AS CONTRADIÇÕES DE UM CENTRO DE ATENÇÃO PSICOSSOCIAL
SILVA, Arthemis Pavoni Florêncio da
[email protected]
É difícil trabalhar com a população caracterizada pelo sofrimento psíquico com
o propósito de reinserção social e promoção de autonomia, pois as estruturas das
instituições que lidam com essa população ainda a classificam em diagnósticos
psiquiátricos e propõem normas de comportamento, reforçando estigmas.
Muito já foi feito no Brasil em favor da desinstitucionalização e da reinserção
social das pessoas caracterizadas como “portadoras de transtornos mentais”.
Exemplos disso são a Luta Antimanicomial, que “constitui-se como um
importante movimento social na sociedade brasileira, na medida em que se organiza e
se articula tendo em vista transformar as condições, relações e representações acerca
da loucura em nossa sociedade” (LÜCHMANN, 2007), e a Lei n° 10216, que “dispõe
sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e
redireciona o modelo assistencial em saúde mental”, a qual, entre outras resoluções,
veda “a internação de pacientes portadores de transtornos mentais com características
asilares”, ou seja, instituições que não possuam como característica “assistência
integral à pessoa portadora de transtornos mentais, incluindo serviços médicos, de
assistência social, psicológicos, ocupacionais, de lazer e outros”. (BRASIL, 2001)
Existem serviços de saúde mental que, na teoria, propõem que o indivíduo não
se torne dependente da instituição, mas que, na prática, não atingem esse objetivo, pois
o usuário passa a ter a instituição como único local de convivência.
Dessa forma, o usuário é privado de outras atividades, como o acesso à
educação, à saúde, à cultura, ao trabalho, ou seja, à total integração social.
Ainda trabalhamos na saúde mental a exemplo do mito grego da Cama de
Procusto, ou seja, tentando encaixar indivíduos em modelos, em vez de fortalecer a
autonomia e respeitar a alteridade.
Tomaremos como exemplo o trabalho realizado em um CAPS III localizado na
periferia da região metropolitana de São Paulo.
O objetivo é descrever a população atendida, as atividades realizadas, a equipe
que trabalha na instituição e refletir sobre as práticas.
1
CAPS Sul - Oeste
A autora é psicóloga da equipe multidisciplinar de um CAPS III, o CAPS Sul - Oeste,
localizado no município de Diadema, São Paulo.
Trata-se de um município de “população, segundo números do Censo IBGE 2010, de
386.039 habitantes, o que ocasiona uma densidade demográfica de 12.574 pessoas por km², a
segunda maior do país. A cidade é a 14ª economia do Estado de São Paulo e a 41ª economia
do Brasil. O PIB per capita, previsto para 2010, é de R$ 25,9 mil.” (DIADEMA, 2014).
Diadema conta com três Centros de Atenção Psicossocial III (CAPS III); um CAPS ad
(álcool e outras drogas) III e um CAPS infantojuvenil.
“Centros de Atenção Psicossocial (CAPS) são unidades de atendimento intensivo e
diário aos portadores de sofrimento psíquico grave, constituindo uma alternativa ao modelo
centrado no hospital psiquiátrico (...). Os Centros de Atenção permitem que os usuários
permaneçam junto às suas famílias e comunidades”. (SILVA, 2000)
CAPS III são instalados em municípios com população acima de 200 mil habitantes.
Funciona 24h, diariamente, também nos feriados e finais de semana. (BRASIL, 2006)
O objetivo do CAPS, segundo o Ministério da Saúde é:
Prestar atendimento em regime de atenção diária; gerenciar os
projetos terapêuticos, oferecendo cuidados clínicos, eficientes e
personalizados; promover a inserção social dos usuários por meio de
ações intersetoriais que envolvam educação, trabalho, esporte, cultura
e lazer, montando estratégias conjuntas de enfrentamento dos
problemas; organizar a rede de serviços de saúde mental de seu
território; dar suporte e supervisionar a atenção à saúde mental na
rede básica, PSF (Programa Saúde da Família), PACS (Programa de
Agentes Comunitários de Saúde); regular a porta de entrada da rede de
assistência em saúde mental de sua área; coordenar, junto com o gestor
local,
as
atividades de
supervisão
de
unidades
hospitalares
psiquiátricas que atuem no seu território; manter atualizada a listagem
dos pacientes de sua região que utilizam medicamentos para a saúde
mental. (BRASIL, 2004)
2
Os CAPS III são peculiares por oferecerem atendimento 24 horas por dia, o que acaba
por ser semelhante a uma internação, apesar de ser dado o nome de “acolhimento 24h” ou
“regime de hospitalidade noturna”.
Aos usuários que se encontram em situação de maior gravidade, como os que
apresentam crises agudas de depressão, auto ou heteroagressividade, é indicado o
acolhimento 24h. Esse regime apresenta regras rígidas de horários, possibilidade de
contenções físicas e químicas, e a obrigatoriedade de permanecer no CAPS até a alta
médica.

Espaço Físico
Há CAPS que funcionam em prédios construídos especificamente para este
fim, porém muitos, como o CAPS em questão, funcionam em casas adaptadas, muitas
vezes inadequadas.
O CAPS Sul-Oeste funciona em uma casa de quatro andares sem acesso para
pessoas com necessidades especiais de locomoção, pois não há rampas ou outro meio
de acesso aos andares superiores que não sejam as escadas.
No andar térreo, o CAPS Sul - Oeste possui uma área para fumantes, uma
recepção, um posto de enfermagem e duas salas para atendimento, todos sem
isolamento acústico, pois foram improvisadas em uma garagem, com paredes de gesso
(“drywall”) que não chegam ao teto.
O espaço físico é inadequado, pois não há privacidade para o atendimento: as
salas não permitem que se resguarde a privacidade dos atendimentos. Além disso,
muitos atendimentos são realizados em uma mesa ao lado dos banheiros.
No primeiro andar, há uma cozinha, utilizada para preparar os lanches e café
dos usuários e como refeitório para os funcionários; uma sala de estar, onde os
usuários passam grande parte do tempo assistindo televisão ou descansando; três
quartos, onde são alocados os usuários em acolhimento 24h (Hospitalidade diurna e
noturna) e dois banheiros para uso dos usuários, além de um terraço amplo, protegido
por uma rede.
Esse espaço é inadequado, pois as pessoas correm risco de cair das escadas ou
das varandas.
No segundo andar, há uma área aberta, utilizada para oficinas e atendimentos
em grupo, refeitório e um banheiro.
3
No terceiro andar, há uma sala para o setor administrativo, um banheiro e um espaço
onde é guardada a medicação e feita sua separação, bem como um espaço onde, ao mesmo
tempo, são feitas as reuniões de equipe e também se guardam roupas, insumos e roupas de
cama dos usuários. Nesse andar há um acesso a um pequeno terraço.
A casa apresenta com frequência problemas de entupimento dos esgotos e problemas
na rede elétrica, além de inúmeros desgastes no acabamento e móveis, que raramente são
concertados em tempo de evitarem-se transtornos.

