THERAPEUTIC RESIDENCY: PERMANENCIES AND BREAKS IN WORK PRACTICES

ABSTRACT.

n Brazil, the functioning of therapeutic residences tends to present challenges, such as the lack of social support, which can hinder the production of health care and affect the workers of the service. Therefore, this study aimed to report the experience of conducting workshops with professionals of a therapeutic residence, besides describing the challenges and potentialities faced by professionals when producing health care. To this end, a qualitative-descriptive study, experience report was carried out, based on the social constructionism approach. Data were collected from semi-structured interviews, recorded, with five professionals of a therapeutic residence, followed by four workshops, adapted from the methodology ‘Rhythms of Life’, and field diaries of the first author. From the reports presented, the study participants clearly reported many more challenges than potentialities to produce mental health care. However, the spaces for talking and listening offered to professionals seem to have provided reflections that enabled the construction of positive meanings related to mental health work.

Keywords:
Health personnel; health care services; health care policy

RESUMO.

No Brasil, o funcionamento das residências terapêuticas tende a apresentar desafios, tais como a falta de apoio social, que podem dificultar a produção do cuidado em saúde e afetar os trabalhadores do serviço. Por isso, a presente pesquisa tem como objetivo relatar a experiência de realização de oficinas com profissionais de uma residência terapêutica, além de descrever os desafios e potencialidades enfrentados pelos profissionais ao produzirem o cuidado em saúde. Para tanto, realizou-se um estudo qualitativo-descritivo, do tipo relato de experiência, embasado na abordagem metodológica do construcionismo social. Os dados foram coletados a partir de entrevistas semiestruturadas, gravadas, com cinco profissionais de uma residência terapêutica, seguidas por quatro oficinas, adaptadas a partir da Metodologia ‘Ritmos da Vida’, e diários de campo da pesquisadora. A partir dos relatos apresentados percebe-se que as participantes do estudo relataram muito mais desafios do que potencialidades para a produção do cuidado em saúde mental. Contudo, os espaços de fala e de escuta ofertados às profissionais parecem ter disponibilizado reflexões que possibilitaram a construção de sentidos positivos relacionados ao trabalho em saúde mental.

Palavras-chave:
Pessoal da saúde; serviços de saúde; política de saúde

RESUMEN.

En el Brasil, el funcionamiento de las residencias terapéuticas tiende a presentar desafíos, como la falta de apoyo social, que pueden dificultar la producción del cuidado en salud y afectar a los trabajadores del servicio. Por eso, la presente investigación tiene como objetivo relatar la experiencia de realización de talleres con profesionales de una residencia terapéutica, además describir los desafíos y potencialidades enfrentados por los profesionales al producir el cuidado en salud. Para ello, se realizó un estudio cualitativo-descriptivo, del tipo relato de experiencia, basado en el enfoque metodológico del construccionismo social. Los datos fueron recolectados a partir de entrevistas semiestructuradas, grabadas, con cinco profesionales de una residencia terapéutica, seguidas por cuatro talleres, adaptados a partir de la Metodología ‘Ritmos da Vida’, y diarios de campo de la investigadora. A partir de los relatos presentados se percibe que las participantes del estudio relataron mucho más desafíos que potencialidades para la producción del cuidado en salud mental. Sin embargo, los espacios de habla y de escucha ofrecidos a las profesionales parecen haber ofrecido reflexiones que posibilitaron la construcción de sentidos positivos relacionados con el trabajo en salud mental.

Palabras clave:
Personal de salud; servicios de salud; política de salud

Introduction

In Brazil, the Therapeutic Residential Service [TRS] or therapeutic residence appears within the scope of the Unified Health System [SUS], with the aim of social reintegration and rescue of autonomy and citizenship of people with mental suffering, from the offer of housing for those who have been living for many years in psychiatric hospitals and who did not have social support or a place to live (Portaria/GM nº 106, 2000). Often, they are people with deep marks of abuse suffered during long periods of hospitalization in psychiatric hospitals (Junior & Loffredo, 2018).

This service is also in accordance with Law 10216 (Lei nº 10.216 (2001), which guarantees the protection and rights of people with mental disorders and the redirection of services (Ordinance/GM 10216, 2001). The TRS is also part of the Psychosocial Care Network (RAPS), which has the function of creating, expanding and articulating health care points for people in mental suffering and with needs resulting from drug use (Portaria/GM nº 3.088, 2011).

