, to Bahia1010. Bahia L. A Démarche do Privado e Público no Sistema de Atenção à Saúde no Brasil em Tempos de Democracia e Ajuste Fiscal, 1988-2008. In: Lima JCF, Matta GC, organizadores. Estado, Sociedade e Formação Profissional em Saúde. Rio de Janeiro: Editora Fiocruz; 2008. p. 123-185. the care network of SUS is composed of public and private establishments and outsourcing services and there is a trends of professionals that graduate (graduation, improvement, MBA) in health public system to migrate to private system, like if it was a manner of professional ascent. Thus, the period that professionals from OSS spend in public sector seems to be related to formation for work, different of professionals from the City that got prepare before to realize the work in CAPSis.
This reflects in what we could observe from the report of professionals about the sense given to work: while professionals from OSS look for improve in profession to have a job, gain professional experience and act in clinic; professionals from City showed interested in knowing better the theories dealing about human subjectivity, so having a profession that makes social sense besides of revealing an important sense of team work.
The Social Organizations are devices used to the management of health unities were formalized in 1998 by law number 846 and they are defined by Bresser Pereira99. Bresser Pereira LC. A Reforma do Estado dos anos 90: Lógica e Mecanismos de Controle. Cadernos MERE da Reforma do Estado. Brasília: Ministério da Administração Federal e Reforma do Estado; 1997. Caderno 1. as public institute of private right, with a management contract with state and, then, is finantiated partial or event totally by public budget. This way of management represents, for many, the health outsourcing, the job precariousness and the end of SUS.
According to Dal Rosso1111. Dal Rosso S. Mais trabalho! A intensificação do trabalho na sociedade contemporânea. São Paulo: Boitempo; 2008.the OSS appeared from changings that were happening in several parts of the world. So, the management model matches with toyotism, organization mode of Japanese capitalist production, that started to spread in world from 70’s, meaning a new alternative to solve problems faced by east capitalism. The objectives of toyotism was of increasing productivity, decrease costs and promote a precise control of quality. This model, characteristic of industrial production, migrated to several sectors on State guard, including health field. In this sense, these organizational, technological and management changings affected the services sector, among them the health field, including public health.
The children and adolescents’ mental health field, following this trend suffers significant impacts, the numbers of workers contractors is decreased and the wages are reduced. This reality is illustrated by the interviewed subjects: among the 8 interviewed, 4 reported have more than one job to be able to be sustained and all of them complain about precariousness and lack of investment in services. We can understand that with it, the dedication and involvement of worker with the practice become surficial and, speaking of children in psychic suffering, it can have significant impacts in treatment. Besides, the lack of investment of superior instances can influence in motivation for work.
So, the social/economic/political context affects the quality of CAPSis and impacts in professional trajectory of children and adolescents’ mental health workers, both in their experiences and services acting.
2. The institutional operation and the contradictions
The professionals complain about the distance between public management and reality of CAPSis indicating that the proposal of administration by OSS, that according to Bresser Pereira99. Bresser Pereira LC. A Reforma do Estado dos anos 90: Lógica e Mecanismos de Controle. Cadernos MERE da Reforma do Estado. Brasília: Ministério da Administração Federal e Reforma do Estado; 1997. Caderno 1. sought a better communication between services and superior instances, meanwhile did not have the impacts that were propose in improvement of services:
As this is the first CAPSis to be managed by this OSS, by the ignorance of what the services makes, OSS cannot identify the necessary money. We have to keep money to buy food, toys, material for the users.Subject 1
Everything is barred, it is not just us that cannot provide, cannot exchange, there is a lot of social control and bureaucracy, it is terrible. Subject 5
Besides this distance cited by workers between management and the daily services, they reveal in their speeches that the work bonds in OSS are different of public service:
When I was finishing the medical residency, my supervisor in the psychiatric unity said: look, a CAPSis from this unity is going to open and I wanted to call you to work there [...] I went and when the CAPS opened she invited a few people she knew. Here there are many people that came because knew someone from inside”.Subject 2
The professionals start to not be gazetted, it is observed in the speech above that each OSS has the own selection criteria of human resources that involves selective process and indication.
How the professional gets inside the institution and the work contract realized mark the bond with the job. A professional of OSS has the work contract set by CLT and, like in any other company, makes that risk of DESEMPREGO is constantly present and the productivity required and valued, while a gazetted professional hardly is fired. In this case, it is not about a situation of corporative commodity characterized popularly as “privilege of public official” to indicate prerogatives and one type of behavior not well engaged with service but, on contrary, the employment bond which nature is given by public competition presents, in these circumstances, as a guarantee of implicative and active exercise of function like it can be exemplified in the next speech of a City Professional:
Maybe I have a kind of personality that would not match, maybe I have chosen also because this is a service that you can speak more about what you think without being so afraid since your boss is not your employer.Subject 6
According to reports of professionals, how the institutional hierarchy organizes and the existence of a career plan also are different in administration of City and OSS. According to the interviewed, at CAPSis from OSS, professionals rise on career much faster than professionals from City, that report not having any career plan.
