Abstract

Introduction

This article problematizes findings related to the production of bonds in healthcare practices, collected in an investigation carried out with guiding users. It aims to give visibility to issues that tension the strategies used by professionals of Brazil's National Healthcare System (SUS) when they organize their care practices.

According to Cecílio and Matsumoto¹1. Cecílio LCO, Matsumoto NF. Uma taxonomia operacional de necessidade de saúde. In: Pinheiro AF, Ferla AA, Mattos RA, organizadores. Gestão em redes: tecendo os fios da integralidade em saúde. Rio de Janeiro: IMS/UERJ/CEPESC, Caxias do Sul: EdUCS/UFRS; 2006. p. 37-50., the bond is one of the operational components that compose users’ health needs. Its production was viewed as a technical and assistance guideline in many municipal experiences²2. Merhy EE. Em busca da qualidade dos serviços de saúde: os serviços de porta aberta para a saúde e o modelo tecno-assistencial em defesa da vida. In: Cecílio LCO, organizador. Inventando a mudança na saúde. São Paulo: Hucitec; 1994. p. 117-60.^–77. Franco TB, Bueno WS, Merhy EE. O acolhimento e os processos de trabalho em saúde: o caso de Betim, Minas Gerais, Brasil. Cad Saude Publica. 1999; 15(2):345-53. of implementation of the SUS in the 1980s and 1990s. It is possible to find a version of the concept in some ministerial documents related to Primary Care and published in the end of the 1990s. In these documents, it is called “responsibility bond” and “commitment and co-responsibility bond” and it is defined as something produced by a continuous interaction, with potential for “[…] solving individuals’ problems and maintaining their health”⁸8. Ministério da Saúde (BR). Saúde da Família: uma estratégia para a reorientação do modelo assistencial. Brasília: MS; 1997. (p.15). Documents from the beginning of the 2000s refer to it as an operational guideline for the materialization of the principles of the SUS⁹9. Ministério da Saúde (BR). Experiências inovadoras no SUS: relatos de experiências: desenvolvimento de novas tecnologias assistenciais de atenção aos usuários: secretarias estaduais e municipais de saúde. Brasília: Ministério da Saúde; 2002.. In the directive that approves the Política Nacional de Atenção Básica (PNAB - National Primary Care Policy)¹⁰10. Ministério da Saúde (BR). Portaria n. 2.488, de 21 de Outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS) [Internet]. Brasília, DF: Ministério da Saúde; 2011 [citado 1 Mar 2018]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html.
http://bvsms.saude.gov.br/bvs/saudelegis... , the term is understood sometimes as a principle, sometimes as a foundation and guideline for Primary Care, and has a more precise definition: the bond “[…] is the construction of affectivity and trust relationships between user and health professional. It enables the intensification of the process of co-responsibility for health that is built over time, and carries in it a therapeutic potential.”¹⁰10. Ministério da Saúde (BR). Portaria n. 2.488, de 21 de Outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS) [Internet]. Brasília, DF: Ministério da Saúde; 2011 [citado 1 Mar 2018]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html.
http://bvsms.saude.gov.br/bvs/saudelegis... Furthermore, the directive mentions that the bond is a device required for the coordination of care:

Summoning the understanding expressed in the PNAB to the debate without considering it the sole truth about the theme, the bond implies knowledge of users’ life histories and constitutes something that needs to be permanently constructed between professionals and users - something that implies mutual trust and that, we propose, constitutes the expression of the event of care, viewed here as production in the intercessional meeting¹¹11. Merhy EE, Feuerwerker LCM, Gomes MPC. Da repetição à diferença: construindo sentidos com o outro no mundo do cuidado. In: Franco TB, organizador. Semiótica, afecção & cuidado em saúde. São Paulo: Hucitec; 2010. p. 60-75.^,1212. Slomp Junior H, Feuerwerker LCM, Merhy EE. Histórias de vida, homeopatia e educação permanente: construindo o cuidado compartilhado. Cienc Saude Colet. 2015; 6(20):1795-803..