Residences can be divided into types I and II, in which type I is intended to serve a maximum of eight people, and type II houses up to ten people, with a greater degree of dependence, which, therefore, require more intensive support of caregivers (Portaria/GM nº 3.588, 2017). Each module can accommodate a proportion of ten residents for five permanent caregivers, distributed in a day and night shift, and a nursing technician with a daily shift (Portaria/GM nº 3.090, 2011). Caregivers working in the TRS are responsible for carrying out “[…] psychosocial rehabilitation activities that have housing as their organizing axis, such as: self-care, activities of daily living, attendance at outpatient services, home management, literacy, leisure and assisted work, in the perspective of social reintegration” (Portaria/GM nº 1.220, 2000, p. 1). However, although Ordinance 106/2000 regulates the TRS and establish the activity ‘caregiver in health’, it does not specify who such a worker is and their level of qualification (Ribeiro Neto & Avellar, 2009).

The functioning of therapeutic residences is still challenging due to difficulties related to management and financing, clientele and responses from other sectors and the community (Furtado, 2006). Despite this, it is expected that TRS workers know how to face situations such as residents’ crises and perform a service inside a house (Ribeiro Neto & Avelar, 2009). All of this makes it difficult to manage and take an individualized look at residents (Neves, Souza, Tavares, & Vasconcelos, 2014), affecting the production of health care (Libério, 2001; Merhy, 1999) and contributing to the professional workload (Liberio, 2001).

In addition to all the difficulties reported, there is a research gap with these professionals, since most studies are focused on TRS characterization (Barioni, 2013; Bressan & Marcolan, 2016; Kantorki, Cortes, Guedes, Franchini & Demarco, 2014) and for residents (Matsumoto, Barros, & Cortes, 2016; Nóbrega & Veiga, 2017; Ribeiro Neto & Avellar, 2016; Sztajnberg & Cavalcanti, 2014). Therefore, taking as a reference the relevance and need for studies aimed at TRS professionals, the present study aimed to report the experience of conducting interviews and workshops with professionals of a TRS, in addition to identifying and describing the challenges and potentialities faced by professionals when producing health care.

Method

The present study is a qualitative experience report, referring to a practice carried out in a therapeutic residence (Type II). ⁴The residence where the research was carried out was established in 2012 after a lawsuit that banned an association that treated patients in subhuman conditions, transferring the responsibility of the institution to the municipality and the state of Minas Gerais. It currently has 21 residents and 17 workers, who take turns in the morning, afternoon and evening shifts, with a six-hour shift each, from Monday to Friday, and 12-24-hour shifts. In this distribution, in each working period there are an average of five employees to work with all the residents. It is noteworthy that this therapeutic residence was selected because it is a field of practice of an academic league of the university where the authors of the study are linked. During the study period, the municipality had three therapeutic residences and currently there are five. Admission to the TRS occurs through a selection process or removal from other institutions.

The intervention started after a favorable opinion from a Research Ethics Committee (CEP) (opinion 2524215). After authorization from the CEP, all workers at the residence were individually invited to participate in the study. After signing the Informed Consent (IC), a semi-structured, audio-recorded individual interview was administered to each TRS worker who accepted to participate in the study, in order to characterize the participants in a sociodemographic way, as well as to identify the challenges and potentialities faced by professionals in the performance of their work. At the end of the interviews, workshops were offered in the morning and afternoon, due to the higher turnover of professionals.

Workshops, also audio-recorded, were carried out in order to provide a space for workers, when identifying their potential, to respond to the impasses at work, which corroborates the proposal of permanent health education (Portaria/GM nº 198, 2004). Workshops were conducted by the first author of the manuscript (represented by P.), together with a research assistant. Meetings were formulated and adapted from the methodology called ‘Rhythms of Life’ with the objective of helping people to face conflicts. The proposal uses Collective Narrative Practices and musical instruments as a reference. In this study, the methodology was organized into four stages: ‘my instrument’ and ‘my interpretation’, worked together in the first meeting; ‘the orchestra of life’; ‘getting into tune’, and ‘our music’ (Müller, 2012). Field diaries were also made with the researcher’s perceptions and feelings (Oliveira, 2014), on the days of the interviews and workshops.

In this study, only the set of data collected in interviews and workshops in the afternoon was considered, due to the more expressive participation of professionals who worked in this period. Therefore, the study corpus consisted of 5 interviews and 4 workshops, in addition to field diaries.

The corpus was read exhaustively with curiosity and willingness to meet the different (Mcnamee & Hosking, 2012). Subsequently, it was organized and analyzed based on the proposal by Spink and Medrado (2013), which considers information as discursive practices, produced by language, from a historical-social and culturally determined location, and in studies that deal with mental health care.

Results and discussion

Five professionals participated in the study, all women (represented by flower names), aged between 36 and 56 years, with a period of work in the TRS between 3 months and 6 years. All participants worked at the residence in the afternoon, between May and July 2018. Among them, coincidentally, 4 had the role of caregiver and were Nursing technicians (Orquídea, 42 years old, 3 months of experience; Rosa, 43 years old, 1 year and 4 months of experience; Tulipa, 38 years old, 1 year and 5 months of experience; Violeta, 36 years old, 6 years of experience) and one of them had the role of Nursing technician and formation in Pedagogy (Margarida, 56 years old, 1 year and 5 months of experience).

