Abstract

This article focuses on the inter-subjective aspects involved in the care of psychosocial crises of adolescents, their representations and developments. A qualitative research was developed from a psycho-sociological perspective by constructing life story narratives of adolescents treated at a Psychosocial Care Center for Children and Adolescents (CAPSi). It was based on the theoretical contributions of René Kaës on group and cultural aspects of the crisis, as well as its relation to adolescence. Life narratives, constructed through in-depth interviews with adolescents, close relatives, and CAPSi caretakers depict crisis as a “surprise”, as violence and estrangement, an episode that must be forgotten, denied, silenced, and medicalized. We concluded that the crisis involves strong mental suffering for adolescents, for the people close to them, and for caretakers, which calls into question the possibilities and limits of care. We, therefore, highlight the importance of protected spaces in both the institution and the health network that would allow the collective construction of new meanings, representations and destinies of crisis, both by users and caretakers.

Key words
Adolescence; Crisis; Psychosocial care; Life narratives; Psychosociology

Introduction

Attention to situations of psychosocial crisis is considered one of the most difficult aspects and, at the same time, strategic of the public assistance in Health Mental¹1. Pitta AMF. Um balanço da reforma psiquiátrica brasileira: instituições, atores e políticas. Cien Saude Colet 2011; 16(12):4579-4589.^,22. Dell'acqua G, Mezzina R. Resposta à crise. In: Delgado J. A loucura na sala de jantar. São Paulo: Resenha; 1991. p. 53-79.. The crisis is a complex experience that involves important psychological distress often associated with strangeness experiences, depersonalization, loss of identity references, disorientation, and loss of control, among other painful experiences of the psychological point of view and of difficult understanding. Therefore, the suffering inherent to the crisis is not restricted to the individual who experiences it directly, but extends to their family, people close to them, and professionals involved in their care, and can even generate a circuit of inefficient admissions³3. Pereira MO, Sá MC, Miranda L. Um olhar sobre a atenção psicossocial a partir do itinerário terapêutico de adolescentes em crise. Cad Saude Publica 2014; 30(10): 2145-2154.. The theme of the psychosocial crisis becomes even more relevant when we focus on the problem of adolescents that deal with, besides changes and conflicts of this moment of life, a frame of severe mental disorder, an aspect still little explored in academic texts and official documents⁴4. Braga CP, D'Oliveira AFLP. A continuidade das internações psiquiátricas de crianças e adolescentes no cenário da Reforma Psiquiátrica Brasileira. Interface (Botucatu) 2015; 19(52):33-44.^,55. Lauridsen-Ribeiro E, Tanaka OU, organizadores. Atenção em Saúde Mental para crianças e adolescentes no SUS. São Paulo: Hucitec; 2010..

Although hegemonic, the traditional Psychiatry conception of crisis⁶6. Kaplan HI, Sadock BJ, Grebb JA. Compêndio de Psiquiatria. 7ª ed. Porto Alegre: Artes Médicas; 1997. has been criticized since the seventies, by the different Psychiatric Reform movements, such as the Italian Democratic Psychiatry²2. Dell'acqua G, Mezzina R. Resposta à crise. In: Delgado J. A loucura na sala de jantar. São Paulo: Resenha; 1991. p. 53-79. proposing that the crisis be understood as a complex existential moment. Thus, the intervention on it must not separate the subject of its history and of the environment in which it is lived, contrary to what the classical psychiatric hospitalization does with the urgency to remove symptoms before understanding their meaning to the subject that experiences them²2. Dell'acqua G, Mezzina R. Resposta à crise. In: Delgado J. A loucura na sala de jantar. São Paulo: Resenha; 1991. p. 53-79..

In this work, we emphasize the inter-subjective aspects involved in the crisis of teenagers, based in the contributions of René Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.

8. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11-

9. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005.^-1010. Kaës R. Um singular Plural. São Paulo: Edições Loyola; 2011., author that proposes an extension of the concept of crisis, as well as of relations between it, adolescence, and care. The main point of his contributions is the challenge of reducing the crisis to an individual phenomenon and recognition of which (inter) subjective, group, and cultural elements compete simultaneously in its production and development.

Kaës¹⁰10. Kaës R. Um singular Plural. São Paulo: Edições Loyola; 2011. highlights that the intersubjectivity does not only mean: “[…] a regimen of interactions between individuals who communicate their feelings through empathy, but […] the dynamic structure of the psychological space between two or various subjects. This space contains specific processes, formations, and experiences […]” Intersubjectivity is, thus, what these subjects share, and what represents them and what connects them through the unconsciousness’ own mechanisms, such as repressions, denials in common, fantasies, unconscious desires, shared significants.

To Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982., the crisis is the core trademark of the organization of the psychological apparatus in a constant game between destruction and creation forces, disorganization, and creativity. The crisis is both inevitable and an important source of enrichment, an experience of breaks and conflicts that, for its preparation, requires the maintenance of a frame, possible space to create an illusion camp⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982., understood as a paradoxical area, proper for playing and for experiences of the cultural field. It is the condition for the establishment of transitions between different types of reality, where the tension between individual and collective becomes tolerable and the crisis can be creative and not only disruptive.

It is from this conception that Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.^,88. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11- formulates the notion of intermediate, one of the central concepts in his work. The intermediary would be an instance of communication between the intrapsychic and the group, the place of articulation, of symbolization and conflict. The failure of this articulation would be precisely what is understood as a crisis.

Important moments in life are always crossed by the crisis, such as adolescence, marked by the passage of a social code and of a structure relative to other relational modes. This inevitable break of ties and meanings can trigger, simultaneously, the crisis of the parents, family members, as well as health services, school, and other institutions of society, always changing. Thus, for Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982., adolescence itself appears not only as an intermediary function, a moment of loss of internal and external objects (that is, references and targets of emotional/libidinal investment), but of possibilities.

In this perspective, we consider as crisis those mental health emergency situations that bring as central “serious psychological distress”, a set of affections of the unbearable order that can destabilize various dimensions of the teenager's life, such as subjective, familial, social dimensions³3. Pereira MO, Sá MC, Miranda L. Um olhar sobre a atenção psicossocial a partir do itinerário terapêutico de adolescentes em crise. Cad Saude Publica 2014; 30(10): 2145-2154.^,77. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.

8. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11-

9. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005.

10. Kaës R. Um singular Plural. São Paulo: Edições Loyola; 2011.^-1111. Pereira MO, Sá MC, Miranda L. Adolescência, crise e atenção psicossocial: perspectivas a partir da obra de René Kaës. Saúde Debate 2013; 37(99):664-671..

This article presents part of the results of a research that was dedicated to the reconstruction of the trajectory of adolescents and their families in the search for care in situations of psychosocial crisis. Here the representations of the crisis among adolescents, families, and health professionals at a Psychosocial Care Center for Children and Adolescents (CAPSi) are discussed, as well as the “exists” or “destinations” built by these subjects, that is, the strategies to deal with madness and psychological distress³3. Pereira MO, Sá MC, Miranda L. Um olhar sobre a atenção psicossocial a partir do itinerário terapêutico de adolescentes em crise. Cad Saude Publica 2014; 30(10): 2145-2154.^,1111. Pereira MO, Sá MC, Miranda L. Adolescência, crise e atenção psicossocial: perspectivas a partir da obra de René Kaës. Saúde Debate 2013; 37(99):664-671..

Methodology

This is a qualitative study, with clinical-psycho-social approach, of psychoanalytic base. This approach addresses the study of groups and organizations, highlighting their symbolic and imaginary dimensions and the problem of suffering and production of meaning¹²12. Lévy A. Ciências Clínicas e organizações sociais-sentido e crise de sentido. Belo Horizonte: Autêntica, FUMEC; 2001.. In this perspective, although we recognize that the concept of representation refers to diverse theoretical traditions, we understand it as, simultaneously, the process and the result of a psychological activity of attempted interpretation/control of the real. Such process and its results do not conform a homogenous closed system, but a floating and contradictory one, overdetermined by unconscious myths and fantasies and by the social and economic concrete conditions in which the representation activity develops. Thus, the conception of representation adopted here not only has a conscious/cognitive dimension, but also an unconscious one and has a double support: on the psychological and intersubjective processes, on the one hand, and on the social processes¹³13. Giust-Desprairies F. Representação e Imaginário. In: Barus-Michel J, Enriquez E, Lévy A, organizadores. Dicionário de Psicossociologia. Lisboa: Climepsi Editores; 2005. p. 174-189..

