MATRIX SUPPORT IN MENTAL HEALTH ACCORDING TO THE PROFESSIONALS OF THE FAMILY HEALTH STRATEGY

Abstracts

The aim of this research was to understand the meaning of the matrix support for mental health offered by the staff of a Centro de Atenção Psicossocial - CAPS (Psychosocial Care Center) under professionals working in three units of the Estatégia de Saúde da Família - ESF (Family Health Strategy) in Goiânia, Goiás. Twelve professionals were interviewed from a semi-structured interview, consisting of open and closed questions, which investigated: demographic data of the participants; vocational training; working time in the ESF; understanding of the matrix support. The data pointed to joint activities among the CAPS and the family health teams, and the CAPS psychiatrist and psychologist professionals have been most often associated to the matrix support. The study also identified that was requested the matrix support for users who needed medication review and who had previous psychiatric diagnosis or inappropriate behavior. According to the interviewers, the importance of reviewing the medication and the presence of the CAPS in the territory were positives aspects related to the matrix support, which indicates the existence of the medical knowledge as a guiding behaviors and a distant care of integrality. The article concludes that the family health teams recognize the contribution of the logic of the matrix support, but that is centered on an understanding of biologicist character on psychological distress.

Matrix support; psychosocial care center; family health

O objetivo desta pesquisa consistiu em compreender o sentido do apoio matricial em saúde mental oferecido pela equipe de um Centro de Atenção Psicossocial (CAPS) segundo profissionais que atuavam em três unidades da Estratégia de Saude da Família (ESF) em Goiânia, Goiás. Foram entrevistados doze profissionais a partir de um roteiro semiestruturado, formado por questões abertas e fechadas, que investigou dados sociodemográficos dos participantes, formação profissional, tempo de trabalho na ESF e compreensão sobre o apoio matricial. Os dados apontaram a realização de atividades conjuntas entre as equipes do CAPS e da Saúde da Família, sendo o psiquiatra e o psicólogo os profissionais do CAPS mais frequentemente associados ao matriciamento. O estudo ainda identificou que era solicitado apoio matricial para usuários que necessitavam de revisão de medicação e que possuíam diagnóstico psiquiátrico prévio ou comportamentos inadequados. Para os entrevistados, a importância da revisão da medicação e a presença do CAPS no território foram pontos positivos do matriciamento, o que denota a existência do saber médico como orientador das condutas e um cuidado distante da integralidade. Conclui-se que as equipes de Saúde da Família reconhecem a contribuição da lógica do apoio matricial, mas que esta lógica encontra-se centrada em uma compreensão de caráter biologicista sobre o sofrimento psíquico.

Apoio matricial; centro de atenção psicossocial; saúde da família

El objetivo de esta investigación fue comprender el significado del apoyo matricial en salud mental ofrecido por el equipo de un Centro de Atención Psicosocial (CAPS) según profesionales que actuaban en tres unidades de la Estrategia de Salud de la Familia (ESF) en Goiânia-GO. Fueron entrevistados doce profesionales mediante un guión semiestructurado, formado por preguntas abiertas y cerradas, que investigó: datos demográficos de los participantes; la formación profesional; el tiempo de trabajo en la ESF; la comprensión sobre el apoyo matricial. Los datos apuntaron la realización de actividades conjuntas entre los equipos del CAPS y de la Salud de la Familia, siendo el psiquiatra y el psicólogo los profesionales del CAPS más frecuentemente asociados al apoyo matricial. El estudio también identificó que se les pidió el apoyo matricial para los usuarios que necesitaban de revisión de la medicación y que tenían un diagnóstico psiquiátrico previo o comportamientos indecuados. Según los entrevistados, la importancia de la revisión de la medicación y la presencia del CAPS en el territorio fueron puntos positivos del apoyo matricial, lo que denota la existencia del conocimiento médico como orientador de las conductas y una atención distante de la integralidad. Se concluye que los equipos de Salud de la Familia reconocen la contribución de la lógica del apoyo matricial, aunque ésta se centra en una comprensión del carácter biologicista sobre el sufrimiento psíquico.