The administration model taken by OSS coincide with toyotism model, that according Merlo and Lápis1212. Merlo A, Lápis N. A saúde e os processos de trabalho no capitalismo: Reflexões na interface da psicodinâmica do trabalho e da sociologia do trabalho. Psicologia & Sociedade 2007; 19(1):61-68. has as objective that the subject feels more participatory in work. It starts to have several managers; all observe and control each other, making that the way of control be indirect. The group pressure on individuals and the psychic reactions of self control among the members are created by work groups. These presuppositions that obey to the productive logic and of technological efficacy differ from the presuppositions of mode of Psychosocial Attention. As argued before, mentioning Costa Rosa et al.33. Costa-Rosa A, Luzio CA, Yasui S. Atenção Psicossocial: rumo a um novo paradigma na Saúde Mental Coletiva. In: Amarante P, organizadores.Archivos de Saúde Mental e Atenção Psicossocial. 2ª ed. Rio de Janeiro: Editora Fiocruz; 2003. p. 13-44., a basic parameter of psychosocial attention are inter relations of all the involved (service users, professionals, family and society) and what reach is horizontality.
So we highlight an important contradiction to be considered: in one hand the psychosocial attempt of changing interpersonal relations sane and insane, and in other the socioeconomic and cultural context marked by capitalist logic, that imposes competitive and asymmetric relations.
This contradiction between the proposal of mode of psychosocial attention and socioeconomic model present in our society has a significant impact both in professional insertion in the children and adolescents’ mental health field and professional living of workers.
An important factor in the decision to work in children and adolescents’ mental health field mentioned by the interviewed was the difficult or the lack of interest in the insertion in other possible acting areas inside their professions and in other professions, and once the option is realized the authors report and important level of satisfaction with the taken decision:
That is what happened, I did medical school and during graduating I realized I had anguish,, I knew my manual technique part was bad. So the part of surgeries, delicate with hands I knew I could not do anyway. But so other things, I had anguish with emergency you know? And to be real I think my option for psychiatry has something good, not only in the practice but also in what of the possible clinics of medicine, which one would give me more return, more satisfying, which one I would be better. I think I chose correctly and in the part of child also think I chose correctly, I think I am good even in practice. Subject 2
My values started to be conflicting, I did not want to sell anything, I did not want to get inside the capitalist world, it did not converged with my ideals... I was not happy. Locked the college and to make psychology so since beginning I got interested in mental health.Subject 3
In these cases we can suggest the hypothesis of certain identification between the object of work (subjects of suffering) and the subject (professional) that exercises. The selling of belongings fostered and facilitated by publicist intervention and the intervention of mental health professional on recovering the work strength of worker (qualification of work strength in job) operate in same context and logic of capitalist world. However, there are differences between the two interventions that localize in imaginary plan and symbolical plan and it is, probably, in these differences that we can understand about the professional choice of metal health professional.
For the fact of the “insane” be in the margin of the productive society, so, disposed; the work with them can propitiate the idea to be operating with people and runs “out of the order” capitalist. We can think that when promoting the citizen rescue of socially excluded by reason of mental disorder it is raising to a certain dignity the ones that the capitalist order, in principle, has no interest and, in this case, o work of worker in mental health also starts to be valorized as an acting professionally dignifying to the margin of capitalist interest by the incessant gain. We can think that in the same way that insane is out of social contract, the workers in this area of mental health also have difficulties, question or contest the logic of capitalist production what means that they are against the world and want to create new alternatives for how madness is socially seen.
This interpretation gets stronger when you have the next speech:
When I graduated there was something that distressed me in adult that was that work question that I think that influenced if the patient kept sick or not. The fact of not working mostly where I was that was the hospital of state public server, public workers and that let me distressed. I think that hindered a lot the treatment the work question, the benefit of not working [...] And with kids there was not it, kid does not work, do not get Money. Subject 2.
In this case, it is explicit that the work immediately with those, just like the kid, that are definitely out of productive order earn the worker by identification or contagion the condition to be working out of capitalist world. Highlighting an important characteristic of professional life of workers of CAPSis.
Therefore, the attempt of workers of CAPSis of forward the counter of the capitalist world finds concrete barriers when encountering to changing process that have been happening that insert the field in Market logic.