To have access to the representations of the crisis, we rely on the narratives of adolescents and their families about their therapeutic itineraries (TI)¹⁴14. Bellato R, Araújo LFS, Castro P. O itinerário terapêutico como uma tecnologia avaliativa da integralidade em saúde. In: Pinheiro R, Silva AGJ, Mattos RB, organizadores. Atenção Básica e Integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: CEPESC, IMS/UERJ, Abrasco; 2008. p. 167-185. in search of assistance. Bellato et al.¹⁴14. Bellato R, Araújo LFS, Castro P. O itinerário terapêutico como uma tecnologia avaliativa da integralidade em saúde. In: Pinheiro R, Silva AGJ, Mattos RB, organizadores. Atenção Básica e Integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: CEPESC, IMS/UERJ, Abrasco; 2008. p. 167-185. identified two main fields of study that utilize TIs in health. The first consists on the demonstration of the search trajectory through care, resulting of a “choice” made by the person from a wide range of options. The second field proposes the understanding of the condition of becoming sick through a biographical trajectory, based on studies that understand the cultural environment as a determinant of the choices of the subject. In the camp of tension between these fields, the TI can be considered as an evaluative resource in health¹⁴14. Bellato R, Araújo LFS, Castro P. O itinerário terapêutico como uma tecnologia avaliativa da integralidade em saúde. In: Pinheiro R, Silva AGJ, Mattos RB, organizadores. Atenção Básica e Integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: CEPESC, IMS/UERJ, Abrasco; 2008. p. 167-185.^,1515. Costa ALRC, Figueiredo DLB, Medeiros LHL, Mattos M, Maruyama SAT. O percurso na construção dos itinerários terapêuticos de famílias e redes para o cuidado. In: Pinheiro R, Martins PH. Avaliação em saúde na perspectiva do usuário: abordagem multicêntrica. Rio de Janeiro, Recife, São Paulo: CEPESC/IMS-UERJ, Editora Universitária UFPE, Abrasco; 2011. as well as a strategy in research on the trajectories understood by those users and their families, as well as on the meanings given to the illness and care¹⁵15. Costa ALRC, Figueiredo DLB, Medeiros LHL, Mattos M, Maruyama SAT. O percurso na construção dos itinerários terapêuticos de famílias e redes para o cuidado. In: Pinheiro R, Martins PH. Avaliação em saúde na perspectiva do usuário: abordagem multicêntrica. Rio de Janeiro, Recife, São Paulo: CEPESC/IMS-UERJ, Editora Universitária UFPE, Abrasco; 2011..

Regarding the methodology for the construction of the TI, stands out its complex, interpretive, and dialogic character¹⁶16. Pontes AL, Furtado S, Martins C, Matta GC, Morosini MVCG. Itinerários Terapêuticos e Estratégia de Saúde da Família: discursos sobre o processo saúde-doença e acesso aos serviços de saúde no trabalho do Agente Comunitário de Saúde. In: Pinheiro R, Silva AGJ, Mattos RB, organizadores. Atenção Básica e Integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: CEPESC, IMS/UERJ, Abrasco; 2008. p. 197-214., being indispensable multiple contacts that can be developed through interviews with users, professionals, managers, and family, supplemented with the analysis of documents or patient records¹⁴14. Bellato R, Araújo LFS, Castro P. O itinerário terapêutico como uma tecnologia avaliativa da integralidade em saúde. In: Pinheiro R, Silva AGJ, Mattos RB, organizadores. Atenção Básica e Integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: CEPESC, IMS/UERJ, Abrasco; 2008. p. 167-185.

15. Costa ALRC, Figueiredo DLB, Medeiros LHL, Mattos M, Maruyama SAT. O percurso na construção dos itinerários terapêuticos de famílias e redes para o cuidado. In: Pinheiro R, Martins PH. Avaliação em saúde na perspectiva do usuário: abordagem multicêntrica. Rio de Janeiro, Recife, São Paulo: CEPESC/IMS-UERJ, Editora Universitária UFPE, Abrasco; 2011.^-1616. Pontes AL, Furtado S, Martins C, Matta GC, Morosini MVCG. Itinerários Terapêuticos e Estratégia de Saúde da Família: discursos sobre o processo saúde-doença e acesso aos serviços de saúde no trabalho do Agente Comunitário de Saúde. In: Pinheiro R, Silva AGJ, Mattos RB, organizadores. Atenção Básica e Integralidade: contribuições para estudos de práticas avaliativas em saúde. Rio de Janeiro: CEPESC, IMS/UERJ, Abrasco; 2008. p. 197-214..