Perfil da população atendida, segundo cadastro de usuários do CAPS:
Em regime de Hospital Dia, ou seja, o usuário vai ao CAPS pela manhã e permanece até
às 15 horas, comparece a média de 30 pessoas por dia.
Dos usuários ativos, 55% pertencem ao sexo masculino e 45% ao feminino. No total: 248
ativos.
Os usuários do CAPS, de acordo com o cadastro da unidade, têm as seguintes
hipóteses diagnósticas (HD), feitas pelo médico psiquiatra, de acordo com o Código
Internacional de Doenças (ORGANIZAÇÃO PANAMERICANA DE SAÚDE, 2009): F.
06(outros transtornos mentais devidos a lesão e disfunção cerebral e a doença física), 9 casos;
F. 06 associado a outras HD, 5 casos; F. 10 (transtornos mentais e comportamentais devido ao
uso de álcool),3 casos; F. 20 (esquizofrenia), 58 casos; F. 20 associado a outras HD, 11 casos;
F.22 (transtornos delirantes persistentes), 1 caso; F. 23 (transtornos psicóticos agudos e
transitórios), 1 caso;F. 25 (transtornos esquizoafetivos), 10 casos; F. 25 associado a outras
HD, 2 casos; F. 29 (psicose não orgânica não especificada), 11 casos; F. 29 associado a outras
HD, 11 casos; F. 31 (transtorno afetivo bipolar), 2 casos; F. 31 associado a outras HD , 14
casos; F. 32 (Episódios depressivos), 5 casos; F. 32 associado a outras HD, 5 casos; F. 33
(transtorno depressivo recorrente), 12 casos; F.34 (transtornos de humor [afetivos]
persistentes), 1 caso; F.41 (outros transtornos ansiosos), 1 caso; F.44 (transtornos
dissociativos [de conversão]), 1 caso; F.44 associado a outras HD, 1 caso; F. 60 (transtornos
específicos da personalidade), 6 casos; F. 60 associado a outras HD, 7 casos; F. 70 (retardo
mental leve), 4 casos; F. 70 associado a outras HD, 3 casos; F. 71 (retardo mental moderado),
4 casos; F. 72 (retardo mental grave), 1 caso. (ver gráfico em anexo).
4
Pelo cadastro, foi possível acessar os dados referentes à Hipótese Diagnóstica
(HD) de 188 usuários ativos, sendo a maioria F.20 (30,85% ou 36,7% se
considerarmos os F.20 associados a outras HD).
Também é representativo o número de casos de F.31 associados a outras HD; F.33;
F29 (com e sem associação com outras HD); F.25; F.06 (com e sem associação com
outras HD); F.32; F.70 e F.71.

Equipe Multidisciplinar:
A equipe do CAPS é composta por: 1 diretora,
terapeuta ocupacional de nível
superior, diarista (40horas semanais); 1 médico psiquiatra, que atende três vezes por
semana (20 horas semanais); 2 professores de educação física de nível superior, que
fazem atividades uma vez por semana cada um; 1 enfermeira psiquiatra
(36 horas
semanais) de nível superior diarista, 4 enfermeiros de nível superior plantonista (12X36
horas) e 1 enfermeira folguista; 1 assistente social
de nível superior diarista (30
horas/semanais); 1 psicóloga de nível superior diarista ( 30 horas /semanais), 1 psicóloga
de nível superior diarista (40 horas/semanais);1 terapeuta ocupacional de nível superior
diarista (30 horas/semanais); 13 assistentes de enfermagem, de nível médio plantonistas
(regime 12 X36 horas ) e 1 diarista; 2 auxiliares administrativos de nível médio diaristas;
6 auxiliares de serviços gerais, de nível fundamental, plantonistas e 1 diarista (
40horas/semana) ; 4 vigilantes plantonistas; 1 recepcionista, diarista (40 horas semanais) ;
1 motorista diarista, perfazendo um total de 43 funcionários.
A equipe multiprofissional composta pelos técnicos de nível superior e dos assistentes
de enfermagem se reúne diariamente das 11:30h às 12:30h para a Reunião de Passagem de
Plantão, quando se discutem os casos que são atendidos no plantão do período da manhã e
os “internados”, ou seja, como estão evoluindo os acolhidos em HDN.
Uma vez por semana, é feita a Reunião Geral, às quintas-feiras das 10h às 12h, quando
são discutidos casos mais pormenorizadamente e as mais diversas situações tanto
terapêuticas, de relacionamento de equipe e administrativas.
Uma vez por mês, os técnicos de nível superior vão ao Matriciamento de Saúde
Mental na Unidade Básica de Saúde (UBS) que referencia para discutir casos.

Atividades (grade de atividades em anexo)
5

ASSEMBLEIA: reunião coordenada pela diretora da unidade, com o intuito de discutir as
atividades, propor idéias, colocar críticas e sugestões. Todos os usuários podem participar.

BENEFÍCIO: grupo coordenado pela assistente social, que acolhe dúvidas relativas aos
benefícios sociais e propõe ações nesse sentido. Participam os usuários e familiares
interessados. Grupo fechado, com agendamento prévio.

ACOLHIMENTO: grupo aberto coordenado pela autora, psicóloga, com o objetivo de escutar
as demandas dos usuários, seu momento atual e acolhê-los no CAPS no início da semana.

HISTÓRIAS: oficina aberta de contos e mitos, coordenada pela autora, psicóloga. Tem o
objetivo criar vínculo, trabalhar os conteúdos inconscientes e exercitar a criatividade.

PROJETO DE VIDA: grupo fechado, coordenado pelas duas psicólogas. Tem por objetivo
levar o grupo a construir projetos e trabalhar sobre eles.

PSICOEDUCAÇÃO: grupo aberto coordenado por uma psicóloga. Tem por objetivo explicar
questões relativas ao tratamento e às medicações.

FAMÍLIA: grupo aberto a todos os familiares de usuários, coordenados por psicóloga. Tem
por objetivo acolher e orientar os familiares.

CAMINHADA: grupo aberto, coordenado pela professora de educação física. Tem por
objetivo promover condicionamento físico, explorar o território e consciência corporal.

EXPRESSÃO CORPORAL: grupo aberto, coordenado pela professora de educação física,
que, por meio da atividade física e artística, promove consciência cultural e inserção social.

ATIVIDADE FÍSICA: grupo aberto de orientação sobre saúde, coordenado pelo professor de
educação física, com exercícios físicos e estímulo ao usuário a frequentar espaços extraCAPS, possibilitando a reinserção social.

AUTO-CUIDADO: grupo aberto coordenado pelos técnicos de enfermagem. Tem por
objetivo resgatar a auto-estima dos usuários, promovendo orientações sobre higiene,
sexualidade e executando ações como corte de cabelos, barba, manicure e maquiagem.

BAZAR: atividade coordenada por uma técnica de enfermagem, que consiste em organizar a
venda de vestuário doado, a fim de arrecadar recursos para as festas e outras atividades do
CAPS.

ARTESANATO: oficina aberta coordenada pelos técnicos de enfermagem com o objetivo de
promover vínculo com a instituição, observar a interação entre os usuários e produzir
decoração para as festividades.
6

GRUPO DE MÚSICA: grupo aberto coordenado por um oficineiro voluntário, que consiste
em atividades musicais, como tocar violão e cantar, com o objetivo de vincular o usuário ao
tratamento e promover criatividade e expressão.

CONVIVÊNCIA (HOSPITAL DIA): os usuários passam o dia no CAPS e fazem as refeições
(café da manhã, almoço e lanche). A equipe de enfermagem afere a pressão arterial e a
glicemia de todos. Aqueles com maior dificuldade locomoção ou menos autonomia são
levados com o transporte do CAPS.