Brunello et al.¹³13. Brunello MEF, Ponce MAZ, Assis EG, Andrade RLP, Scatena LM, Palha PF, et al. O vínculo na atenção à saúde: revisão sistematizada na literatura, Brasil (1998-2007). Acta Paul Enferm. 2010; 23(1):131-5. carried out a review about bonds in healthcare in Brazil and concluded that the establishment of this type of relationship between teams and users might, in fact, improve professionals’ knowledge of the real problems of the assisted population and motivate them to search for solutions, together, for the problems and for an improvement in the services. Garcia Jr.¹⁴14. Garcia Jr CAS. Produção de vínculos: a relação entre médicos cubanos e usuários do Sistema Único de Saúde a partir do Programa “Mais Médicos” [Internet]. Porto Alegre: Rede UNIDA; 2017 [citado 1 Mar 2018]. Disponível em: http://historico.redeunida.org.br/editora/biblioteca-digital/colecao-micropolitica-do-trabalho-e-ocuidado-em-saude/producao_de_vinculos.pdf.
http://historico.redeunida.org.br/editor... approaches the power relations that the bond production practice engenders among care subjects and states that this practice can be established “[…] despite the differences they have in translating and reassembling, based on the exchange of experiences, an ethos of care.”¹⁴14. Garcia Jr CAS. Produção de vínculos: a relação entre médicos cubanos e usuários do Sistema Único de Saúde a partir do Programa “Mais Médicos” [Internet]. Porto Alegre: Rede UNIDA; 2017 [citado 1 Mar 2018]. Disponível em: http://historico.redeunida.org.br/editora/biblioteca-digital/colecao-micropolitica-do-trabalho-e-ocuidado-em-saude/producao_de_vinculos.pdf.
http://historico.redeunida.org.br/editor... (p. 129)

We believe that the bond will be developed or not in the context of health work depending on the way in which relationships among workers with different educational backgrounds occur, as well as relationships between workers and users. The nature of health work is that it is live and produced in the act in the several encounters between worker and user, in which both of them practice self-government and bring with them their values and life histories¹⁵15. Merhy EE. Desafios de desaprendizagens no trabalho em saúde: em busca de anômalos. In: Lobosque AM, organizador. Caderno saúde mental: os desafios da formação. Belo Horizonte: ESPMG; 2009. p.23-36.. The meaning that will be impressed on health practices and, consequently, the uses that will be given to the protocols and norms employed by health professionals are under intense negotiation and dispute. This process occurs in arenas crossed by forces politically and socially implicated in disputes of projects, imposing purposes on the care production process that, sometimes, may not be cure and health promotion¹⁶16. Merhy EE. O SUS e um dos seus dilemas: mudar a gestão e a lógica do processo de trabalho em saúde (um ensaio sobre a micropolítica do trabalho vivo). In: Fleury S, organizadora. Saúde e democracia, a luta do CEBES. São Paulo: Lemos; 1997. p.125-42..

Thus, we ask: What is the power of the bond as a tool-concept¹⁷17. Merhy EE. O cuidado é um acontecimento e não um ato [Internet]. 2014 [citado 23 Jan 2018]. Disponível em: http://eps.otics.org/material/entrada-outras-ofertas/artigos/o-cuidado-e-acontecimento-e-nao-um-ato/view.
http://eps.otics.org/material/entrada-ou... ^,1818. Abrahão AL, Merhy EE. Formação em saúde e micropolítica: sobre conceitosferramentas na prática de ensinar. Interface (Botucatu). 2014; 18(49):313-24. to reorganize teams’ working processes? Would it be possible that, on behalf of the bond, health professionals also commit iatrogenesis, interdictions and daily micro-violences? What ethical and moral values have sustained the construction of bonds in the daily routine of health work? We invite the experiences lived with guiding users¹⁹19. Gomes MPC, Merhy EE, organizadores. Pesquisadores In-Mundo: um estudo da produção do acesso e barreira em saúde mental. Porto Alegre: Rede UNIDA; 2014. in the fieldwork carried out in a city located in the South of Brazil, and the learning that resulted from them, to this debate.