The beginning was not easy. For the researcher, it was difficult to build a reliable space, since when arriving at the residence, even at a previously scheduled time, the professionals continued with their tasks. “It was not easy. I felt like a pole, as if I wasn’t even there” (P. Field diary, 1st day of interview) and, “Sometimes it gives me the impression that our presence bothers, they don’t want us there” (P. Field diary, 2nd day of interview). The professional difficulty was related to their ability to speak, which generated discomfort: “This is horrible, for those who don’t like to talk like I do!” (Rose, 2nd workshop). The lack of space for workers to share their work-related anxieties seems to help in understanding Rosa’s strangeness to speak in a group.

However, the contents worked in the first stage of the workshops provided a moment for participants to rescue their potentialities through musical instruments, such as: guitar, viola, guitar, flute and violin. Later, they moved from their private stories to the construction of an orchestra, discussing values such as: respect for differences, attunement, empathy, understanding, friendship, partnership and complementarity. In these moments of face-to-face interactions, the activated voices built the notion of collaboration, resulting from a negotiation process situated in a historically-socially constituted space of interpersonality (Spink & Medrado, 2013).

In the second stage, difficulties that the orchestra faces daily were reported, such as the age difference and the fatigue caused by the work, however, they are characterized as a harmonic group, which values respect. They also reported a lack of harmony more with the residents than among the team itself.

The lack of attunement seems to be fought with some mechanistic practices, for example, as reported by Orquídea: “Prepare the boys’ report, observe how they are doing, offer the afternoon snack, the medication, take care of them, bathing, changing diapers” (Orchid, interview). It should be noted that although the TRS focus of this study is categorized as Type II, it has a very high number of residents (21), compared to the number of caregivers (average of 5). Therefore, the large workload imposed to these professionals can also contribute to the difficulty in the process of psychosocial rehabilitation of residents. In addition, Orquídea reported that a difficulty faced is to link the resident to their family of origin, when it exists, and how much this affects her: “[…] the family does not answer, they hang up the phone, give the wrong number, say they cannot talk, ask the girls to talk to ask not to call again. Wow, that was the day I suffered the most!” (Orquídea, interview). On the other hand, the fact that the professionals work in an environment similar to that of a house is a way for them to maximize the autonomy of the residents.

Professionals also feel a lack of innovation in care practices. Because of this, they look to other people for what they could do themselves: “Having more activities for them would be very important for them to decentralize from smoking, eating, because they are so idle, they think all the time about food, in cigarettes, in leaving! There is a lot missing” (Orquídea, interview). The apparent difficulty of innovation seems to be related to the scarce spaces for training in mental health available, since in the workshops they also demonstrated that they did not know how to deal with recurrent situations of a TRS, such as in moments of aggressiveness of the residents: “I do not mistreat, but I just don’t want to be spanked. If you punch me, get punched. If you kick me, get kicked” (Violeta, 3rd workshop) and “I get beaten and cry” (Margarida, 3rd workshop). In this way, Violeta and Margarida seem to demonstrate the overload they experience. This tiredness can also be seen in: “It is not a heavy job, but it is a job that tires the mind, because we talk too much, we talk all the time” (Tulipa, interview), and: “[…] we get angry, we scream […] you keep repeating the same thing, they drive us crazy” (Violeta, interview). The need for more training spaces can also be seen in: “I thought this matrix support program opened up some things for me that I didn’t see from that side, right?!” (Tulipa, interview). This corroborates Antonacci, Kantorski, Willrich, Argiles, Coimbra and Bielemann, when stating that the lack of training of professionals working with mental health makes it difficult to produce new forms of care. Faced with so many difficulties, it is necessary to analyze the professional view of their workplace (Vasconcellos & Azevedo, 2012).

At various times, it is questionable whether the residence has managed to fulfill its role, especially from Tulipa’s speech, which seems to reflect a desire to transform the house into a total institution (Goffman, 1987):

“There’s no electric fence, the gates are all at the front, so you can’t go around them [...] you would have a comprehensive view of the whole house [...] you can’t have an open kitchen because of a knife, it had to be wide, it had to have a window, so that we could see everything in the place” (Tulipa, 3rd workshop). Considering the way in which the professionals work, it is as if they were far from what is recommended, including the propositions of the Psychiatric Reform (Argiles, Kantorski, Willrich, Antonacci, & Coimbra, 2013).