Fluxo de atendimento:
O acolhimento é “portas abertas”, ou seja, todos que procurem atendimento de
segunda a sexta-feira, das 8h às 11h e das 14h às 17h serão atendidos por um
profissional de nível superior.
O plantão de acolhimento avalia se o usuário será inserido no CAPS, baseandose nos critérios de gravidade do caso e hipótese diagnóstica, se há prejuízo das
atividades diárias e a não inserção social.
O usuário que está estável o suficiente para trabalhar, estudar, ou manter suas
atividades cotidianas com autonomia, deverá ser atendido nas UBS (Unidades Básicas
de Saúde), que deverão possuir equipe de saúde mental.
E o usuário que estiver em situação de gravidade, com risco de auto e
heteroagressividade, crises de alucinação e delírios incapacitantes, ideação suicida,
será encaminhado para atendimento no Pronto Socorro para avaliação imediata do
psiquiatra, podendo ser reencaminhado ao CAPS.
O plantonista, em conjunto com o usuário acolhido na unidade, realiza um
Projeto Terapêutico Singular (PTS) provisório e marca um atendimento de referência
com o técnico de nível superior responsável pela a região de moradia do usuário.
O técnico de referência torna-se responsável por construir, juntamente com o
usuário, o PTS e reavaliá-lo periodicamente.
As referências são organizadas de acordo com regiões. Cada região é atendida
por uma Unidade Básica de Saúde (UBS). O CAPS Sul –Oeste atende a população
referenciada por 5 UBS.
O PTS abrange a possibilidade de consultas com psiquiatra, participação nos
grupos e oficinas, atendimentos individuais, atendimentos de referência, ingestão
7
medicamentosa supervisionada, inclusão no transporte do CAPS e refeições, conforme a
necessidade de cada usuário, avaliada em conjunto com sua referência.
Há casos de usuários que frequentam diariamente o CAPS, inclusive aos finais de
semana, das 8h às 17h, até aqueles que comparecem a cada dois meses.
Conclusão
A incapacidade, a impossibilidade de ser inserido socialmente, de conviver e desfrutar
de todos os espaços comuns da comunidade, não apenas do CAPS, são estigmas reforçados
pela estrutura médico-centrada e autoritária da Instituição.
As normas para inclusão no CAPS são as mesmas de exclusão social. Faz parte da
exclusão enquadrar o usuário em uma Hipótese Diagnóstica, que acaba por servir de rótulo
para exclusão em outros ambientes.
Exemplo dessa estrutura autoritária é o fato do portão de entrada ser mantido fechado
quando algum usuário em HDN (Hospitalidade Diurna e Noturna) apresenta risco de evasão.
O controle é feito pelo vigilante. Muitas vezes essa conduta é aplicada a outros usuários, que
encontram-se em HD (Hospitalidade Diurna) e necessitam pedir permissão para sair.
“Quem é a sua referência?”; “Qual é o seu projeto?”; “Já tomou o seu remédio?”, são
perguntas frequentes feitas aos usuários, demonstrando que a referência, o projeto terapêutico
e o remédio são autoridades inquestionáveis e determinantes das ações do usuário.
Na prática, o usuário participa muito pouco da construção de seu PTS e raramente é
estimulado à autonomia.
O CAPS é um local de excluídos e os mantêm nessa condição tanto pelo espaço físico
trancado, como pela conduta autoritária dos profissionais em proibir a saída sem permissão
quando eles estão lá por livre e espontânea vontade.
O CAPS Sul-Oeste atinge pequena parte dos objetivos de um CAPS, pois a maior
parte das ações se dá dentro da instituição, focando a estabilidade do quadro psiquiátrico em
detrimento do trabalho com a comunidade, promoção de autonomia, ações intersetoriais que
envolvam educação, trabalho, esporte, cultura e lazer etc.
As discussões em equipe são focadas, na maior parte das vezes, em como estão os
usuários (chamados de “pacientes”), se o quadro psiquiátrico estabilizou-se ou agravou-se e
quais condutas serão tomadas para atingir o objetivo de estabilizar o quadro psiquiátrico do
usuário.
8
A autora propõe que, a partir da reflexão sobre as práticas no CAPS Sul-Oeste, seja
construído um projeto institucional de forma a aproximar o serviço dos parâmetros
antimanicomiais a fim de proporcionar maior inserção social e autonomia aos usuários.