Methodology

The experiences analyzed here were collected in the research entitled “National Observatory for the Production of Different Modalities of Care in the Context of Implementation of Thematic Healthcare Networks in the SUS: An assessment of those who seek care, those who provide it, and those who use it”, carried out nationwide from December 2013 to December 2016 by 52 researchers in the interinstitutional research line “Micropolitics of Work and Healthcare”²⁰20. Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v. 1.^,2121. Feuerwerker LCM, Bertussi DC, Merhy EE, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v. 2.. The research aimed to analyze care production in the healthcare networks of 17 cities from all the Brazilian regions, based on the understanding that, beyond professional and institutional norms and hierarchies, care is also a production conducted by workers in their micropolitics, in the different projects they dispute¹⁹19. Gomes MPC, Merhy EE, organizadores. Pesquisadores In-Mundo: um estudo da produção do acesso e barreira em saúde mental. Porto Alegre: Rede UNIDA; 2014.^,2222. Merhy EE, Feuerwerker LCM, Silva E. Contribuciones metodológicas para estudiar la producción del cuidado en salud: aprendizajes a partir de una investigación sobre barreras y acceso en salud mental. Salud Colect. 2012; 1(8):25-34..

The analysis presented here refers to care production experiences observed in monthly encounters that lasted two to three days per month, with teams from three primary care units and one emergency unit. It also refers to encounters with workers from other services.

The research was carried out through a cartographic approach. This approach aims to produce knowledge from affections and intercessions experienced by individuals in the investigation process, including the researchers, and its objective is to give visibility to the tensions present in these encounters, giving voice to what was felt but had not been said yet²³23. Deleuze G, Guattari F, organizadores. Mil platôs - capitalismo e esquizofrenia. Rio de Janeiro: Ed. 34; 1995. Postulados da linguística; p.11-60.^–2525. Benet M, Merhy EE, Pla M. Devenir cartógrafa. Athenea Digital. 2016; 16(3):229-43..

Thus, based on the encounters among researchers - those who were external to the services and those who, besides the role of researchers, were also protagonists of the care production process (users, workers and managers) -, it was possible, together with the guiding users, to extract the scenes presented in this article.

The tool-concept “guiding user” departs from an ethical-methodological bet in which the centrality of the experience lived by the user shifts the investigator's view so that he assumes the user's perspective, in the government of himself, as the reference to the meanings that must be given to health practices. In other words, it is a bet on the professionals’ adherence to the life of the other as ethics, shifting the other from the position of object to that of co-producer of knowledge²⁰20. Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v. 1.^,2121. Feuerwerker LCM, Bertussi DC, Merhy EE, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v. 2. and care. In this study, we followed the guiding users Sueli, Ricardo and Rosa. The names are fictitious.

The study complied with the ethical principles of the Declaration of Helsinki of the World Medical Association and with Resolution 466/2012 of the National Health Council for the obtention of participants’ informed consent, and ensured data confidentiality. The investigation was approved by the National Research Ethics Committee under no. 560597/2014.

Results and discussion

The results that were considered central to the reflection proposed in this article are brought in the form of “scenes” that occurred while the researchers were following the three guiding users. They are presented in this section intertwined with the discussion.

Mutual acknowledgement as a condition for the construction of bonds

Sueli is a 47-year-old woman who begins her journey across different points of the health network in 2014, referred or by herself, with recurrent complaints of headache, dizziness and blurry vision. After many fruitless passages in the network, she is diagnosed as having a benign frontal lobe brain tumor with a diameter of approximately seven centimeters. She undergoes a surgery to remove it, not without difficulties to obtain such intervention, even after the diagnosis had been made. In one of our visits to the Primary Care Unit of Sueli's catchment area, the team responsible for her care invites us to visit her.