Apoyo matricial; centro de atención psicosocial; salud de la familia

The subject of this article was the matrix support in mental health carried out by a staff of a Centro de Atenção Psicossocial - CAPS (Psychosocial Care Center) closely with the primary care. According to the Ministério da Saúde - Health Ministry (2004), a CAPS can be defined as an equipment of open mental health, community and connected to the Sistema Único de Saúde - SUS (Unified Health System), which works as a reference and treatment unit for people with severe or persistent mental disorders. These frameworks imply the need for intensive, community and personalized care.

The services offered by the CAPS are held outdoors, located within its territory and the subject / user must be considered in his social, interactional and existential aspects, which implies in multidimensional and comprehensive support from the staff. Thus, the CAPS aims, besides attending the users on its region, to provide them the full exercise of citizenship and greater interaction among the members of the family and the community (Ministério da Saúde 2004).

According to the Ministério da Saúde (2004), the CAPS differ according to the size, physical structure, therapeutic activities, the number and diversity of professionals, and the specific type of demand. It can be noted, regarding the users and opening hours, that: (a) the CAPS I, II and III daily serve adults with severe and persistent mental disorders, and the CAPS III operates 24 hours, seven days a week; (b) the CAPSi serves, daily, children and adolescents with mental disorders; and (c) the CAPSad serves users with disorders arising from the use and alcohol and other drugs addiction, in a harm reduction perspective.

On the CAPS, users are assisted through medical consultations, individual and / or group psychotherapy, therapeutic workshops, community activities, among others. The activities that can benefit a user is defined from an individualized therapeutic project that focuses on offering the necessary treatment, respecting individual possibilities and seeking to rehabilitate the subject in all the psychosocial aspects (Onocko-Campos & Furtado, 2006).

By offering the daily service, the CAPS aims to prevent psychiatric hospitalizations, to articulate the network to guarantee the rights of the users, to provide support / assistance to other service units in the primary healthcare system. Thus, the CAPS should be within their coverage area, the main articulator of attention and mental health policy network (Onocko-Campos & Furtado, 2006).

One of the main strategies developed by the CAPS to joint care network is the realization of the Matrix Support or Matrix, understood as "a new way to produce health in which two or more teams in a shared building process, create a proposed pedagogical-therapeutic intervention" (Chiaverini, 2011, p.13).

In the health field, the word matrix indicates the possibility of "suggesting that reference professionals and specialists maintain a horizontal and not vertical relationship, as recommended by the tradition of health systems" (Campos & Domitti cited by Penido, Alves, Sena, & Freitas, 2010, p.472). In turn, the term support indicates a horizontal relationship, without authority, based on dialogic procedures. The same authors point out that the matrix support can be developed through the exchange of knowledge, from providing guidance, joint interventions, complementary interventions by the supporter, but always with the reference team with responsibility for the case, even if the expert support is needed at different times.

The tools used by the professionals to perform the matrix include: the development of the unique therapeutic project in matrix support of mental health; the interconsultation; joint home visit; contact distance; the Genogram; the Ecomap; continuing education in mental health; beyond the creation of groups in the primary health care (Chiaverini, 2011).

The matrix support for mental health in the primary care involves an important articulation that must be performed between CAPS and the family health teams (Barban & Oliveira, 2007; Bezerra & Dimenstein, 2008; Bezerra et al, 2009; Jorge, Souza, & Franco, 2013). Since 1994, the federal government started to encourage the implementation of the Programa Saude da Família - Family Health Program (now the Estratégia de Saúde da Família - ESF (Family Health Strategy) in the primary care in the municipalities. This new strategy seeks to tackle public health problems, such as the overcrowding and the centralization of specialized equipment (secondary and tertiary), the low resolution and the illness chronicity. Thus, the teams of the ESF have health responsibility and provide a service through an interdisciplinary team (Chiaverini, 2011).

The relationship among the ESF and the staff of the CAPS mental health team appears as a new organizational and methodological arrangement that allows a broader look at the clinic, besides enriching dialogue among professionals from various specialties (Chiaverini, 2011). Thus, according to the literature, the actions of the matrix support in mental health should come from the CAPS, which is an equipment that occupies a prominent place in the promotion of mental health from the Psychiatric Reform (Bezerra et al., 2009).