Aiming at a deeper understanding of the crisis experience and of the search for care, we opted for the use of life narratives or stories as methodology of an autobiographical approach as the basis for the construction of the TIs. The methodological and operational nature of life narrative technique is oriented to produce oral reports through memories of personal stories and more general reflections on the subject researched, being a perspective that seeks to apprehend “the collective through the individual”¹⁷17. Schraiber LB. Pesquisa qualitativa em saúde: reflexões metodológicas do relato oral e produção de narrativas em estudo sobre a profissão médica. Rev Saude Publica 1995; 29(1):63-74.^,1818. Takeuti MN, Niewiadomski C, organizadores. Reinvenções do sujeito social: teorias e práticas biográficas. Porto Alegre: Sulina; 2009.. Thus, by this intermediate, the singular and social areas coexist, as the individual enrolls in a social and historical context that, in turn, is expressed in individual speeches¹⁸18. Takeuti MN, Niewiadomski C, organizadores. Reinvenções do sujeito social: teorias e práticas biográficas. Porto Alegre: Sulina; 2009..

Therefore, considering the theoretical approach of psychoanalytical basis adopted here, we start from a very particular understanding of the concept of itineraries³3. Pereira MO, Sá MC, Miranda L. Um olhar sobre a atenção psicossocial a partir do itinerário terapêutico de adolescentes em crise. Cad Saude Publica 2014; 30(10): 2145-2154., not restricting them to the factual and objective aspects, but seeking to refer to the senses produced by the subjects about their experiences, both in a cognitive dimension and in an unconscious and intersubjective one¹²12. Lévy A. Ciências Clínicas e organizações sociais-sentido e crise de sentido. Belo Horizonte: Autêntica, FUMEC; 2001.^,1313. Giust-Desprairies F. Representação e Imaginário. In: Barus-Michel J, Enriquez E, Lévy A, organizadores. Dicionário de Psicossociologia. Lisboa: Climepsi Editores; 2005. p. 174-189..

Three teenagers, their families, and five professionals of a Psychosocial Care Center (CAPSi) participated in the study. The choice of the teenagers happened from the indication of the service team, considering, as inclusion criteria, those who were already users of the CAPSi in function of history of severe psychological distress, being there before or since the crisis, and who felt able to talk about their life experiences. The exclusion criteria of subjects were: (i) teenagers who were experiencing episodes of more intense mental distress during the survey; (ii) subjects whose psychological problems were related to drug addiction. The choice for deepening the uniqueness of the experiences led us to work with the number three subjects³3. Pereira MO, Sá MC, Miranda L. Um olhar sobre a atenção psicossocial a partir do itinerário terapêutico de adolescentes em crise. Cad Saude Publica 2014; 30(10): 2145-2154.^,1717. Schraiber LB. Pesquisa qualitativa em saúde: reflexões metodológicas do relato oral e produção de narrativas em estudo sobre a profissão médica. Rev Saude Publica 1995; 29(1):63-74.^,1818. Takeuti MN, Niewiadomski C, organizadores. Reinvenções do sujeito social: teorias e práticas biográficas. Porto Alegre: Sulina; 2009..

Two meetings were held with each adolescent and, complementarily, some family members and five professionals were interviewed. The empirical material of the research was: transcripts of the interviews and the field diary. The latter, for bringing the record of the impressions and feelings of the researcher during the field work, it was important for the analysis of narrative, favoring analogies and interpretations, according to the clinical and social-psychological perspective adopted.

The study was approved by the Ethics Committee of the Escola Nacional de Saúde Pública Sérgio Arouca and all subjects signed the Informed Consent term, in accordance with the 196/96 and 251/97 Resolutions of the Conselho Nacional de Saúde.

Letícia, Thiago, and Luciana are fictitious names assigned to the interviewed adolescents. Their families also received fictitious names and professionals are referred by their respective professional categories.

The analysis was done after fluctuating readings of the interviews and of the field diary, including considerations on the impressions and feelings mobilized in the researcher by the relationship with the research subjects and experience of field situations. From these readings, we highlight arguments, images, representations, contradictions, and silences that in the narratives of the subjects conformed different meanings about the phenomenon studied¹⁷17. Schraiber LB. Pesquisa qualitativa em saúde: reflexões metodológicas do relato oral e produção de narrativas em estudo sobre a profissão médica. Rev Saude Publica 1995; 29(1):63-74.. The association of these elements, the research questions, and the theoretical framework basis allowed the conformation of six emerging categories, one of them being divided in four subcategories, as will be presented and discussed below.