If we take the concept of bond expressed in the policies, we can think that, if a bond had been established at some moment of the relationship between Sueli and that team, it did not exist in the witnessed scene. In this scene, similarly to what happens with so many Suelis we assist on a daily basis, the door was closed and the bond was not produced. But what led her to give up the possibility of establishing a bond with the team? It seems that this is a key point to reflect on the events of Sueli's trajectory.

When she fails to receive the care she needed, she no longer sees the team as a reference. The team, in turn, searches for an explanation to Sueli's behavior within a given repertoire of knowledge: “she is confused, she had a tumor extracted from her head and this has affected her reasoning”. Thus, when the team argues that Sueli allegedly has an incapacitating condition, they question her autonomy. However, Sueli upsets them precisely because she refuses to adhere to a project outlined without her participation and does not accept to lose control over her body and life as a condition to the establishment of the bond. A mismatch is established and the only alternative that remains to the team is an immediate and radical interventionism on the health problems²⁶26. Slomp Junior H, Feuerwerker LCM, Land MGP. Educação em saúde ou projeto terapêutico compartilhado? O cuidado extravasa a dimensão pedagógica. Cienc Saude Colet. 2015; 20(2):537-46., grounded on the guideline of assuming responsibility at any cost for the user's care, even if they have to construct the bond “by force”. But is it possible to construct bonds unilaterally, exercising control over the other's life?

It is possible to notice the repetition of an instituted expectation about the user: the desire that they should be “lamb people”²⁷27. Seixas CT, Merhy EE, Baduy RS, Slomp Junior H. La integralidad desde la perspectiva del cuidado en salud: una experiencia del Sistema Único de Salud en Brasil. Salud Colect. 2016; 12(1):113-23.- docile, obedient, easily handled and controlled. However, lamb people do not exist. Even if, during the day, they let the “master” think he is in control, at night they take the wool off and the hypertensive lamb person smokes the cigarette she swears she does not have anymore, the diabetic lamb person hides away to eat candies, etc. Some lamb people brace themselves and take the wool off in the light of day, lock the master outside and do whatever they want. And when they cease being a lamb, they really annoy teams that do not have opportunities to reflect on their practice and assume the responsibility for prescribing how the other should lead his life.

The findings of this study suggest that the bond is something that can be constructed, but it can also be deconstructed or never be achieved. Therefore, it must be cultivated. Thus, the bond is something that can only be constructed if the other also wants it, if both consider themselves “valid interlocutors”, that is, if they assume the ethical posture of seeing the other in the relationship as someone with whom it is necessary to establish pacts²⁶26. Slomp Junior H, Feuerwerker LCM, Land MGP. Educação em saúde ou projeto terapêutico compartilhado? O cuidado extravasa a dimensão pedagógica. Cienc Saude Colet. 2015; 20(2):537-46.^,2828. Merhy EE. O conhecer militante do sujeito implicado: o desafio de reconhecê-lo como saber válido. In: Franco TB, Peres MAA, organizadores. Acolher Chapecó: uma experiência de mudança do modelo assistencial, com base no processo de trabalho. São Paulo: Hucitec; 2004. v. 1, p. 21-45., someone who has needs, desires, expectations and a type of knowledge that, in the majority of times, is different from mine - and this enriches my practice²⁷27. Seixas CT, Merhy EE, Baduy RS, Slomp Junior H. La integralidad desde la perspectiva del cuidado en salud: una experiencia del Sistema Único de Salud en Brasil. Salud Colect. 2016; 12(1):113-23.. Based on this acknowledgement, it becomes possible to share therapeutic projects in the space between the desires of users and workers²⁹29. Seixas CT, Baduy RS, Bortoletto MSS, Lima JVC, Kulpa S, Lopes MLS, et al. Vínculo e responsabilização: como estamos engravidando esses conceitos na produção do cuidado na atenção básica? In: Feuerwerker LCM, Bertussi DC, Merhy EE, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v. 2, p.391-407..

It is clear that operating this concept in the complexity of the daily routine of the health work is neither simple nor natural. Furthermore, when we present this scene, we do not intend to disqualify these workers nor stigmatize their practice in a Manichean way. In fact, we witnessed that they assumed responsibility for Sueli and for many other users of that service in countless situations.