According to Toloi and Fortes (2005/2007), the proposed Matrix Support in Mental Health applied to the EFS requires interaction between specialized teams (CAPS) and family health teams and the matrix support the official strategy elected by the Ministério da Saúde to guide the actions of mental health in the primary care. For the work of the matrix teams be more effective, it is necessary to have a greater coordination with the primary care teams (ESF) As they are the teams that are closer to families and communities, they are of fundamental importance for the users to have coverage and treatment for mental illness (Bezerra et al., 2009), as well as other targeted strategies to promote mental health.

In Natal-RN, Brazil, the implementation of the matrix support by the CAPS aimed at empowerment of the primary care team to ensure broad access to mental health care to the population (Bezerra & Dimenstein, 2008). Traditional interventions such as the renewal of prescriptions were one of the most sought actions by the users. The ESF professionals felt need for support to improve the welcome. Besides, these profissionals perceived the matrix support as a channel to express their anxieties of daily work. Difficulties in handling cases of mental health in the territory were reported by community workers to matrix supporters in Bahia, such as how to seek the closest approach with the family when it shows no interest and how to deal with a person in crisis (Silva, Santos & Souza, 2012).

From 2008, with the establishment of the Núcleos de Apoio à Saúde da Família - NASF (Support Centres for Family Health ), the matrix support became the responsibility of the teams of the NASF, closely to the primary care, involving existing equipment in the territory (such as the CAPS, schools, units health). According to MS Ordinance 154/2008 (Ministério da Saúde, 2008), the NASF should seek the qualification of ESF work in order to have integrality in the user care from the physical and mental standpoint. In the case of the matrix support in mental health, the NASF teams should provide support for the cases of people with mental illness, develop strategies for vulnerable groups to improve care, avoid actions that promote the medicalization and psychiatrization, not spread the hospice model care, develop partnership with families to care for users and mobilize community resources to develop the necessary actions to the served populations by the ESF.

In January 2014, the country had 5,352 municipalities with family health teams, which amounted to 57% of national coverage. In the same period, there were 2624 NASF accredited by the Ministério da Saúde, so only a small part of Brazilian municipalities had NASF in operation (Ministério da Saúde, 2014).

RESEARCH PROBLEMS

In the city of Goiania, where this study was conducted, only one NASF (Bairro São Carlos NASF) was in operation in 2014, covering only part of one of the five health districts of the municipality (Municipality of Goiania, 2014). Thus, the matrix in mental health in the primary care occurred primarily under the responsibility of the CAPS.

The matrix topic is relatively new and there are few publications about how they have being implemented in the Central-West region of Brazil. This project arose from the need to understand the direction of matrix actions for family health teams supported by a CAPS located in Goiania-Goias, considering that: a) a large number of users sent to the CAPS were welcomed in this service, but by "failing to the CAPS profile", according to the team, they were sent to other network services; b) the users scheduled for the ESF did not show up for the first service in the CAPS.

Facing to what was previously stated, the aim of this study was to understand the meaning of the matrix support for mental health for ESF professionals. The specific objectives were to identify, according to the ESF professionals: (a) the CAPS role; (b) which professionals can perform the matrix support; (c) the appropriate actions to matrix support; (d) the criteria used by the ESF teams to direct the users to the CAPS.

METHOD PARTICIPANTS

he study gathered twelve professionals from three family health teams who were matrixed by the Beija-Flor CAPS.

The following inclusion criteria were adopted: join a team of the three Unidade de Atenção Básica à Saúde da Família - UABSF (Basic Care for the Family Health Unit) matrixed by the II and IV teams of the Beija Flor CAPS and have availability to provide taped interview. Besides the profile described above, it is highlighted also the convenience criterion, because the ESF teams matrixed by the II and IV teams of the Beija Flor CAPS were those who the authors could invite to participate given the available schedules for the data collection. It was adopted as a criterion for exclusion: working time in the ESF lower than 2 months.

Local

It was chosen as the local, three UABSF which received the matrix support from the Beija-Flor CAPS, Goiania-GO, in 2013. The CAPS was opened in 2003 to care for adults with severe and persistent mental disorders, in an area of about 500,000 inhabitants, which includes the Goiânia Southwest District Health. This region has 32 Equipes de Saúde da Família - ESF (Family Health Teams), covering 20 microregions (Secretaria Municipal de Saúde de Goiânia - Municipal Health Secretary of Goiania, 2011). At the time of the collection, the staff of the CAPS consisted of 38 employees, 25 top-level technicians and 13 professional of primary and secondary education level (Secretaria Municipal de Saúde de Gioânia, 2013). In January 2013, there were 230 active users with registration, from them 85 in intensive care, 127 semi-intensive and 21 non-intensive. From January to November 2012, 221 welcomes were scheduled, 47 people were bound, 59 referred to other services, 46 users waited a case study and 69 people did not attend the reception (Secretaria Municipal de Saúde de Gioânia, 2013b).