Results and discussion: Representations and destinies of the crisis

Between the emergent categories of the analysis process, we present below those that refer to the representations of the crisis, including the way how its treatment or resolution was thought – what we here call “destinies”.

The crisis as a fright and surprise

The first crises of the teenagers were lived as something without explanation, marked by strangeness, as Letícia tells us:

Her mother also reminds of what happened:

Thiago's mother makes comments in the same direction:

In the same vein, one of the professional observes:

Despite the above lines indicating the experience of crisis as confusion, disruption, something associated to the experience of the uncontrolled and of the unexpected, it is worth to recall Kaës⁹9. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005. who states that this is not characterized, in fact, by novelty. Even if it appears suddenly, being marked by a unique and singular character, its causes and origins, as well as its solution, they would be drawn on the past history and on the memories of the subjects, but also in the group and cultural⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.. In this sense, it is also worth drawing attention to the metaphor used by the professional to represent the crisis as “a wave that comes rushing in and dunks you.” This is an image very propitious to the adolescent universe, suggesting the intensity that the identification of the inter subjective processes³3. Pereira MO, Sá MC, Miranda L. Um olhar sobre a atenção psicossocial a partir do itinerário terapêutico de adolescentes em crise. Cad Saude Publica 2014; 30(10): 2145-2154.^,77. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.^,99. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005.^,1010. Kaës R. Um singular Plural. São Paulo: Edições Loyola; 2011. can assume. Of this follows the experience of unpredictability - fright or surprise - that the crisis of the adolescent caused not only on herself but also on the service professionals, referring to the understanding of Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982. on the inseparability of the singular and collective dimensions of the crisis.

The crisis of the adolescent as condensation of other crises

For the family the crisis also raised a strong suffering:

Thiago's reference technician comments on the anguish of the mother and two brothers, after his first crisis:

These passages corroborate the idea that the crisis is not only individual, involving elements of intrapsychological, interpsychological, and material realities⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.. Some stories of the adolescents illustrate this aspect: after Letícia's first crisis, her father decides to leave home and go back to his hometown, in another region of the country, due to the worsening of his “Panic Disorder”. Her mother on the other hand decides to move with her daughter to another city where relatives lived. This move occurred concurrently with the onset of the second crisis of the teenager, marked by fights with new colleagues, that would have “made her go berserk”. The third crisis, years later, is attributed by Letícia to problems at home and at school, her father's absence, and, especially, the fact that her mother had gotten sick. After this crisis the father returned from his hometown to help in his daughter's care.

The interrelation of the psychological, intersubjective, and social/institutional aspects imposed by the crisis experience⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982. can also be glimpsed at in the case of Luciana, whose second crisis he'd been associated with the death of her mother, to whom the professionals seemed strongly linked. According to them, for a few years she had been fulfilling an important role in the Grupo de Familiares, so that when the team learned of her death “the house went down” (sic).

Assuming that metaphorically several “houses” went down, we believe that, to some extent, Luciana's mother exercised an intermediary function⁹9. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005. along with the team, allowing for the transit between rigid positions, represented by the house and the service, the “normality” and the “disease”, the condition of those who care and who are cared for, among others¹⁰10. Kaës R. Um singular Plural. São Paulo: Edições Loyola; 2011.. Partially because of this, her death was felt as the collapse of the service itself.

A week after her mother's death, Luciana said she was pregnant, which caused a “crisis” in the father and an “outburst” in the service, according to the psychologist. Some changes in her Singular Therapeutic Project (PTS) were thought and maintained up to the third crisis, the moment of birth of her daughter, when “the whole family was shaken”, according to her brother. One of the professionals associates the different disorganization experiences in a assumption of cause for Luciana's third crisis:

We understand that Luciana's mother exercised the intermediary function⁹9. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005. also for the daughter, to whom attributed this place's “figurine”, something beautiful, valuable, but fragile at the same time. With her mother's death, Luciana has “no place” in the house, in the family, and in life. Concomitantly, the pregnancy requires her to leave the place of daughter to be a mother, function that is associated with a new time of crisis.

Through these examples, we hope to have shown that the crisis, usually located in only one subject, is awakened by (and awakens) instabilities, breaks, insufficiencies in psychological, social, institutional, and cultural instances⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.. These instances are needed so that the subject prepares the crisis and, paradoxically, in this process, they end up being transformed.