Symmetry as ethics and condition to the production of bonds

In November 2014, the researchers contacted the workers of an Emergency Unit and asked them to make a narrative about a user that had affected them in some way - due to success, to some difficulty or to failure. Ricardo, the chosen user, was a 37-year-old man diagnosed as having alcoholic neuropathy. He was bedridden and lived in a house without piped water or electricity that was known by the neighbors and the Family Health team (FHT) as “oca”, a reference to indigenous dwellings in Brazil. Ricardo lived with his family - five brothers and sisters, three nephews and the father - of Paraguayan and Indian origin. There were many bottles of spirits in the house, a strong smell of marijuana and inhalant drugs, and several signs of violence were invariably perceived by the team. Ricardo did not walk, rarely talked or moved his arms and, in the first encounters, repeated the sentence insistently: “I need to be hospitalized, will you do this for me? No one takes care of me here, only Ana, when she can. If I continue here, I'll die”.

After weekly visits, the FHT decides to request the assessment of the physiotherapist of the Núcleo de Apoio à Saúde da Família (NASF - Family Health Support Nucleus), who recommends daily sessions. However, it is not possible to schedule the sessions due to hindrances in the services: there is no place, the patient does not have the adequate profile, there is no transportation, there is no patient sitter. The team feels their hands are tied and define Ricardo as a problem, a complex case.

In the first encounters, it was visible that there were many barriers to his treatment. However, there were workers like Lia, who Ana, Ricardo's sister, called “the one who falls and stand up with us”. During the 24 months of research, we perceived that Lia, the FHT worker who conducted the research team to the “oca”, knew that family's history in detail: the thing we call bond had been constructed among them.

In Ricardo's story, as well as in Sueli's, the construction of relationships between interlocutors who consider themselves as mutually valid also emerges as a necessary condition to the construction of the bond. When Lia views Ricardo as a “[…] subject who lives a complex life, has knowledge and desires, with whom the team needs to talk in order to produce, in a shared way, new possibilities of handling problems and sufferings”²⁶26. Slomp Junior H, Feuerwerker LCM, Land MGP. Educação em saúde ou projeto terapêutico compartilhado? O cuidado extravasa a dimensão pedagógica. Cienc Saude Colet. 2015; 20(2):537-46. (p.1802), she validates his and his family's existence and the ways in which they relate to life. Ricardo and his family, in turn, feeling acknowledged in their difference - even though, at that moment, their demand was not met -, also perceive the interlocution with Lia as valid, which allows them to establish a relationship based on mutual acknowledgement.

Thus, the differences between the subjects involved did not constitute an asymmetry between them and did not produce, neither in the worker nor in the user, a feeling of repulsion against each other; rather, it produced a feeling of symmetry. In these relationships where the individuals involved, despite their differences, consider themselves valid interlocutors, it is possible to establish a relation of “symmetry”, not as harmony and equality, but as dissolution of frontiers between interlocutors³⁰30. Sztutman R. Encontros: Eduardo Viveiros de Castro. Rio de Janeiro: Azougue Editorial; 2008.. There is not a denial of singularities and no one overlooks the fact that there are differences. The univocal subject/object relation is deconstructed and it is understood that the encounter between a user and a worker is not a simple encounter of different individuals; many times, it is an encounter of distinct worlds. This requires actions in relationships of symmetry, of equivalents - symmetry between the self and the other as an ethical and political bet on a certain mode of relationship³¹31. Merhy EE, Gomes MPC, Silva E, Santos MFL, Cruz KT, Franco TB. Redes vivas: multiplicidades girando as existências, sinais da rua. Implicações para a produção do cuidado e a produção do conhecimento em saúde. Divulg Saude Debate. 2014; (52):153-64..