REFERÊNCIAS BIBLIOGRÁFICAS
BRASIL,
Lei
nº
10.216,
de
6
de
abril
de
2001,
disponível
em
www.planalto.gov.br/ccivil_03/leis/leis_2001/110216.htm, acessado em 02 de março de
2014.
______ Ministério da Saúde, “Criação e implantação de rede de assistência em Centros de
Atenção Psicossocial para o atendimento de pacientes com Transtornos causados pelo Uso
Prejudicial e/ou dependência de Álcool e outras Drogas (CAPS ad). Brasília, 2004
CRUZ, Marcelo Santos e FERREIRA, Salete Maria Barros; “A rede de saúde na assistência a
usuários de álcool e outras drogas: papel das UBS, CAPS ad, hospitais gerais e hospitais
psiquiátricos” In: BRASIL, Secretaria Nacional Antidrogas, “SUPERA, Sistema Para
Detecção do Uso Abusivo e Dependência de Substâncias Psicoativas: encaminhamento,
Intervenção Breve, Reinserção social e Acompanhamento”, 2006
DIADEMA, Prefeitura de Diadema, Secretaria de Comunicação, disponível em
http://www.diadema.sp.gov.br/municipio/a-cidade/1783-dados-gerais.html, acessado em 16
de julho de 2014.
LÜCHMANN, Lígia Helena Hahn., RODRIGUES, Jefferson. O Movimento Antimanicomial
no Brasil. Ciência e Saúde Coletiva. (, 12 (2):399-407, 2007.
ORGANIZAÇÃO PANAMERICANA DE SAÚDE, Classificação Estatística Internacional de
Doenças e Problemas Relacionados à Saúde, Décima Revisão, 2009
SILVA, ACZ, Centros de Atenção Psicossocial In: FARAH, Marta Ferreira Santos,
BARBOZA, Hélio Batista, Novas Experiências de Gestão Pública e Cidadania, 2000).
Programas e Serviços
9
Tema: Programas e serviços
HD
70
60
50
40
30
CID X
20
10
0
F
F
F
F
F
F
F F
F
31
20
29
60
06
32
70 25
44
F
F
F
F F
F
F
F F F1
F F F F F F
F
AS AS AS
AS AS AS
AS AS
AS
20
33
29
25 06
60
32
70 71 0
31 22 23 34 41 44
72
SO SO SO
SO SO SO
SO SO
SO
C
C
C
C
C
C
C C
C
CID X 58 14 12 11 11 11 10 9 7 6 5 5 5 4 4 3 3 2 2 1 1 1 1 1 1 1
TABELA DE ATIVIDADES
HORA
8:30
Segunda-Feira
9:00
10:00
ACOLHIMENTO
HISTÓRIAS
14:00
VÍDEO
16:00
BENEFÍCIO
Terça-feira
CAMINHADA
Quarta-feira
PROJETO DE
VIDA
Quinta-feira
Sexta-feira
ATIVIDADE
FÍSICA
FAMÍLIA
CONSCIÊNCIA ARTESANATO
CORPORAL
AUTO PSICOEDUCAÇÃO
CUIDADO
ASSEMBLEIA
MÚSICA
10
AS CONTRADIÇÕES DE UM CENTRO DE ATENÇÃO PSICOSSOCIAL
SILVA, Arthemis Pavoni Florêncio da
[email protected]
Muito já foi feito no Brasil em favor da desinstitucionalização e da reinserção social das pessoas
caracterizadas como “portadoras de transtornos mentais”, porém ainda trabalha-se na saúde mental tentando
encaixar os indivíduos em modelos, em vez de fortalecer sua autonomia e respeitar a alteridade. O presente
trabalho toma como exemplo um CAPS III, localizado na periferia da região metropolitana de São Paulo, de
modo a refletir sobre as práticas realizadas. É feita a descrição do espaço físico, do perfil da população atendida,
da equipe multidisciplinar, das atividades realizadas e do fluxo de atendimento. Concluiu-se que o CAPS SulOeste atinge pequena parte dos objetivos de um CAPS, pois a maior parte das ações se dá dentro da instituição,
focando a estabilidade do quadro psiquiátrico em detrimento do trabalho com a comunidade, promoção de
autonomia e reinserção social.
Programas e Serviços.
THE CONTRADICTIONS OF A CENTER OF PSYCHO-SOCIAL ATTENTION
SILVA, Arthemis Pavoni Florêncio da
[email protected]
It is difficult to work with the population – who is characterized for the psychic
distress – with the proposal of social reintegration and autonomy promotion, because the
structures of the institutions that handle with that population still classifying them in
psychiatric diagnoses and propose behavior standards, reinforcing stigmas.
Much has already been done in Brazil in favor of deinstitutionalization and social
reintegration of individuals characterized as "people with mental disorders".
For instance, the "Anti-asylum fight"‒which "consists as an important social motion in
the Brazilian society to the extent that it organizes and articulates it in order to transform the
conditions, relations and representations about the insanity in our society" (LÜCHMANN,
2007)‒, and No. 10216 Law which "provides for the protection and rights of people with
mental disorders and redirects the mental health care model" and, among other resolutions,
prohibits "the internment of mental disorders patients with asylum characteristics". In other
words, institutions that don't have "full assistance to people with mental disorders, including
medical services, social assistance, psychological, occupational, recreational and other".
11
(BRASIL, 2001)
There are mental health services that, in theory, proposes that the individual doesn't
become dependent of the institution, but in practice it fails, because the user now have the
institution as its main place of coexistence. In that way, the user is deprived of other activities
such as access to education, healthcare, culture, labor, in other words, of full social
integration.
We still working in mental health such as the myth of Procrustes Bed, which means
trying to fit individuals into molds, instead of consolidate its autonomy and respect its
alterity.
We will now take as example the work done in a CAPS III located at the outskirts of
Sao Paulo's metropolitan area.
The objective is to describe the attended population, the performed activities and the
working team of the institution and to reflect about the practices.
The South-West CAPS
The author is a psychologist in the multidisciplinary team of a CAPS III, the SouthWest CAPS, located in Diadema, Sao Paulo.
It is a city of "population, according to 2010 IBGE Census, of 386.039 inhabitants,
which means a population density of 12.574 persons per square kilometer, the second most
densely populated city in Brazil. It is also the 14th largest economy of the Sao Paulo state and
the 41st largest economy of Brazil . Its GDP per capita in 2010 was R$ 25,900." (DIADEMA,
2014).
Diadema city has three Centers of Psycho-Social Attention III (CAPS III); one ad
CAPS (for alcohol and other drugs treatment) and one juvenile CAPS.
“The Centers of Psycho-Social Attention (CAPS) are units of intensive and daily care
for serious psychological distress carriers, providing an alternative to the model centered on
the psychiatric hospital (…). The CAPS allow users to remain with their families and
communities." (SILVA, 2000)
The CAPS’ III are located in the cities with more than 200.000 inhabitants. It operates
24 hours daily, also on holidays and weekends. (BRASIL, 2006)
The CAPS target, according to the brazilian Ministry of Health is:
12
Providing treatment in a daily attention regime; manage the therapeutic
projects offering clinical, efficient and personalized care; promote the social
inclusion of users through intersectoral actions involving education, labor,
sports, culture and leisure, assembling joint strategies of coping problems;
organize the network of mental health services of its territory; give support and
supervise the mental health care in the basic health service, Family Health
Program (PSF), Community Health Agents Program (PACS); regulate the
gateway of mental health assistance network of its field; coordinate, along with
the local manager, the supervisory activities of psychiatric hospital units that
operate in its territory; maintain the list of patients that use medicines for mental
health of its region updated. (BRASIL, 2004)
CAPS III are peculiar because they offers a 24 hours day service, which
ends up of being similar to an internment, despite of being called a "24 hour
hosting" or "nightly hospitality regime"
For the users who find themselves in more severe situations, such as acute
crisis of depression, self or heteroaggressiveness, the 24 hours hosting is
indicated. This regime has strict rules of schedule, physical and chemical
contention possibilities and the mandatory of stay at the CAPS until medical
discharge.
•The Physical Space
There are CAPS running on buildings that was constructed specifically
for that purpose, however many of it, as the CAPS which we are speaking of,
operates in adapted houses, often inappropriate.
The South-West CAPS operates in a four-floor house with no access for
people with special mobility needs, because there are no ramps or any other
means to access the upper floors, besides the stairs.
On the ground floor, the South-West CAPS has a smoking area, a
reception, a nursing ward and two rooms for appointments, all of that with no
soundproofing walls, since it was improvised in a garage area, with drywalls that