The matrix activities along the teams were organized into four main focuses: (1) to raise the teams awareness that are not matrixed yet; (2) to enable the ESF teams, seeking to provide scientific basis so that the professionals could conduct the cases; (3) to provide technical advice; (4) to promote expansion of the matrix to other ESF units covered by the Beija-Flor CAPS (Secretaria Municipal de Saúde de Gioânia, 2011).

After initial actions to raise awareness of the family health teams about the role of the CAPS, the matrix was performed on each unit once a month, with previous day and time schedule. Before that date, the Agentes Comunitários de Saúde - ACS (Community Health Agents) made a survey of all the users that they found in their territory with psychiatric history or current issues in the field of mental health, and on the appointed day, the CAPS experts attended the family health unit to discuss with the ACS as well as nurses and sometimes with the doctor, and to set behaviors such as: (a) the user could be served in the unit in interconsultation; (b) conducting home visits; (c) schedule host in the CAPS when it is realized, by the ACS reporting, that the user already has profile for the CAPS.

Instrument

It was elaborated an interview guide consisting of open and closed questions from the study of the texts by Chiaverini (2011), Rose and Cunha (2012) and Tofoli and Fortes (2005-2007) about the Matrix Support on Mental Health. The research script was investigating: (a) demographic data of the participants; (b) vocational training and working time in the ESF; (c) understanding of the matrix support (matrix support professionals who perform, actions of matrix support and referral criteria for the CAPS).

Data collection procedures

The interview script was tested on a member of the family health team in the area not covered by this project before the start of data collection (instrument/ interview pilot pre-test), allowing the discussion of the relevance and the order of the objective and opened questions by the authors. After the pilot interview, some adjustments were made in the instrument. To begin collecting, a visit to each health unit family to exposure of the goals and procedures of the research and scheduling date for data collection, which was held in a private room of the health service itself was conducted.

Ethical aspects

The project was referred for evaluation and authorization of the Secretaria Municipal de Saúde de Goiânia (Goiânia SMS) and then forwarded to the Ethics Committee on Human Research of the PUC-Goias, then it has been approved by the Opinion 362 648/2013. The research began after deliverying a copy of the Opinion to the Goiania SMS to obtain the referral / authorization of placing in service for data collection. The Free Informed Consent Instrument was used for all the participants, which ensures, according to CNS Resolution 466/2012, the identity secrecy as well as the free participation in the study.

To protect the identity of the respondents, acronyms were adopted. Thus, the first respondent means S1, S2 denotes the second and so sucessively. Another precaution to ensure confidentiality to the participants regarding the non-disclosure of the UABSF names whose practitioners were interviewed.

Methods of data analysis

The objective questions were entered into a spreadsheet to calculate the frequencies and percentages of responses with SPSS software. The open questions were transcribed for content analysis, followed those steps outlined by Bardin (1977): (a) pre-analysis, (b) exploration of the material and (c) treatment of the results, inference and interpretation.

RESULTS AND DISCUSSION

Among the respondents, the majority were female (11), with a mean age of 37 years (between 26 and 51 years), married (07), having completed high school (08). Most worked as a community health agent (09), a doctor and two nurses. The working week was 40 hours. Among the participants, seven worked for more than four years in the family health teams, with minimal binding of 7 months and a maximum of 13 years and the maximum length of experience in the health services was equal to 20 years.

The Table 1 presents the participants' understanding of the matrix support from the answers to objective questions. According to the respondents, joint activities are those that occur most frequently, in the matrix support there is little afraid in relation to the contact with the user with a mental disorder by the interviewees, as well as the understanding of the need for support from the CAPS to the users served by the ESF and frequent meetings.

On the perception that this staff that were interviewed had about the ESF professionals who can perform the matrix, the answers that most frequently involved the categories that occupy a prominent place or tradition in mental health (psychiatrist, psychologist). However, as the data showed, the number of occupational categories that can perform this support is much broader and encompasses many areas of knowledge and wisdom.