Our movements while we search for symmetric relationships

Our first encounter with Rosa occurs when we listen to the narrative constructed by the FHT. They present her as a case that they considered difficult but succeeded in terms of articulating the various health services involved. We then start to outline our “provisional profile” of Rosa, understanding this profile as something incomplete, transitory, open to movements of dismantling and remodeling caused by new intensities generated by the encounters³²32. Baduy RS, Kulpa S, Tallemberg C, Seixas CT, Cruz KT, Slomp Junior H, et al. “Mas ele não adere!” – o desafio de acolher o outro que é complexo para mim. In: Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v.1, p. 220-7..

The encounters with this user were difficult to the research team. They disorganized the team, defied their certainties and imposed shifts from the place of wise people to a place of openness to an individual who is very different from them. In the search for other angles of Rosa's provisional profile, other narratives were found:

In this relationship, the researchers experience a certain “disarrangement”, a “discomfort” with what sounds a strong capture of actions in the area of health, when they meet the user, due to the focus on their own logic of a morally operated knowledge. They view the other as their object of action, a reaffirmation of the health professional's knowledge over the other's, a reinforcement of what is considered the ‘correct’ way of leading life. These are movements that transform differences into inequalities of knowledge and forms of living, where there is asymmetry between the knowledge/power of some in relation to the others¹¹11. Merhy EE, Feuerwerker LCM, Gomes MPC. Da repetição à diferença: construindo sentidos com o outro no mundo do cuidado. In: Franco TB, organizador. Semiótica, afecção & cuidado em saúde. São Paulo: Hucitec; 2010. p. 60-75.. But why is it that, when the worker we have in us meets another person that is very different from himself, he produces effects of control over the other's life? Or can it be that we walk through this choice almost unconsciously, in a scape from the tensions that symmetric encounters between mutually valid players can generate?

The bet that emerges from the analyses of our research is a movement of inversion of the action that controls and dominates the other's life, which occurs precisely in the field of soft technologies³³33. Merhy EE, Feuerwerker LCM. Novo olhar sobre as tecnologias de saúde: uma necessidade contemporânea. In: Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v.1, p. 59-72., a territory of deterritorialization that generates noise and can be the driving force of a self-analytical process related to the daily production of care, enabling other relationships. For example, the creation of spaces for symmetric encounters with Rosa. In fact, this is also what is experienced while we walk with Rosa across different spaces of care, when other narratives emerge:

At this moment, therefore, some CRAS workers put themselves in a position of symmetry in relation to Rosa, walking with her and experiencing events from within the movements of her life. The possibility of understanding Rosa's profile as provisional, constructed in an intensive moment of relationship with the user, enabled the team to see her as a multiplicity under constant production: Rosa starts to be considered a valid interlocutor to speak about herself, her desires and her trajectory. At some moment, the opening to the encounter with the other, considered as someone who is very different from us, happened, potentializing us for acting together with her, producing other possibilities of care³²32. Baduy RS, Kulpa S, Tallemberg C, Seixas CT, Cruz KT, Slomp Junior H, et al. “Mas ele não adere!” – o desafio de acolher o outro que é complexo para mim. In: Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v.1, p. 220-7..

Researchers under (self) analysis: what do the guiding users teach us about bond production?

We usually look at the processes we experience, either in the daily routine of health work or as researchers, from the outside, as if we mastered the secrets of the other's life. At some moments of our experience with each of the guiding users presented here, we felt the sensation that we had the formula to those teams’ action, that we would be more skilled in the production of bonds and shared therapeutic projects²⁶26. Slomp Junior H, Feuerwerker LCM, Land MGP. Educação em saúde ou projeto terapêutico compartilhado? O cuidado extravasa a dimensão pedagógica. Cienc Saude Colet. 2015; 20(2):537-46.. We also made prescriptions and judgements, and it was necessary to deconstruct this place.