do not reach the ceiling.
The physical space is inappropriate, because there is no privacy to attend the
13
patients: the rooms do not allow safeguard the privacy of the consultation. In
addition, many consultations are held on a table next to the toilets.
On the first floor, there is a kitchen used to prepare snacks and coffee for
the users and as a mess room for the employees; one living room where the users
spend most of their time watching TV or resting; three bedrooms, where the 24
hours hosting users (Day and Night Hospitality) are allocated, and two bathrooms
for the users, plus a large terrace protected by a safety net.
That space is very inadequate, because people are in risk to fall off the
stairs or of the balconies.
On the second floor there is an open area used for workshops and group
meetings, a mess room and a bathroom.
On the third floor there is a room for administrative business, a bathroom,
a room where the medicines are stored and its separation is made, and another
space where the team meetings are made, where also clothes, supplies and bed
sheets of the users are stored. There is also an access to a small terrace in this
floor.
The house frequently has sewer cloggings and electric grid problems, as well as
countless damages on furniture and other problems that are rarely repaired in
time to avoid inconvenience.
•Profile of the population attended, according to the CAPS's registration of
users:
Under the Day Hospital regime, which means that the user goes to the
CAPS in the morning and stays up to 3pm, on average 30 people a day appear at
the CAPS.
Of active users, 55% were males and 45% females. They are, in total, 248
active.
The CAPS users, according to the unit's records, has the following
diagnostic hypothesis (HD), diagnosed by a psychiatrist according to the
International Classification of Diseases (ORGANIZAÇÃO PANAMERICANA
DE SAÚDE, 2009): F.06 (other mental disorders due to known physiological
condition), 9 cases; F.06 combined with other HD, 5 cases; F.10 ( alcohol related
14
disorders), 3 cases; F.20 (schizophrenia), 58 cases; F.20 combined with other
HD, 11 cases; F.22 (persistent delusional disorders), 1 case; F.23 (acute and
transient psychotic disorders), 1 case; F.25 (schizoaffective disorder), 10 cases;
F.25 combined with other HD, 2 cases; F.29 (unspecified nonorganic psychosis),
11 cases; F.29 combined with other HD, 11 cases; F.31 (bipolar disorder), 2
cases; F.31 combined with other HD, 14 cases; F.32 (depressive episode), 5
cases; F.32 combined with other HD, 5 cases; F.33 (recurrent depressive
disorder), 12 cases; F.34 (persistent mood [affective] disorders), 1 case; F.41
(other anxiety disorders), 1 case; F.44 (dissociative [conversion] disorders), 1
case; F.44 combined with other HD, 1 case; F.60 (specific personality disorders),
6 cases; F.60 combined with other HD, 7 cases; F.70 (mild mental retardation), 4
cases; F.70 combined with other HD, 3 cases; F.71 (moderate mental
retardation), 4 cases; F.72 (severe mental retardation), 1 case. (see the attached
graph).
Through the records, it was possible to access data related to Diagnostic Hypothesis
(HD) of 188 active users, the majority F.20 (30.85% or 36.7% if we consider the F.20
combined with other HD).
The number of cases of F.31 combined with other HD is also representative; F.33; F29
(with and without combination with other HD); F.25; F.06 (with and without combination
with other HD); F.32; F.70 and F.71. (6)
• Multidisciplinary team:
The CAPS team is composed of: 1 Principal, Occupational Therapist with higher
education (day shift, 40 hours weekly); 1 psychiatrist that attends three days a week (20 hours
weekly); 2 physical education teachers with higher education, who do activities once a week
each one; 1 psychiatrist nurse with higher education (day shift, 36 hours weekly); 4 nurses on
duty with higher education (12 per 36 hours) and 1 replacement nurse; 1 social assistant with
higher education (day shift, 30 hours weekly); 1 psychologist with higher education (day
shift, 30 hours weekly); 1 psychologist with higher education (day shift, 40 hours weekly); 1
occupational therapist with higher education (day shift, 30 hours weekly); 13 nursing
assistants on duty with secondary education (12 per 36 hours) and 1 dayworker; 2
15
administrative assistants day shift with secondary education; 6 general services assistants on
duty with elementary education and 1 day shift (40 hours weekly); 4 watchmen on duty; 1
receptionist (day shift, 40 hours weekly); 1 day shift driver, totaling 43 employees.
The multidisciplinary team composed of higher education technicians and the nursing
assistants meets daily from 11:30am to 12:30pm for the Change-of-Shift Report, when it is
discussed the cases attended on morning shift and about the "interned", in other words, how
the hosted in HDN are evolving.
Once a week (on Thursdays, from 10am to 12pm), the General Meeting is taken for
discuss cases more detailedly and also several of situations, both therapeutic, of team's
relationship and administrative topic.
Once a month, the higher education technicians go to the Matricial of Mental Health
on the Basic Health Unit (UBS) which references it for discussing cases.
•Activities (see the schedule attached)
•ASSEMBLY: meeting coordinated by the unit's Principal, in order to discuss the
activities, propose ideas, and for critics and suggestions. All users can participate.
•SOCIAL BENEFIT: coordinated by the social assistant, who collects questions
regarding social benefits and proposes actions in this theme. For users and interested relatives.
Closed group, with prior appointment.
•EMBRACEMENT: open group coordinated by the author, a psychologist, in order to
listen to the users’ demands, how it is being their current moment and to welcome them to
CAPS at earlier the week.
•STORIES: open tales and myths workshop coordinated by the author. Aims to create
a bonding, work the unconscious contents and stimulate creativity.
•LIFETIME PROJECT: a closed group, coordinated by two psychologists. Aims to
lead the group to build projects and work on them.
•PSYCHOEDUCATION: open group coordinated by a psychologist. Aims to explain
issues related to treatment and medications.
•FAMILY: open group to all users’ relatives, coordinated by a psychologist. Aims to
welcome and guide the family.
•WALKING: open group, coordinated by the P.E... Aims to promote the body
conditioning, exploring the territory and body awareness.
16
•BODY EXPRESSION: open group, coordinated by P.E. teacher that, through
physical and artistic activities, promotes cultural awareness and social inclusion.
• PHYSICAL ACTIVITY: open group of health orientations, coordinated by P.E.
teacher with physical exercises and stimulation to the user for visiting spaces beyond the
CAPS, enabling social reintegration.
•SELF-CARE: open group coordinated by nursing technicians. Aims to restore users’
self-esteem, providing guidance on hygiene, sexuality and performing actions like haircutting,
shaving, manicure and makeup.
•SALE: coordinated by a nurse technician, which consists in organizing the sale of
donated clothes in order to raise funds to parties and other activities made at the CAPS.
•HANDCRAFT: open workshop coordinated by nursing technicians in aim to promote
bonds with the institution, observing the interaction between users and producing decorations
for the festivities.
•MUSIC GROUP: open group coordinated by a volunteer, which consists in musical
activities, like playing guitar and singing, in aim to link user to treatment and promote
creativity and expression.
•ACQUAINTANCESHIP (DAY HOSPITAL): the users spend the day at CAPS and
eat meals (breakfast, lunch and snack). The nursing team measures the blood pressure and
blood glucose of all. Those with more difficulty or less autonomy in locomotion are taken
with the CAPS transportation.
•Attendance flow:
The host service is "by open doors", which means that everyone who is seeking for an
attendance from Monday to Friday, from 8 to 11am and from 2 to 5pm will be cared by a
professional with higher education.
The hosts on duty evaluate if the user will be inserted on CAPS based on the severity
and diagnostic hypothesis of the case, if there is harm on daily activities and a social
exclusion.
The user stable enough to work, study or maintain its daily activities with autonomy