Table 1
Participants´ Understanding About the Matrix Support in Mental Health.

The joint activities realized by the CAPS-ESF and frequent meetings aim initially for an understanding of the direction of the matrix by respondents, considering that the matrix support is defined as the production of health in shared activity among the teams (Chiaverini, 2011). The data presented in Table 1 point for conducting joint operations, according to all participants, joint home visits (83%) and knowledge sharing among the teams (81%). Similarly, 11 respondents (91%) did not associate the matrix forwarding the user to the expert or the interventions under responsability only by the CAPS, which denotes the emphasis on working together the ESF-CAPS.

According to Penido et al (2010), deleting the exercise of the routing logic and the encouragement of interdisciplinary practices to comprehensive health care, in addition to "the increase of the response capacity of health problems for the local team and the streamlining of the access and the use of specialized resources" (p. 468), are targets of the matrix support. The answers about not having been trained to deal with people with psychiatric disorders, question answered positively by only 3 respondents (25%) or fear of being assaulted (33%), can be highlighted as an expression of this resolutive capacity.

Reasons for requesting matricial - Review and adjustments in medication

Half of the respondents indicated the need for the user re-evaluation medical, by the CAPS team, as a justification for requesting the matrix support: "Those patients who come often, who we try to talk and/or to medicate, but which does not seem to have any effect, so we feel the need of a more qualified person for this" (S7). The revision or adjustment of medication was seen as a necessity due to various situations, such as: users whose prescription was repeated by a general practitioner for a long time, users who need to take injectable medication, users who need medication prescribed by a specialist in mental health.

So that medication that he was taking was prescribed for more than last 10 years ... He was sent to the CAPS staff and he could not take pills and neither drop remedies, so in his case, he takes injection so far. The CAPS staff brings injection and he comes here to take. (S4).

As observed when analyzing the data presented in this study, the ESF professionals who were interviewed were able to understand the actions of the matrix support as predominantly those involving drug prescriptions and guidelines, as highlighted by Jorge et al. (2013). In the study, the authors felt that medication was the main item considered as the construction of the therapeutic projects on the family health strategy. Even more broadly, the article by Bezerra et al. (2009) concluded that the drug was seen as the main therapeutic practice in the public health services. In this sense we can see a matrix understanding by professionals of family health strategies in line with the daily practice of the SUS, but with an ignorance of the implications and changes which the matrix support proposes when breaking the hierarchy of services, with the reference and counter-reference logic, besides offering interdisciplinary and generalist support.

According to Pinto et al. (2012), when the action most commonly requested to the matrix support is a medical consultation, which reveals the emphasis on the medical model, in the so-called hard technologies, rather than the behaviors construction involving co-responsibilities of professionals, relatives and resources from the territory. This practice implies rarely in comprehensive care and often medicine prescriptions, as conduct (Jorge, Souza, & Bessa, 2013).

Psychiatric diagnosis

More than half of the respondents' professionals requested the matrix support when they believed that the user had a psychiatric diagnosis. They reported that, in most cases, these users did not consider themselves ill, did not accept the treatment, not taking the prescribed medication, in addition to having inappropriate behavior "By that person happens to us, we realize that the person is having something, but this diagnosis I can not do, I don´t know how to do it, but we realize that the user has something wrong" (S3).

The respondents' professionals reported some users behaviors that motivated the matrix support requested, such as: aggression, undress in public, using disconnected words, do not leave the house for fear of being persecuted and suicide attempt: "People sometimes report suicide attempt ... They are people who are very isolated, they cry a lot, who have no perspective of life. That´s why I ask for help [to the CAPS]" (S10).

The interviews describe an expectation for the diagnosis and medicalization of the user in order to control their behavior and consequently they are far from mental health care model in the perspective from Psychiatric Reform and from the SUS, as they approached the medical rationality, centered in the sickness and in the individual sessions (Yasui, 2007). The mental health care advocated by the ideals of the Psychiatric Reform privilege the collective attention in the territory, with the prospect of intersectoral work and social inclusion. Although the answers to objective questions have highlighted the joint care ESF-CAPS, which is in line with the perspective of the matrix support, the answers to open questions pointed to the individual care and centered in the figure of the psychiatrist, therefore, with little emphasis to the interdisciplinary actions.