The crisis as violence and strangeness

The narratives about the crisis, whether of relatives or teenagers, bring memories of difficult times, marked by violence, like Graça remembers, telling that Letícia came home and started to “(…) get nervous, and started to stomp her feet, and say things she'd never said”, “undressing”. Letícia also highlights the aggressiveness and strangeness:

In the same vein, Henrique remembers that in her second crisis, Luciana “screamed inside the house, broke everything, threw the new computer on the floor, which was her darling”. In the third crisis the teenager did not recognize herself as the mother to the daughter who'd just been born and stopped eating and showering, ending up with a weakened body.

For Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982. it is inevitable that losses and movements inherent to the crisis would involve experiences of disorientation and violence. In the accompanied stories, we noticed a quest for the control lost, by both parents and the service, which often resulted in certain violence in the strategies. The CAPSi, for example, before the crisis of the users, had, in all cases, as first action the transference of these to a space associated with the possibility of containment and control: the General Hospital (HG) of the Municipality, with which the service has difficulty of communication, making it impossible to monitor the teens during hospitalization.

We will consider the notion of frame proposed by Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.^,99. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005.^,1010. Kaës R. Um singular Plural. São Paulo: Edições Loyola; 2011. we understand that the welcoming of subjects in crisis requires the psychological work of the family members and staff themselves, a work of access to representations, meanings, feelings that the crisis produces in them. For this instances of support in the institutions are necessary, that enable other destinies for the crisis.

Destinies of the Crisis

The crisis as what needs to be forgotten

Among the adolescents only Letícia spoke directly about the crisis; Thiago and Luciana said they did not remember that experience. While we understand the difficulty of commenting on a difficult time with a researcher with whom the bond is still initial, we also assume that these adolescents could not find, in their paths, propitious spaces to develop some kind of development, or even recall of the crisis. Such impossibility would have prevented the crisis experiences from being incorporated in the life narratives of the interviewed, leading us to signify them only as “fright”, “surprise”.

Even Letícia, in hearing some of her mother's words, seemed surprised by the reports of the period in which she had been hospitalized. Many times it seemed that was the first time she had heard that story, lividly her, but little thought. We consider, with Kaës⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982., the need for spaces that allow the recall as favoring a sense of this experience. However, we did not identify the existence of this type of work in the researched CAPSi. In our view, the absence of these spaces can contribute to the crystallization of the representations of the crisis as a fright or negative surprise.

The denying of the crisis

One of the consequences of the absence of spaces of sharing memories and meanings of crisis experiences seems to be the denial of it. This phenomenon can be observed in Graça, Letícia's mother, who describes difficult behaviours of agitation and instability of the teenager during her hospitalization in the HG, but, at the same time, says that the her crisis was “weaker” than those exhibited by the other hospitalized girls. While acknowledging that Letícia was “very excited”, “wanting to take off her clothes”, and screaming, she looked at the same behaviour in other girls with strangeness. Graça even suggested that there should be different wings in the service, so that her daughter would not be close to people “worse off than her”.

Letícia's psychiatrist also points out that she is not a “neuralgic patient” and “does not have a serious condition”. It is noteworthy that the professional, at the time of the interview, said she had forgotten that Letícia had undergone a recent hospitalization. This suggests that the process of denial of the crisis is a not only a defence of adolescents and their families, but also of professionals, in face of the instability and suffering that it raises⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.^,88. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11-.

The crisis as externality: expulsion of the crisis

The first crisis as one for which there is no explanation is also the one that is characterized by externality. It is the one that happened “out of the home”, far away. For Thiago, the first crisis started at school; for Letícia it happened on the beach, and for Luciana on the street. In addition to the place where it happens, the crisis is associated by the adolescents and their families to factors “external” to the subject and, thus, it is justified by spiritual issues, school problems, medications, et cetera.

For the CAPSi it seems that the crisis, and not only the first, is the one that should also happen “outside”, what should be “expelled”, it can not be thought, questioned, or experienced by the staff. It is what we noticed in seeing that the attention to the crisis of the teenagers had been assigned exclusively to the General Hospital, having difficulty in the construction of care strategies in the CAPSi itself or joint actions with other institutions. Analog movement is identified when professionals justify the crisis by family issues (the parents did not notice, did not know to speak, et cetera), not questioning possible limits or needs for change of the teenagers’ Singular Therapeutic Projects.

Looking to elaborate the crisis

Despite the processes of denying crisis experiences, the interviewees were able to recognize some resources that they used to overcome it. Letícia, for example, remembers the phone call to her father and her mother's presence during the days of hospitalization in the HG as something that soothed her. She also presents the hymns of the church as an effective personal resource:

In one of the cases, CAPSi's investment is also identified as an important support for the crisis. Luciana's brother and a professional emphasize that the improvement of the adolescent was a result of, mainly, increasing the days in which she remained in the service, providing a car for her transport, and the intensification of the contact between professionals and the family.