should be attended at the Basic Health Units (UBS), which must have a mental health team.
To the user in a severity situation, with risks of self and heteroaggressiveness,
crippling bouts of hallucination and delusions, suicidal ideations will be referred to the ER for
17
immediate evaluation by the psychiatrist, and may be forwarded to the CAPS.
The professional on duty, together with the user hosted at the unit, performs a temporary
Single Therapeutic Project (PTS) and schedules a reference attendance with the higher
education technician responsible for the user's residence area.
The technician of reference becomes responsible for constructing the PTS along with the user
and reevaluates it periodically.
The references are organized according to regions. Each region is served by a Basic
Health Unit (UBS). The South-West CAPS attends the population referenced by five UBS.
The PTS includes the possibilities of psychiatric consultations, take part on groups and
workshops, individual consultations, reference attendances, taking medicines under
supervision, inclusion in the CAPS transport service and meals, as needed for each user,
evaluated together with its reference.
There are cases of users that visit the CAPS daily, including weekends, from 8am to 5pm, and
even those who appears from two in two months.
Conclusion
The inability and impossibility of being socially integrated, to live with and enjoy all
community common areas, not only of the CAPS, are stigmas reinforced by the medicalcentered and authoritarian structure of the Institution.
The rules for inclusion on the CAPS are the same rules for social exclusion. Part of the
exclusion is to fit users in a Diagnostic Hypothesis, which ends on serve as a stamp title for
exclusion in any other places.
An example of that authoritarian structure is the fact that, when some user in Day and Night
Hospitality regime (HDN) presents the risk of "escape" of the CAPS, the front gate remains
locked. The control is done by the guard. This procedure is also frequently applied to other
users, who are in Daytime Hospitality (HD) and need to ask permission to leave.
"Who is your reference?"; "What is your project?"; "Have you already taken your medicine?”,
are frequently questions asked to users, proving that the reference, the therapeutic project and
the medicines still are unquestionable and determinant authorities on user's actions.
In practice, the user participates too little of his PTS's building and is rarely encouraged
to autonomy.
18
The CAPS is a place for the excluded and maintain that condition either by the locked and
limited physical space, as for by the authoritarian behavior of professionals to prohibit the exit
without permission when the users are there of their own free will.
The South-West CAPS reaches only a small part of a CAPS purpose, since most of actions
happens inside the institution, focusing the stability of the psychiatric diagnose in prejudice of
the work with the community, the autonomy promotion, intersectorial actions which involves
education, labor, sport, culture, leisure, etc.
The team discussions are focused, most cases, in how the users (called "patients") are, if his
psychiatric condition is stabilized or got worse and which conduct has to be taken to achieve
the target of stabilizing the user's psychiatric presentation.
The author proposes that, from the reflection on practices in South-West CAPS, should be
built an institutional project in order to approximate the today offered service of the antiasylum parameters, to provide a larger social inclusion and autonomy to the users.
•BIBLIOGRAPHIC REFERENCE:
BRASIL,
Lei
nº
10.216,
de
6
de
abril
de
2001,
disponível
em
www.planalto.gov.br/ccivil_03/leis/leis_2001/110216.htm, acessado em 02 de março de
2014.
______ Ministério da Saúde, “Criação e implantação de rede de assistência em Centros de
Atenção Psicossocial para o atendimento de pacientes com Transtornos causados pelo Uso
Prejudicial e/ou dependência de Álcool e outras Drogas (CAPS ad). Brasília, 2004
CRUZ, Marcelo Santos e FERREIRA, Salete Maria Barros; “A rede de saúde na assistência a
usuários de álcool e outras drogas: papel das UBS, CAPS ad, hospitais gerais e hospitais
psiquiátricos” In: BRASIL, Secretaria Nacional Antidrogas, “SUPERA, Sistema Para
Detecção do Uso Abusivo e Dependência de Substâncias Psicoativas: encaminhamento,
Intervenção Breve, Reinserção social e Acompanhamento”, 2006
DIADEMA, Prefeitura de Diadema, Secretaria de Comunicação, disponível em
http://www.diadema.sp.gov.br/municipio/a-cidade/1783-dados-gerais.html, acessado em 16
de julho de 2014.
19
LÜCHMANN, Lígia Helena Hahn., RODRIGUES, Jefferson. O Movimento Antimanicomial
no Brasil. Ciência e Saúde Coletiva. (, 12 (2):399-407, 2007.
ORGANIZAÇÃO PANAMERICANA DE SAÚDE, Classificação Estatística Internacional de
Doenças e Problemas Relacionados à Saúde, Décima Revisão, 2009
SILVA, ACZ, Centros de Atenção Psicossocial In: FARAH, Marta Ferreira Santos,
BARBOZA, Hélio Batista, Novas Experiências de Gestão Pública e Cidadania, 2000).
Programs and services
70
60
50
40
30
20
10
0
DIAGNOSTIC HYPOTHESIS
ICD
F
F
F
F
F
F
F F
F
31
20
29
60
06
32
70 25
44
co
co
co
co
co
co
co co
co
F
F
F
F F
F
F
F F F1
F F F F F F
F
m
m
m
m
m
m
m m
m
20
33
29
25 06
60
32
70 71 0
31 22 23 34 41 44
72
bi
bi
bi
bi
bi
bi
bi bi
bi
ne
ne
ne
ne
ne
ne
ne ne
ne
d
d
d
d
d
d
d d
d
ICD 58 14 12 11 11 11 10 9 7 6 5 5 5 4 4 3 3 2 2 1 1 1 1 1 1 1
ACTIVITIES SCHEDULE
TIME
8:30am
Monday
9:00am EMBRACEMENT
10:00am STORIES
2:00pm
VIDEO
4:00pm
SOCIAL BENEFIT
Tuesday
WALKING
Wednesday
LIFETIME PROJECT
Thursday
Friday
PHYSICAL
ACTIVITY
FAMILY
BODY
AWARENESS
SELF-CARE
HANDCRAFT
ASSEMBLY
PSICHOEDUCATION
MUSIC
GROUP
THE CONTRADICTIONS OF A CENTER OF PSYCHO-SOCIAL ATTENTION
20
SILVA, Arthemis Pavoni Florêncio da
[email protected]
It is difficult to work with the population – who is characterized for the psychic
distress – with the proposal of social reintegration and autonomy promotion, because the
structures of the institutions that handle with that population still classifying them in
psychiatric diagnoses and propose behavior standards, reinforcing stigmas.
Much has already been done in Brazil in favor of deinstitutionalization and social
reintegration of individuals characterized as "people with mental disorders".
For instance, the "Anti-asylum fight"‒which "consists as an important social motion in
the Brazilian society to the extent that it organizes and articulates it in order to transform the
conditions, relations and representations about the insanity in our society" (LÜCHMANN,
2007)‒, and No. 10216 Law which "provides for the protection and rights of people with
mental disorders and redirects the mental health care model" and, among other resolutions,
prohibits "the internment of mental disorders patients with asylum characteristics". In other
words, institutions that don't have "full assistance to people with mental disorders, including
medical services, social assistance, psychological, occupational, recreational and other".
(BRASIL, 2001)
There are mental health services that, in theory, proposes that the individual doesn't
become dependent of the institution, but in practice it fails, because the user now have the
institution as its main place of coexistence. In that way, the user is deprived of other activities
such as access to education, healthcare, culture, labor, in other words, of full social
integration.
We still working in mental health such as the myth of Procrustes Bed, which means
trying to fit individuals into molds, instead of consolidate its autonomy and respect its
alterity.
We will now take as example the work done in a CAPS III located at the outskirts of
Sao Paulo's metropolitan area.
The objective is to describe the attended population, the performed activities and the
working team of the institution and to reflect about the practices.
21
The South-West CAPS
The author is a psychologist in the multidisciplinary team of a CAPS III, the SouthWest CAPS, located in Diadema, Sao Paulo.
It is a city of "population, according to 2010 IBGE Census, of 386.039 inhabitants,
which means a population density of 12.574 persons per square kilometer, the second most
densely populated city in Brazil. It is also the 14th largest economy of the Sao Paulo state and