3. CAPSi: construction model
Another important difference observe between workers of OSS and City Hall are interest significant different about the search of learning. The ones from OSS reveal bigger interest in studying neurology and psychiatry and professionals from the City got more interested by theories that work with groups with institutional questions, like for psychoanalysis.
In end of medical residency I started to think about what I wanted to do, so I had big interest in autism, that is why I went to by psychiatric. Subject 2 – professional of OSS
In graduation a child approach gets widespread, it is more about pathologies. Subject 4 – professional of OSS
If I could go back in time I would make the formation in psychoanalysis [...] I study psychoanalysis in years and I think it takes a different place [...] The place of knowledge in public services stays first the doctor and second the psychoanalyst. Subject 5- professional of City Hall
I started to make a course of group formation that I thought that was important to answer groups, a course of 4 years of graduation.Subject 8 – professional of City Hall
In the case of OSS, the speeches were exemplified in subjects: 2 and 4 are turned for the interest awakened by “disease” which locus or service is on the individual plan to be answered in a public equipment. But the speeches of professionals of City there is explicit reference to a knowledge that consistent with the logic of a public practice (subject 5) and with a technicality seen as liable to be operated in a collective “groups” (subject 8).
Independent of treatment offered or theoretical perspective of worker, a common complaint reported by professional is the shortage of capacitation offered by CAPSis and consequently the interest in having more formation. Besides, they show alert to the crisis in human resources, for working in children and adolescents’ mental health area and for graduate people for this job.
Among the interviewed none reports being specifically trained to work with children and adolescents’ mental health, they graduate to act with adults’ mental health and migrated to the children and adolescents’ field, and they say that are rare the specific formations for children and adolescents’ mental health. As mentioned22. Reis AOA, Delfini PSS, Dombi-Barbosa C, Bertolino Neto MM. Breve história da saúde mental infantojuvenil. In: Lauridsen-Ribeiro E, Tanaka OY, organizadores. Atenção em saúde mental para crianças e adolescentes no SUS. São Paulo: Editora Hucitec; 2010. p.109-130., the children and adolescents’ mental health was seen during several years as extension of adults’ mental health, just like kids during several years were seen as adults in miniature. However, were developed many theories for children and adolescent that consider the particularity of this field, and to have and quality attention would be necessary that professionals had access to these knowledges and were formed to act specifically in this field.
The professionals also complain about the loneliness feeling in daily work, being this complain the most frequent among the workers of CAPSis of OSS. We observed that how each group articulates can cause this difference, while the workers of City tend to unit the professionals of OSS tend to act invidually in the search for capacitation:
A time we had an institutional supervision that was by the City and after stopped being and the team decided to pay. Subject 8 – professional of City Hall.
In CAPSi the capacitation and formation is very individual[...] So, we have autonomy and I think we have a lot, but sometimes it gets something really loneliness. Subject 4 – professional of OSS.
But it is hard to me, I get really lonely. Subject 2 –professional of OSS
For Dejours1313. Dejours C. Da psicopatologia à psicodinâmica do trabalho. In: Lancman S, Sznelwar LI, organizadores. Christophe Dejours - Da Psicopatologia À Psicodinâmica do Trabalho. Rio de Janeiro: Editora Fiocruz; 2004. p. 47-104. the new pathologies related to work are first of all loneliness pathologies because of disruption of classic forms of solidarity everybody is psychologic lonelier daily. Thus, we can relate this attitude different of each group with the time that entered job Market.
Some professionals reported that their responsibilities are not clear or do not reach aggregate to dimension of social aspect in comprehension and realization of work, becoming very limited. Other workers, aware of their duties, cannot realize them:
I saw that there were things of CAPSi that we were not practicing and were of the practice of CAPSis. Subject 2.
And I think this is our biggest anguish. I think that is what would mostly need, because we realize that the questions are not from person, they are social, it is wider and we cannot go much beyond our here.Subject 6.
Besides these difficulties, professionals manifest the need to have basic guidelines to relized the daily job and given the lack of these foundations realize the job according to their preferences:
I think it is a peculiarity of CAPS because there are several philosophical and psychological lines possible, CAPS will be shaping according to the people that work there [...] Each one were making according to the own knowledge [...] We were creating a few things from the demand, not only based on ordinances[...] It was for the spontaneous demand[...] But I think that one of the things is the lack of a manual [...] We get kind of lost, where do I start?[...] I think that a feel each more the lack of a minimum of a common thinking. But there is no manual, so you have to build your way to work and sometimes you have to see if it Works or not.Subject 2.