The direction of the matrix support, according to the respondents, does not point to a fundamental change of perspective on the logic of building mental health care because it highlights the need for medicalization and psychiatrization (Brazil, 2008). The strategies building for the care of the most vulnerable groups do not appear in the interviews, indicating an individual tracking of cases through psychiatric consultation and often scheduling a medical appointment to the CAPS user, i.e., forwarding the person to service. The creation of strategies which involves health teams is only secondary.

Benefits due to Matrix - Drug prescription

The respondents reported as matrix benefits a more efficient drug prescription, once done by professionals with expertise in the psychiatric area. They also pointed out the ease of obtaining these drugs in the public service, and the appointments occur more quickly and without a bureaucratic form, since it is already scheduled the appointment for the next month.

I think the benefit is this: the patient will not be unaccompanied, without medication. I think it was a benefit, particularly for patients who become aggressive without medication; so that they can attack someone on the street or can attempt against the very same life. (S1)

Only the ease of contact with these people and not that expectation that lasts much time in the system while waiting for that openig, whether or not to treat if it is the case of caring there [in the CAPS] or not ... So these benefits avoid all this trouble, all this waiting, huh? (S2).

The interviewers pointed out as one of the benefits of matrix is a more effective and resolute prescriptions, once made by professional experts. The work of the specialist mental health in the primary care is very important, because according to the participants, the mental disorders users often have repeated prescription by doctors of the basic units for years without the user being reevaluated by a psychiatrist. However, having the matrix conducted by this only bias is to limit the work that is characterized by an understanding of health from a broader and integrative way, which requires interdisciplinary knowledge that expands with the participation of diverse specialties (Bezerra & Dimenstein 2008). The analysis of the interviews allowed to observe that to the participants the matrix support is almost a synonymous of psychiatric evaluation and drug prescriptions.

The prospect of respondents denotes an understanding of mental health as the absence of unpleasant or aggressive behavior, which leads to an understanding biologicist linked to the psychiatric diagnosis and not to the broader understanding of health. This understanding per se also explains the importance of the physician to evaluate, to diagnose and to control the inappropriate behavior.

Del Barro, Perron and Ouellette (2010) ask us if the psychotropic medications are the answer to suffering in the mental health field. The pharmacological approach parallels the biological view of psychopathological disorders. When one seeks psychiatric care and having his difficulties understood as psychiatric symptoms, there is the possibility of a diagnosis accompanied by pharmacology. Moreover, we must emphasize that thre interviews with professionals also highlighted that a large number of users have no received a timely re-evaluation, which may contribute to the emergence of problems related to the inadequate dosage of psychotropic drugs, a fact that must be avoided.

Observed improvement in the user behavior

Another benefit reported by professionals refers to the significant improvements of user behavior in terms of self-esteem, the perspectives for life, planning for the future, the decrease in aggression and inappropriate behavior manifested.

There is a case of a boy who lived a closed existence into the bedroom and from the appointments and medication, he went on to open the windows, to study, he decreased the aggressiveness. And another patient reduced the crises she had. So I think it's very important. (S3).

According to the interviews, the users who receive support through the CAPS matrix support feel more welcome, respected and confident to continue treatment and they are more frequent to the appointments.

There is a patient who has received help from the CAPS staff and even today when he sees me, he thanked me about his feeding. Today he has a super healthy food, take better care of himself after this intervention. It is better the relationship with his relatives. So, thus, there are many benefits and only the patients could benefit from. (S4).

The link between the ESF professionals and the users raises the possibility that mental health interventions are performed by the same, this implies the need to offer tools (knowledge and practices) to these teams and to discuss the complexity of psychological distress to those teams ( Barban & Oliveira, 2007).

Support to the UABSF teams

Another benefit of matrix appointed by the professionals was the support to the ESF staff. The professionals feel more confident in carrying out their work, since it is backed by the CAPS technical staff. Moreover, with the training done by the team of mental health, the ESF professional's teams have a specialized rearguard and their professional needs are well accepted and discussed with the CAPS team. One respondent noted that: "It facilitated more the conversations with patients. We have more confidence ´cause we know where to run at the moment we needed" (S3).

For me, as a nurse, I think it makes me safer to be dealing with the patient. When the patient come he has more affection with us, more freedom, too ... The CAPS seems to bring a little more comfort to us. I felt safer with the presence of the CAPS and it helped me a lot as a professional. (S7).