the 41st largest economy of Brazil . Its GDP per capita in 2010 was R$ 25,900." (DIADEMA,
2014).
Diadema city has three Centers of Psycho-Social Attention III (CAPS III); one ad
CAPS (for alcohol and other drugs treatment) and one juvenile CAPS.
“The Centers of Psycho-Social Attention (CAPS) are units of intensive and daily care
for serious psychological distress carriers, providing an alternative to the model centered on
the psychiatric hospital (…). The CAPS allow users to remain with their families and
communities." (SILVA, 2000)
The CAPS’ III are located in the cities with more than 200.000 inhabitants. It operates
24 hours daily, also on holidays and weekends. (BRASIL, 2006)
The CAPS target, according to the brazilian Ministry of Health is:
Providing treatment in a daily attention regime; manage the therapeutic
projects offering clinical, efficient and personalized care; promote the social
inclusion of users through intersectoral actions involving education, labor,
sports, culture and leisure, assembling joint strategies of coping problems;
organize the network of mental health services of its territory; give support and
supervise the mental health care in the basic health service, Family Health
Program (PSF), Community Health Agents Program (PACS); regulate the
gateway of mental health assistance network of its field; coordinate, along with
the local manager, the supervisory activities of psychiatric hospital units that
operate in its territory; maintain the list of patients that use medicines for mental
health of its region updated. (BRASIL, 2004)
CAPS III are peculiar because they offers a 24 hours day service, which
ends up of being similar to an internment, despite of being called a "24 hour
hosting" or "nightly hospitality regime"
22
For the users who find themselves in more severe situations, such as acute
crisis of depression, self or heteroaggressiveness, the 24 hours hosting is
indicated. This regime has strict rules of schedule, physical and chemical
contention possibilities and the mandatory of stay at the CAPS until medical
discharge.
•The Physical Space
There are CAPS running on buildings that was constructed specifically
for that purpose, however many of it, as the CAPS which we are speaking of,
operates in adapted houses, often inappropriate.
The South-West CAPS operates in a four-floor house with no access for
people with special mobility needs, because there are no ramps or any other
means to access the upper floors, besides the stairs.
On the ground floor, the South-West CAPS has a smoking area, a
reception, a nursing ward and two rooms for appointments, all of that with no
soundproofing walls, since it was improvised in a garage area, with drywalls that
do not reach the ceiling.
The physical space is inappropriate, because there is no privacy to attend the
patients: the rooms do not allow safeguard the privacy of the consultation. In
addition, many consultations are held on a table next to the toilets.
On the first floor, there is a kitchen used to prepare snacks and coffee for
the users and as a mess room for the employees; one living room where the users
spend most of their time watching TV or resting; three bedrooms, where the 24
hours hosting users (Day and Night Hospitality) are allocated, and two bathrooms
for the users, plus a large terrace protected by a safety net.
That space is very inadequate, because people are in risk to fall off the
stairs or of the balconies.
On the second floor there is an open area used for workshops and group
meetings, a mess room and a bathroom.
On the third floor there is a room for administrative business, a bathroom,
a room where the medicines are stored and its separation is made, and another
space where the team meetings are made, where also clothes, supplies and bed
23
sheets of the users are stored. There is also an access to a small terrace in this
floor.
The house frequently has sewer cloggings and electric grid problems, as well as
countless damages on furniture and other problems that are rarely repaired in
time to avoid inconvenience.
•Profile of the population attended, according to the CAPS's registration of
users:
Under the Day Hospital regime, which means that the user goes to the
CAPS in the morning and stays up to 3pm, on average 30 people a day appear at
the CAPS.
Of active users, 55% were males and 45% females. They are, in total, 248
active.
The CAPS users, according to the unit's records, has the following
diagnostic hypothesis (HD), diagnosed by a psychiatrist according to the
International Classification of Diseases (ORGANIZAÇÃO PANAMERICANA
DE SAÚDE, 2009): F.06 (other mental disorders due to known physiological
condition), 9 cases; F.06 combined with other HD, 5 cases; F.10 ( alcohol related
disorders), 3 cases; F.20 (schizophrenia), 58 cases; F.20 combined with other
HD, 11 cases; F.22 (persistent delusional disorders), 1 case; F.23 (acute and
transient psychotic disorders), 1 case; F.25 (schizoaffective disorder), 10 cases;
F.25 combined with other HD, 2 cases; F.29 (unspecified nonorganic psychosis),
11 cases; F.29 combined with other HD, 11 cases; F.31 (bipolar disorder), 2
cases; F.31 combined with other HD, 14 cases; F.32 (depressive episode), 5
cases; F.32 combined with other HD, 5 cases; F.33 (recurrent depressive
disorder), 12 cases; F.34 (persistent mood [affective] disorders), 1 case; F.41
(other anxiety disorders), 1 case; F.44 (dissociative [conversion] disorders), 1
case; F.44 combined with other HD, 1 case; F.60 (specific personality disorders),
6 cases; F.60 combined with other HD, 7 cases; F.70 (mild mental retardation), 4
cases; F.70 combined with other HD, 3 cases; F.71 (moderate mental
retardation), 4 cases; F.72 (severe mental retardation), 1 case. (see the attached
graph).
24
Through the records, it was possible to access data related to Diagnostic Hypothesis
(HD) of 188 active users, the majority F.20 (30.85% or 36.7% if we consider the F.20
combined with other HD).
The number of cases of F.31 combined with other HD is also representative; F.33; F29
(with and without combination with other HD); F.25; F.06 (with and without combination
with other HD); F.32; F.70 and F.71. (6)
• Multidisciplinary team:
The CAPS team is composed of: 1 Principal, Occupational Therapist with higher
education (day shift, 40 hours weekly); 1 psychiatrist that attends three days a week (20 hours
weekly); 2 physical education teachers with higher education, who do activities once a week
each one; 1 psychiatrist nurse with higher education (day shift, 36 hours weekly); 4 nurses on
duty with higher education (12 per 36 hours) and 1 replacement nurse; 1 social assistant with
higher education (day shift, 30 hours weekly); 1 psychologist with higher education (day
shift, 30 hours weekly); 1 psychologist with higher education (day shift, 40 hours weekly); 1
occupational therapist with higher education (day shift, 30 hours weekly); 13 nursing
assistants on duty with secondary education (12 per 36 hours) and 1 dayworker; 2
administrative assistants day shift with secondary education; 6 general services assistants on
duty with elementary education and 1 day shift (40 hours weekly); 4 watchmen on duty; 1
receptionist (day shift, 40 hours weekly); 1 day shift driver, totaling 43 employees.
The multidisciplinary team composed of higher education technicians and the nursing
assistants meets daily from 11:30am to 12:30pm for the Change-of-Shift Report, when it is
discussed the cases attended on morning shift and about the "interned", in other words, how
the hosted in HDN are evolving.
Once a week (on Thursdays, from 10am to 12pm), the General Meeting is taken for
discuss cases more detailedly and also several of situations, both therapeutic, of team's
relationship and administrative topic.
Once a month, the higher education technicians go to the Matricial of Mental Health
on the Basic Health Unit (UBS) which references it for discussing cases.
•Activities (see the schedule attached)
25
•ASSEMBLY: meeting coordinated by the unit's Principal, in order to discuss the
activities, propose ideas, and for critics and suggestions. All users can participate.
•SOCIAL BENEFIT: coordinated by the social assistant, who collects questions
regarding social benefits and proposes actions in this theme. For users and interested relatives.
Closed group, with prior appointment.
•EMBRACEMENT: open group coordinated by the author, a psychologist, in order to