I do not know if it is right or wrong, because I confess that actually is really hard to know what is the model [...]So what heppened depended of local agreements [...] How to make mora a policy of mental health, there is not[...] It is because is a total mess, depends on OSS, on manager and on supervisor [...] In time of Luiza Erundina there was a work group in hospitals, so even with different characteristics there was an axis for the city [...]. We must have an axis of CAPS, do you understand? Subject 5
There was no model, there was not in Brazil and from outside we could no copy. So we were making the rules, I remember the first day I came here, that we made a meeting to see what we wanted to do, if it was group, almost nobody knew, but we could prepare what we wanted.Subject 6.
We observed that professionals complain of not having a model to follow. We can realize that difficult results from the lack of concepts, lack of consensus about concepts or the lack of discussion about the same ones, that according to Schwartz1414. Schwartz Y. A linguagem no trabalho. Travail et ergologie: entretiens sur láctivité humains. Schwartz Y, Durrive L, organizadores.A linguagem no trabalho. Uma conversa com Yves Schwartz, filósofo, no dia 10 de abril de 2000, em Aix- en-Provence, com Marcelle Duc e Louis Durrive. Toulouse: Octarès. Seção 3. (no prelo)are fundamental to any activity. The author uses the concept of “double anticipation” that activity and concept dialogue of dialectical form to discuss the matter and value of concepts in any activity: “The concepts do not anticipate everything. It is always necessary this look about activity. However, it is about “understand the job” and it means that there is also a need of concepts! Concepts are needed to a better comprehension in the own experience of job, or it does not free of certain limitations. It is not known verbalize creativity that occurs as you work. To be able to put it into words is something that goes by the concept, which involves dealing with concepts”1414. Schwartz Y. A linguagem no trabalho. Travail et ergologie: entretiens sur láctivité humains. Schwartz Y, Durrive L, organizadores.A linguagem no trabalho. Uma conversa com Yves Schwartz, filósofo, no dia 10 de abril de 2000, em Aix- en-Provence, com Marcelle Duc e Louis Durrive. Toulouse: Octarès. Seção 3. (no prelo).
The mental health field is broad there are several theories and little evidence. It is not possible to have a service that all think the same way. However, a few basic guidelines could be share, an alternative would be the service offer institutionalized spaces and opportunities of having Exchange between workers, where they could speak about what they do, using, forming and investigating concepts.
We can think that in the lack of concepts the process of double anticipation gets impaired and the individual and creative dimension of workers, that influences directly the users of services, gets compromised. In this perspective, Kinoshita1515. Kinoshita R. Contratualidade e reabilitação psicossocial. In: Pitta AMF, organizadora. Reabilitação psicossocial no Brasil. São Paulo: Hucitec; 1996. p. 55-59.affirms that user capability is first determined by relation stablished by the professionals that treat the patient. So it is observed the matter of subjective and training dimension of professionals in process of users’ mental health.
To Canguilhem1616. Canguilhem G. O Normal e o Patológico. Rio de Janeiro: Forense Universitária; 2006. the health individual is the one that can deal with adversities of situations creating creative solutions that not Always are within the norms. Therefore, the health is not related to normality, but creativity. In the mental health field the situations that appear are unexpected and require from professional creativity in the moment, like the speech shows:
It is a practice that requires agility... It changes a lot, there are days very quiet and in others happens a crisis. Subject 2 – professional of OSS
It is evident the need to create new concepts and fort it happens constant dialogues are necessary between professionals, and also the professionals with outside people, that can help with the outside look of institution, in this hard job of dealing daily with children and adolescents in psychic suffering.
The new engineering of work in several areas, started from the State Reform, reached the health field, and children and adolescents’ mental health field, bringing the novelty of management by OSS. The process of contextual transformation that public mental health has been going through is evidence by the marked differences between the report of professionals of CAPSi managed by the OSS and by the City.
The children and adolescents’ mental health is following the changes that have been happening in the work world that walks in opposite sense to the proposals of Psychiatric Reform, making that older professionals do not adapt and the younger ones, following the contextual changes, turn away from the Psychiatric Reform. This scenery, added to complexity of treatment proposals in CAPSis that requires malleability and creativity from professionals given the constant unexpected situations, makes that both groups of professional feel lost and lonely.
The professionals complain about the lack of formation offered by CAPSis and show attentive to the shortage of human resources to work in children and adolescents’ mental health area and to train people for such work.
To deal with the complex questions that children and adolescents’ mental health involves it is hoped creativity from workers of the area that need discussion spaces and potentiation of their work, what is not happening. In front is this scenario, professionals live in a rim of competences, abilities and thoughts that give origin to improvisation, anguish and loneliness feeling.
To CNPq and to Foundation of Support to Research of São Paulo State – FAPESP for the research financing of master’s degree that led to this article.
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