In our encounters with the user, we also felt lost at many moments; sometimes we caught ourselves establishing a relationship with the user as the object we wanted to transform, ignoring his/her story; other times - and these were very frequent -, we faced our non-knowledge, as we exemplify below, in our relationship with a guiding user:

Little by little, in the encounter with the other's life and action, we gradually felt in our bodies the sensations that the teams experienced in the relationships they built with the user, feeling the same impotence, the same discomfort. And it was due to the recognition that our knowledge would not be capable of producing care in that situation that we opened our hearing to the proposals that Ricardo made, searching, based on the possibilities of symmetry that were constructed in each encounter, for other logical matrices to provide us with clues. In this movement, together with him and other workers, we saw that penetrating his world contributed to the construction of his shared therapeutic project. It is in the encounter with the other that we can realize that we need him to construct good solutions.

It is likely that, to many workers, admitting this place of “non-knowledge” involves a sensation of professional failure. We prefer to deny it. But our “non-knowledge” can be linked to the insufficiency of the tools that are available to us and that are recognized by science and health organizations as adequate to intervene in situations where the other has to fit in criteria, protocols and assistance flows that are not very flexible. Many authors⁶6. Cecílio LCO. Inventando a mudança no hospital: o projeto “Em defesa da vida” na Santa Casa do Pará. In: Merhy EE, Campos GW, Cecílio LCO, organizadores. Inventando a mudança na saúde. São Paulo: Hucitec; 1994. p. 187-234.^,2929. Seixas CT, Baduy RS, Bortoletto MSS, Lima JVC, Kulpa S, Lopes MLS, et al. Vínculo e responsabilização: como estamos engravidando esses conceitos na produção do cuidado na atenção básica? In: Feuerwerker LCM, Bertussi DC, Merhy EE, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v. 2, p.391-407.^,3232. Baduy RS, Kulpa S, Tallemberg C, Seixas CT, Cruz KT, Slomp Junior H, et al. “Mas ele não adere!” – o desafio de acolher o outro que é complexo para mim. In: Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v.1, p. 220-7.^–3434. Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65. have already shown the insufficiency of the technologies present in organizations that propose to produce healthcare.

We bet that the point-of-departure for the production of symmetric relations is the discomfort of perceiving our “non-knowledge”, of “feeling displaced, deterritorialized, with a sensation of “I don't know what to do or what to say”. Obviously, it is not possible to predict what we will do; it is a production that will happen in the act at the moment of the caregiving encounter, which is full of uncertainties²⁸28. Merhy EE. O conhecer militante do sujeito implicado: o desafio de reconhecê-lo como saber válido. In: Franco TB, Peres MAA, organizadores. Acolher Chapecó: uma experiência de mudança do modelo assistencial, com base no processo de trabalho. São Paulo: Hucitec; 2004. v. 1, p. 21-45.^,3333. Merhy EE, Feuerwerker LCM. Novo olhar sobre as tecnologias de saúde: uma necessidade contemporânea. In: Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v.1, p. 59-72.. In these situations, one solution is to ally with the other (user or worker) to produce possibilities.

Thus, we have brought the concept of symmetry to problematize this situation, which repeats itself in the daily routine of the health services, and reiterate: symmetry does not cancel difference³⁵35. Merhy EE. A clínica do corpo sem órgãos, entre laços e perspicácias: em foco a disciplinarização e a sociedade de controle. Lugar Comum. 2009; 14(27):283-308. (p.141), but it is possible as a result of difference. However, assuming that this difference does not generate inequality a priori in the relationship, how can we take the other into account, with his way of living, which, many times, causes indignation and repulsion in us? Is it possible not to make judgements and not to have prejudices at the first encounter with an Other who is so different from me? How can we consider his knowledge, place him as a valid interlocutor, and build with him relationships of affectivity and trust, according to the public policy¹⁰10. Ministério da Saúde (BR). Portaria n. 2.488, de 21 de Outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS) [Internet]. Brasília, DF: Ministério da Saúde; 2011 [citado 1 Mar 2018]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html.
http://bvsms.saude.gov.br/bvs/saudelegis... , so that he also acknowledges me as a valid interlocutor and the intercessional encounter takes place?