We understand that these resources represented, for Letícia and Luciana, an intermediary function, that is, the possibility of transiting between the inner reality, marked by disorganization, and outer reality, allowing for the (re)establishment of ties with the other. It is noteworthy that the intermediary is not the object itself (hymn, phone call, et cetera), but the possibility of transiting between different dimensions of reality: between the inner and outer world, between past and future, between the self and the other⁹9. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005..

The medication as cause and solution for the crisis

The narratives of adolescents, relatives, and professionals indicate that the medication is central in the representations of the Thiago and Letícia's crises. In Thiago's first crisis, his family sought the HG as reference service, which medicated him and sent him to the CAPSi. Although she's part of a group of individual psychiatric care in this service, the teenager emphasises: “I improved because of the medication. It was the medication, but I'm still coming”.

After a few months in the service, Thiago experienced a new crisis, that his mother called “rough little crisis” and the psychologist called it “relapse”. Both understand that this phenomenon was a consequence of the lack of medication, not associated to any other factor of distress of the adolescent. The only strategy to deal with this episode was to change the medication from pills to liquid, with no change in his Singular Therapeutic Project or in the offers of service.

In the case of Letícia, only the medication was offered by the HG that attended her in her first crisis (still in another city), with no referral to another service or presentation of other possibilities. Furthermore, the last crisis of the teenager had happened, according to her mother, due to the reduction of the medication and the possibility of error of the laboratory in the manipulation of the formula. Letícia, however, although she points to other factors such as problems at home and at school, emphasizes the medication as what would have helped her to overcome the crisis.

For Graça, the psychological explanation of her daughter is meant as an alert to the “prevention” of other moments like them:

Other CAPSi devices such as groups, moments of cohabitation or monitoring of other non-medical professionals, despite being mentioned by interviewees as important, do not seem to be recognized as part of a “solution to the crisis” or, even, as spaces that can be inhabited in times of crisis. Thus, before the crisis there are no other strategies different from medication: it seems as though overcoming the crisis could forgo the ability of adolescents of creating strategies that take into account their routines and unique ways of life. On top of this, it is also worth noting an element of denial, as, when the medication, or the lack/inadequacy of it, is put in the place of cause of the crisis, many conflicts can be disregarded and hidden⁷7. Kaës R. Crisis, ruptura y superación: análisis transicional en psicoanálisis individual y grupal. Buenos Aires: Publicación Buenos Aires; 1982.^,88. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11-.

The crisis as a loss

The crisis represented major losses in the lives of the adolescents. Thiago stopped playing football with his friends, going to school, “because it is better not to” (sic). Given this situation, his reference professional thought of strategies to refer him to the realization of a sport for “special adolescents”, which, however, was not thought along with Thiago, nor, either, had involved some effort to help the boy return to living with people with whom he already had links.

Letícia also stopped going school after her last crisis and lost interest in daily activities she used to perform. Her mother, at the same time, did not “trust” anymore that a teenager could go to the center of her own city alone, fearing that she could “get lost”:

Letícia laments having gotten “different from others”, because, due to the crisis, she “needed treatment”. She also reported difficulty in writing and “copying down” the subject, because the medication made her hand tremble.

The professionals were also unanimous in linking the crisis to a time of loss, presenting a pessimistic view about the possibilities of creation to be derived from it:

In the interviews, the professionals considered that the crisis experienced during adolescence is more severe than that which occurred in adulthood, because it involves a special loss, not only of what was already had, but also of the future, of what the teenager will no longer be able to live or learn:

The particularities of the work at the time of the crisis in adolescence compared to the crisis in adulthood, are taken by professionals in a special way, due to the involvement with the family, that would be present in the first case:

A professional highlights even that it is also more difficult for the family to accompany a crisis in adolescence than in childhood:

The stories narrated show that, despite the crisis appearing as a loss in the life and routine of adolescents, it does not shapes up as a landmark for changes in care strategies of the CAPSi. We see how problematic this reality is in remembering that Kaës¹⁰10. Kaës R. Um singular Plural. São Paulo: Edições Loyola; 2011. defends that the possibility of the crisis of unfolding as an enrichment source would be the subject's ability to create, from it, a common project in a group. For the author, in being governed by rules of functionality and, at the same time, constituting oneself as a space of welcoming subjects, the group may come to be constitute itself a frame of emergency and development of the components of a personal crisis. The group presented itself, thus, as a result of a joint construction of all the individuals that compose it.