A positive aspect observed in the development of the activities of the matrix support process is the exchange of knowledge and guidance among the CAPS staff and the primary care teams. As noted in the study of Pinto et al. (2012), the professionals should share information about the territory, about the clinical requirements and procedures regarding the approach and management of cases, because it allows for better resolution. When the teams are meant to share their experiences and the encountered difficulties, the work becomes clearer and with the exchange of knowledge, the ability of immediate solutions expands and the effectiveness of the actions are developed. The training in mental health, such strategies of the matrix team to transfer knowledge and practices were not offered to all the interviewed ESF professionals. These professionals seek to find resolution to cases by offering support, discussing with the team itself from the basic unit with the team itself looking for possible mechanisms to solve the demands that arise. So, rather than empower, the strategies of the CAPS must also include to raise awareness of the matrixed teams, in order to understand their anxieties in dealing with the user who is in mental distress, their main anxieties, their doubts and listen attentively and warmly their demands because these professionals have always something to say to the users, even though in an intuitively way (Silva et al, 2012).

The CAPS presence in the territory

Another important aspect was reported by the respondents was related to the presence of the CAPS in the territory. This decreases the reference and the counter-reference, the time the users wait for an appointment, and, in addition, the users do not need to move to other points of the care network, being assisted in their own locality or territory:

These patients we identified ... we often had nothing to do with them. We put in the routing system and do not know when it would happen. We had no counter-reference from that patient, but today as this work is set to be accomplished jointly, we know what is being done, we follow that patient. So sure, for the part of mental health, we notice a big improvement now. (S12).

As it is near here, and as they [CAPS professionals] have been so very affectionate, not mentioning the way how the matter was discussed, it was great because it was all very close. Close to the family, the house and easier to access. (S9).

According to Bezerra et al. (2009), the ESF teams are closer to families and communities, so they are of fundamental importance for the users to have coverage and treatment for mental illness. In this respect, the professionals understand that many users of primary care really need specialized mental health care. This insight shows that these professionals understand their territory and its main demands because they handle day by day with people and their illnesses. It is important, in this sense, to offer to the ESF professionals the opportunity to increase their knowledge because they provide a service in the tip of the system and the more knowledge they have, the more their actions will be assertive (Silva et al., 2012).

The interviewed Professionals noted the importance of the presence of the CAPS in the territory, taking care for the user in the context of his life. By offering this service on the user's environment there are many advantages. First, a greater proximity between the matrix team and the user, thus allowing the construction of extremely important links related to the mental health work. Secondly, the user is not subjected to the inconvenience of moving out of his house to withdraw the medication from the other side of town. Third, joint visits allow all professionals to understand the family dynamics and its interferences. At this time, the specialized literature shows that it is possible to construct the genogram and the ecomap, the matrix tools that helps in the understanding of intra-household and intrasociais dynamics (Chiaverini, 2011); however, these instruments have not been used by the matrix teams in the development of the work in the family health units. The most benefited from the presence of the CAPS in the territory is the user himself since the ESF and the CSPS professionals are building a new model of care (Bezerra et al., 2009).

FINAL THOUGHTS

The practice of matrix can contribute to the reduction of the referrals users from primary care to the CAPS, due to the presence of experts in the area covered by the ESF, giving immediate solutions to the cases on their own territory. Another important aspect that was observed was the interaction between professionals from different specialties. This interdisciplinarity provides an exchange of knowledge and practices in the conduct of important cases with multidetermined demands.

The study pointed out that an improvement is needed in the practices of the matrix support, since so much of the focus is concentrated on the figure of the psychiatrist and the biomedical model of care. Many are the categories that make up the professional staff of the CAPS; so many contributions can be given for the most diverse areas of knowledge for the primary care matrix. This centralization demonstrates the logic of specialized work in mental health, apart from the logic of shared and comprehensive care to individuals and groups in the covered area. The highlight for the medical appointment from the psychiatrist to the ESF user in the family health unit or referring the user to be assisted by the CAPS reveals the professional intervention on the disease, rather than the case study, the joint development of strategies involving different actors and the resources in the territory.

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Publication Dates

• Publication in this collection
  Oct-Dec 2014

History

• Received
  06 Apr 2014
• Accepted
  16 Oct 2014