We also propose that, when we talk about bonds, we often trivialize this concept when we intend to operate it in the daily routine, and we run the risk of producing more barriers than care; more guilt attributed to the user, according to Merhy, “producing subjectifying serialization in the way of desiring and producing life”³⁵35. Merhy EE. A clínica do corpo sem órgãos, entre laços e perspicácias: em foco a disciplinarização e a sociedade de controle. Lugar Comum. 2009; 14(27):283-308. (p.295).

We propose a shift from the idea of “user's adherence to the treatment” to the perspective of “team's adherence to the other's project”, to focus on the needs identified by the other based on his world and his perspective of how he desires to live.

Final remarks

The interaction with the guiding users Ricardo, Rosa and Sueli, whose scenes we chose due to the radicalness of the experienced situations, reveals the challenge faced everyday in situations of many intensities and differences related to thinking/feeling in the area of health.

Another common issue in the scenes are the power relations present in the encounter between health worker and user when the latter is a “rebellious” user, that is, he does not have the same project of life that the worker has. Therefore, it seems that symmetry is, beyond an ethical positioning, a political bet, related to changing meanings/proportions of forces in the relationship, and an esthetic bet, as it summons us to open ourselves to the pulsations in front of us during the encounters. It is no surprise that symmetric relations are hard to construct.

Another point is that we tend to desire a standard user, ideal, submissive, who accepts the life we have outlined as the best for him. People who open the door when requested, who open their lives to be thoroughly investigated, who are not rebellious, who follow prescriptions to the letter, who do not interfere, do not question, who adhere to therapeutic plans that were unilaterally outlined²⁹29. Seixas CT, Baduy RS, Bortoletto MSS, Lima JVC, Kulpa S, Lopes MLS, et al. Vínculo e responsabilização: como estamos engravidando esses conceitos na produção do cuidado na atenção básica? In: Feuerwerker LCM, Bertussi DC, Merhy EE, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v. 2, p.391-407..

When they say how they want to be treated and when they resist the instituted offers that are imposed on them, Sueli, Ricardo and Rosa disclose the tensions produced in the services. When we consider that both the worker and the user bring to the encounter their ways of being and understanding life, we can suppose that resisting the “framing” would precisely be the expression of their power and desire to maintain the government of their own life³²32. Baduy RS, Kulpa S, Tallemberg C, Seixas CT, Cruz KT, Slomp Junior H, et al. “Mas ele não adere!” – o desafio de acolher o outro que é complexo para mim. In: Merhy EE, Baduy RS, Seixas CT, Almeida DES, Slomp Junior H, organizadores. Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis; 2016. v.1, p. 220-7.. After all, my resistance is my capacity to decide what I desire for me.

When the Other is looking for help, he already brings with him, between the lines, a proposal, but we rarely stop to listen to it and ask: “What would you like us to do to help you?” When the individual establishes symmetry by acknowledging the other as a valid interlocutor and allows to be affected by the multiplicity of life in potency, he opens the possibility of producing other existential territories based on the desire of walking again, of being a mother, of having other options of care: the bet is that producing bonds means producing more autonomy to subjects, in symmetric relationships and respecting differences.

We propose to think about care management devices that consider workers and users as valid interlocutors in symmetry relationships, disclosing tensions and difficulties in the engendering of transformations. We propose that this is not produced from external norms and orientations; the experience and the reflection on it are the factors that can transform these daily practices and generate new concepts to sustain symmetric encounters among workers, managers and users. The process of a collective of workers analyzing their practice in the daily routine of the work is conflictive, with different perceptions about what was lived; therefore, it is tense. Due to this, it is necessary to have management devices to strengthen and support workers in this task.

Although the concept of bond in healthcare is, many times, massified, it can be fertilized by an ethical-esthetic-political project that never ends, that puts the focus of the health practices on the health demands and needs of lives respecting their differences, and that potentializes the choices of each user - those that are meaningful to them. It is necessary to avoid making moral judgements, criminalizing the other's desires and choices; it is necessary to escape from the place of knowing what is best to the other, recognizing our non-knowledge and the need of an active action in the attempt to share the production of care among workers and with the user, in a live, symmetric and singular way.

References

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