listen to the users’ demands, how it is being their current moment and to welcome them to
CAPS at earlier the week.
•STORIES: open tales and myths workshop coordinated by the author. Aims to create
a bonding, work the unconscious contents and stimulate creativity.
•LIFETIME PROJECT: a closed group, coordinated by two psychologists. Aims to
lead the group to build projects and work on them.
•PSYCHOEDUCATION: open group coordinated by a psychologist. Aims to explain
issues related to treatment and medications.
•FAMILY: open group to all users’ relatives, coordinated by a psychologist. Aims to
welcome and guide the family.
•WALKING: open group, coordinated by the P.E... Aims to promote the body
conditioning, exploring the territory and body awareness.
•BODY EXPRESSION: open group, coordinated by P.E. teacher that, through
physical and artistic activities, promotes cultural awareness and social inclusion.
• PHYSICAL ACTIVITY: open group of health orientations, coordinated by P.E.
teacher with physical exercises and stimulation to the user for visiting spaces beyond the
CAPS, enabling social reintegration.
•SELF-CARE: open group coordinated by nursing technicians. Aims to restore users’
self-esteem, providing guidance on hygiene, sexuality and performing actions like haircutting,
shaving, manicure and makeup.
•SALE: coordinated by a nurse technician, which consists in organizing the sale of
donated clothes in order to raise funds to parties and other activities made at the CAPS.
•HANDCRAFT: open workshop coordinated by nursing technicians in aim to promote
bonds with the institution, observing the interaction between users and producing decorations
for the festivities.
•MUSIC GROUP: open group coordinated by a volunteer, which consists in musical
26
activities, like playing guitar and singing, in aim to link user to treatment and promote
creativity and expression.
•ACQUAINTANCESHIP (DAY HOSPITAL): the users spend the day at CAPS and
eat meals (breakfast, lunch and snack). The nursing team measures the blood pressure and
blood glucose of all. Those with more difficulty or less autonomy in locomotion are taken
with the CAPS transportation.
•Attendance flow:
The host service is "by open doors", which means that everyone who is seeking for an
attendance from Monday to Friday, from 8 to 11am and from 2 to 5pm will be cared by a
professional with higher education.
The hosts on duty evaluate if the user will be inserted on CAPS based on the severity
and diagnostic hypothesis of the case, if there is harm on daily activities and a social
exclusion.
The user stable enough to work, study or maintain its daily activities with autonomy
should be attended at the Basic Health Units (UBS), which must have a mental health team.
To the user in a severity situation, with risks of self and heteroaggressiveness,
crippling bouts of hallucination and delusions, suicidal ideations will be referred to the ER for
immediate evaluation by the psychiatrist, and may be forwarded to the CAPS.
The professional on duty, together with the user hosted at the unit, performs a temporary
Single Therapeutic Project (PTS) and schedules a reference attendance with the higher
education technician responsible for the user's residence area.
The technician of reference becomes responsible for constructing the PTS along with the user
and reevaluates it periodically.
The references are organized according to regions. Each region is served by a Basic
Health Unit (UBS). The South-West CAPS attends the population referenced by five UBS.
The PTS includes the possibilities of psychiatric consultations, take part on groups and
workshops, individual consultations, reference attendances, taking medicines under
supervision, inclusion in the CAPS transport service and meals, as needed for each user,
evaluated together with its reference.
There are cases of users that visit the CAPS daily, including weekends, from 8am to 5pm, and
even those who appears from two in two months.
27
Conclusion
The inability and impossibility of being socially integrated, to live with and enjoy all
community common areas, not only of the CAPS, are stigmas reinforced by the medicalcentered and authoritarian structure of the Institution.
The rules for inclusion on the CAPS are the same rules for social exclusion. Part of the
exclusion is to fit users in a Diagnostic Hypothesis, which ends on serve as a stamp title for
exclusion in any other places.
An example of that authoritarian structure is the fact that, when some user in Day and Night
Hospitality regime (HDN) presents the risk of "escape" of the CAPS, the front gate remains
locked. The control is done by the guard. This procedure is also frequently applied to other
users, who are in Daytime Hospitality (HD) and need to ask permission to leave.
"Who is your reference?"; "What is your project?"; "Have you already taken your medicine?”,
are frequently questions asked to users, proving that the reference, the therapeutic project and
the medicines still are unquestionable and determinant authorities on user's actions.
In practice, the user participates too little of his PTS's building and is rarely encouraged
to autonomy.
The CAPS is a place for the excluded and maintain that condition either by the locked and
limited physical space, as for by the authoritarian behavior of professionals to prohibit the exit
without permission when the users are there of their own free will.
The South-West CAPS reaches only a small part of a CAPS purpose, since most of actions
happens inside the institution, focusing the stability of the psychiatric diagnose in prejudice of
the work with the community, the autonomy promotion, intersectorial actions which involves
education, labor, sport, culture, leisure, etc.
The team discussions are focused, most cases, in how the users (called "patients") are, if his
psychiatric condition is stabilized or got worse and which conduct has to be taken to achieve
the target of stabilizing the user's psychiatric presentation.
The author proposes that, from the reflection on practices in South-West CAPS, should be
built an institutional project in order to approximate the today offered service of the antiasylum parameters, to provide a larger social inclusion and autonomy to the users.
28
•BIBLIOGRAPHIC REFERENCE:
BRASIL,
Lei
nº
10.216,
de
6
de
abril
de
2001,
disponível
em
www.planalto.gov.br/ccivil_03/leis/leis_2001/110216.htm, acessado em 02 de março de
2014.
______ Ministério da Saúde, “Criação e implantação de rede de assistência em Centros de
Atenção Psicossocial para o atendimento de pacientes com Transtornos causados pelo Uso
Prejudicial e/ou dependência de Álcool e outras Drogas (CAPS ad). Brasília, 2004
CRUZ, Marcelo Santos e FERREIRA, Salete Maria Barros; “A rede de saúde na assistência a
usuários de álcool e outras drogas: papel das UBS, CAPS ad, hospitais gerais e hospitais
psiquiátricos” In: BRASIL, Secretaria Nacional Antidrogas, “SUPERA, Sistema Para
Detecção do Uso Abusivo e Dependência de Substâncias Psicoativas: encaminhamento,
Intervenção Breve, Reinserção social e Acompanhamento”, 2006
DIADEMA, Prefeitura de Diadema, Secretaria de Comunicação, disponível em
http://www.diadema.sp.gov.br/municipio/a-cidade/1783-dados-gerais.html, acessado em 16
de julho de 2014.
LÜCHMANN, Lígia Helena Hahn., RODRIGUES, Jefferson. O Movimento Antimanicomial
no Brasil. Ciência e Saúde Coletiva. (, 12 (2):399-407, 2007.
ORGANIZAÇÃO PANAMERICANA DE SAÚDE, Classificação Estatística Internacional de
Doenças e Problemas Relacionados à Saúde, Décima Revisão, 2009
SILVA, ACZ, Centros de Atenção Psicossocial In: FARAH, Marta Ferreira Santos,
BARBOZA, Hélio Batista, Novas Experiências de Gestão Pública e Cidadania, 2000).
Programs and services
29
70
60
50
40
30
20
10
0
DIAGNOSTIC HYPOTHESIS
ICD
F
F
F
F
F
F
F F
F
31
20
29
60
06
32
70 25
44
co
co
co
co
co
co
co co
co
F
F
F
F F
F
F
F F F1
F F F F F F
F
m
m
m
m
m
m
m m
m
20
33
29
25 06
60
32
70 71 0
31 22 23 34 41 44
72
bi
bi
bi
bi
bi
bi
bi bi
bi
ne
ne
ne
ne
ne
ne
ne ne
ne
d
d
d
d
d
d
d d
d
ICD 58 14 12 11 11 11 10 9 7 6 5 5 5 4 4 3 3 2 2 1 1 1 1 1 1 1
ACTIVITIES SCHEDULE
TIME
8:30am
Monday
9:00am EMBRACEMENT
10:00am STORIES
2:00pm
VIDEO
4:00pm
SOCIAL BENEFIT
Tuesday
WALKING
Wednesday
LIFETIME PROJECT
Thursday
Friday
PHYSICAL
ACTIVITY
FAMILY
BODY
AWARENESS
SELF-CARE
HANDCRAFT
ASSEMBLY
PSICHOEDUCATION
MUSIC
GROUP
30
31