In view of this, in some moments of the workshops, feelings of ineffectiveness arose on the part of the researcher for not telling the team that some statements regressed to the practices recommended by the Reform. However, this anguish was alleviated by visualizing the need for a mental health work environment that promotes spaces of recognition and respect for workers, so that they develop resources to deal with the difficulties and stress that permeate their daily lives (Santos & Cardoso, 2010), so that they can transform their practices. Despite this, at times, professionals also rescued some precepts of the Reform, such as when they still perceive in society the existence of prejudices related to people with mental suffering by insisting on inserting residents in contexts of daily life outside the house, and recognizing the residence as a house with residents: “In addition to prejudice there is fear, most of them I notice when I take them to consultations, many people already give a dirty look [...] here we will not only take care of the patient, we do not say patient, but rather resident” (Margarida, interview).

Thus, revealing historical permanence and disruption, demonstrating that the production of meaning is not a merely cognitive activity, but a dialogical and social practice involving language (Spink & Medrado, 2013), which is perceived in Orquídea’s speech: “Learning everyday here! I do not know how to explain! That we have to be grateful for a lot of good things we have and see what it’ like to live with their difficulties!” (Orquídea, interview).

During the course of the workshops, it was also possible to observe that from the moment the workshops were constituted as a space for talking and listening, they started to be expected by the participants. Agreeing with Spink and Medrado (2013), when stating that this is a remarkable moment for the construction of the group, because from it the phenomenon can be analyzed collectively and not only as an individual experience: “In the beginning, everyone was shy, not wanting to talk, but in that meeting, I felt that there was a group that worked together” (P. Field diary, 3rd workshop). Thus, the initial mechanism also perceived in the interviewees when reporting about their tasks was transformed into other possibilities. Probably because during the workshops there was the construction of different meanings for work (Spink & Medrado, 2013), such as, for example, when workers describe other activities that they had not mentioned in the interviews: “If there are dirty clothes, I say: - So, go and wash it” (Orquídea, 3rd workshop), and: “I teach some things, like, you come and ask for water. They ask and I teach to pick it up” (Margarida, 3rd workshop).

When the workers were not directly asked what they did in the TRS, other functions emerged that they did not consider as daily work activities. Demonstrating that when the person does not focus on the discourse, they can create different discursive practices and not necessarily be restricted to a specific content (Spink & Medrado, 2013). In addition, by problematizing the perception of senses, it is possible to change reality, in order to create new meanings for work (Cadoná & Scarparo, 2015): “In addition to changing diapers, tidying things up, making reports, you also have caring for them to help them clean, do everyday things at home” (P., 3rd workshop). In agreement with Silva and Azevedo (2011) and Kantorki et al. (2014), who stated that the work of professionals in the TRS goes beyond carrying out activities for the residents.

From the reports presented, it is clear that the professionals reported challenges and potentialities for the production of mental health care. However, the spaces for talking and listening seem to have made it possible to build more positive meanings related to work and mental health care, in agreement with Santos and Cardoso (2010), who stated that professionals require support from everyone involved in the residence to develop skills, abilities and attitudes in order to offer care anchored in the biopsychosocial model and thus know how to deal with not only organic, but emotional and social suffering as well.

The workshops ended with the creation of a song built by the workers as an expression of the meaning of the experience they had during the meetings: “Live, dream, work, take care, learn/Be strong inside and out/Transform, give respect, have affection and faith/Walking/Towards a better humanity/With more kindness, more respect and more character/Giving and receiving/What is normal?/Who is normal?/Normal is giving, receiving and respecting/Having less regrets about events […]”, revealing versions of the world of work more associated with the precepts of the Psychiatric Reform.

Final considerations

When reporting the present experience, it was possible to perceive that the professionals of the TRS experience challenges, such as: strangeness of having a place to talk and listen, the lack of support from the family of residents, lack of innovation in the health care process, little training in mental health, overload and, sometimes, the performance of activities dissonant with the precepts of the Psychiatric Reform. However, as a potentiality, professionals perceive work as a way of valuing life and the possibility of creating a different meaning for living. During the workshops, it was also possible to build a space for the production of different meanings for work, as well as for mental health care itself.

In view of the relevance of these findings, the present study demonstrates that a space is required for the improvement of health care, with the aim of formulating more emancipatory care practices for users of mental health services, and for listening to professionals of the TRS.

It should also be noted that some limitations of the study were related to the presence of different professionals at each workshop held, as well as the interference of residents during data collection, since the professionals participated in the study during their working hours. The changes perceived in the workers during the research, however, seem to point to the need for further studies that can apply methodologies capable of mediating the construction of new ways of caring in mental health.

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• 4
  The research was approved by the Ethics Committee of the Federal University of Triângulo Mineiro, CAAE 80693217.7.0000.5154

Publication Dates

• Publication in this collection
  19 Aug 2022
• Date of issue
  2022

History

• Received
  01 Sept 2019
• Accepted
  13 Feb 2021