However, the CAPSi studied did not seem to have containing and lucrative group spaces for collective elaborations. This weakness of developing devices also makes it impossible the meeting of the team with their own losses, with the disillusion and feelings of failure aroused by the violence of the crisis and by the precariousness resources of the service itself (materials, technology, infrastructure, among others). Such experiences tend to bring the service to experience their own crises, but without a group structure, such crises tend to be denied⁸8. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11-.

The crisis as crisis of the institution

We reinforce Kaës’ statements⁸8. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11- on the crisis of the subject and its strength in questioning the institution as a whole, disaggregating contracts, pacts, consensus, and unconscious agreements. This happens because, for the author, alliances between the different subjects that make up the organization are supported by each one's specific defense mechanisms; beliefs and common ideals that establish the representational identity of the team, institution, group.

This contribution of Kaës’⁸8. Kaës R. O interesse da Psicanálise para considerar a realidade psíquica da instituição. In: Correa OBR. Vínculos e Instituições: uma escuta psicanalítica. São Paulo: Escuta; 2002. p.11- is central to understanding the relationship between professionals, teams, and services in psychosocial care. In the context studied, the crisis of the teenagers seemed to destabilize the service that, to defend itself, tends to build institutional reinforcements, be it transferring the patient to the General Hospital, be it considering them weak, forgetting them, depriving the subjects of devices to talk about them, or, even, creating a rigid and fragmented work organization, that separates professionals from the suffering awakened by the contact with users.

Add to this the observation that the precariousness of the material conditions of health services contributes to the exacerbation of the requirement for mental work of the professionals¹⁹19. Sá MC. A Fraternidade em Questão: um olhar psicossociológico sobre o cuidado em saúde. Interface (Botucatu) 2009; 13(Supl. 1):651-654.. Certainly, some of the issues pointed out by the team, such as the fact that CAPSi does not function 24 hours, the difficult communication with the HG and the lack of institutional supervision limit care to the crisis and produce suffering in the professionals.

Thus, in facing the crisis and what is out of control and predictability, we remember the need to “find ourselves in the space-time of the institution in a psychological place where the intrapsychological and intersubjective conflicts can be updated and thought”⁹9. Kaës R. Os espaços psíquicos comuns e partilhados. Transmissão e Negatividade. São Paulo: Casa do Psicólogo; 2005.. These spaces may appear in the form of meetings, workshops, studies, clinical-institutional supervisions, or several other formats to be created, as long as they constitute themselves as devices of speech and construction of respect for alterity¹⁹19. Sá MC. A Fraternidade em Questão: um olhar psicossociológico sobre o cuidado em saúde. Interface (Botucatu) 2009; 13(Supl. 1):651-654..

Final Considerations

We believe that this work contributed to an expanded look on the crisis from marks, impact, and possible meanings that participant subjects were asked to (re)establish through their life narratives. Between users and professionals reigns the abundance of representations of the crisis as strangeness and externality, as well as, as the intensive use of denial as one of the main psychological defences.

Users of the service are not involved in the development of coping strategies for their own crises and, let alone, of their individual therapeutic projects. All of the treatment of the crisis tends to center on external elements to both teenagers and professionals: medication and hospitalization in the general hospital.

We stress, however, that without offering continence to the crisis of its users, the institution refrains from recognizing and developing their own conflicts. Consequently, the crisis of the user, relatives, professionals, and service is experienced only in its destructive dimension.

With the reflections developed here we hope to highlight the importance of the representations that the individuals make about their experiences as well as the urgency of building different collective spaces to address them. It is necessary to work for the creation of various devices, aimed at the sharing of distress and achievements of professionals, at the development of the team conflicts, at the sharing of experiences of users and family and, of course, at the joint creation of support and strategies of resolution of the crises of the individuals and of the institution itself. Recognizing the interdependence of these two, we stress that it is through the devices of support to crisis emergency that it will be able to be lived as well as movements of (re)inventions, of transformations, and acquisition of new possibilities of living.

A build like this is not possible without a management effort to revive networks, provide resources and support to the services, monitor the work possibilities and their challenges. We conclude, therefore, that the attention to the crisis requires work simultaneously political, organizational, technical, and psychological.

References

Publication Dates

History