Abstract

Introduction

The Ministry of Health (MoH) and the World Health Organization (WHO) have issues policies and guidelines geared towards the decentralization of mental health care, in order to prioritize this care network, and in this matter Primary Health Care (PHC) has an important responsibility¹1. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde mental. Brasília, DF: Ministério da Saúde; 2013. (Cadernos de Atenção Básica, nº 34).

2. Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017.-³3. World Health Organization. Integrating mental health into primary care: a global perspective [Internet]. Geneva: WHO; 2008 [citado 6 Dez 2019]. Disponível em: https://www.who.int/mental_health/policy/Integratingmhintoprimarycare2008_lastversion.pdf
https://www.who.int/mental_health/policy... .

PHC is the structuring axis of the health system, and the Family Health Strategy (ESF in the Portuguese acronym) constitutes the care model suggested by the MoH, functioning as the network gateway, managing, coordinating and integrating the work carried out by other levels of attention⁴4. Gazignato ECS, Castro-Silva CR. Saúde mental na atenção básica: o trabalho em rede e o matriciamento em saúde mental na Estratégia de Saúde da Família. Saude Debate. 2014; 38(101):296-304..

The ESF has a large responsibility for health care coverage in PHC, searching to achieve the principles of the right to health and sanitary conscience⁵5. Paim JS. Atenção Primária à Saúde: uma receita para todas as estações? Saude Debate. 2012; 36(94):343-7.. The policies directed towards the strengthening of PHC in Brazil have enabled important shifts, mainly in the model of care and management of health work⁶6. Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saude Debate. 2018; 42(116):11-24..

In spite of these shifts, mental health care in PHC still presents a biologicist tendency, and referral is seen as a care strategy performed in isolation, disregarding the responsibility of the service by the user and the integrality of care⁷7. Martins AKL, Souza AMA, Vieira NFC, Pinheiro PNC, Braga VAB. Mental health practices in the family health strategy: an exploratory study. J Res Fundam Care Online. 2015; 7(1):1905-14. Doi: http://dx.doi.org/10.9789/2175-5361.2015.v7i1.1905-1914.
http://dx.doi.org/10.9789/2175-5361.2015... ,⁸8. Cavalcante CM, Pinto DM, Carvalho AZT, Jorge MSB, Freitas CHA. Desafios do cuidado em saúde mental na Estratégia Saúde da Família. Rev Bras Promoc Saude. 2011; 24(2):102-8..

Referrals to other services, even in situations that are able and should be accompanied by PHC, may be related to the feeling of inability to deal with the demand for mental health⁹9. Gryschek G, Pinto AAM. Saúde mental: como as Equipes de Saúde da Família podem integrar esse cuidado na atenção básica? Cienc Saude Colet. 2015; 20(10):3255-62. Doi: http://dx.doi.org/10.1590/1413-812320152010.13572014.
http://dx.doi.org/10.1590/1413-812320152... ,¹⁰10. Penido CMF, Castro BP, Coimbra JR, Baker VDSIS, Franco RF. Saúde mental na atenção básica: dividir ou somar apoios matriciais? Rev Polis Psique. 2018; 8(1):33-51. Doi: https://doi.org/10.22456/2238-152X.80415.
https://doi.org/10.22456/2238-152X.80415... or as a result of a work training processes that is developed in a decontextualized way, impairing comprehensive care and mental health. The ESF resistance in relation to the expansion of the mental health glance may also be related to the lack or little in-service education¹¹11. Eslabão AD, Coimbra VCC, Kantorski LP, Pinho LB, Santos EO. Rede de cuidado em saúde mental: visão dos coordenadores da Estratégia Saúde da Família. Rev Gaucha Enferm. 2017; 38(1):1-8..

Even currently threatened with extinction, there is another strategy that favors mental health care in the context of PHC, the Family Health and Primary Health Care Expanded Support Center (NASF-AB)¹²12. Brasil. Ministério da Saúde. Secretaria de Atenção Primária a Saúde. Departamento de Saúde da Família. Nota Técnica nº 3, de 27 de Janeiro de 2020. Brasília, DF: Ministério da Saúde; 2020.. This strategy aims to support the consolidation of PHC in Brazil, expanding the possibilities of health care and network, through the work of multiprofessional teams that function jointly with the Family Health teams (ESF) in an integrated manner, conducting case discussions services, shared care among professionals, home visits and joint construction of care, through Single Therapeutic Projects (PTS), in order to qualify actions in the territories of the subjects while seeking in fact, to promote the comprehensiveness of health care by ESF²2. Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017..

Both the transformation of care and the mental health approach are not simple, unidirectional, positivist or superficial processes. For that end, Permanent Education in Health (EPS) is an important training strategy, both for and in the service that enables this transformation, in a contextualized way, problematizing the reality of the subjects, aimed at meaningful learning and analysis of practices¹³13. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde; 2009..

The National Policy for Permanent Education in Health (PNEPS), a strategy for training aimed at the Brazilian National Health System (SUS) and the development of network care, under the responsibility of ordination by the Ministry of Health, was instituted originated by the approval of the Training and Development Policy for SUS: paths to Permanent Health Education (PNEPS)¹³13. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde; 2009.,¹⁴14. Mishima SM, Aiub AC, Rigato AFG, Fortuna CM, Matumoto S, Ogata MN, et al. Perspectivas dos gestores de uma região do estado de São Paulo sobre educação permanente em saúde. Rev Esc Enferm USP. 2015; 49(4):665-73..

This way of working is anchored in meaningful learning and in contextualizing the health needs that the population presents, the health-disease process and the way to deal with it; contributing to the development of individual and collective skills and competences for daily practices and for life; that is, it is not a relationship of teaching and learning, but rather an educative process mediated by the context and by the collective, having a dynamic character directed to the expansion of meanings, through the collective participation and reflection, through the work process¹⁵15. Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra; 1996.,¹⁶16. Brasil. Ministério da Saúde. Secretaria-Executiva. Subsecretaria de Assuntos Administrativos. O Trabalho como fonte de formação: um movimento em construção no Ministério da Saúde – Agenda 2015 de Desenvolvimento dos Trabalhadores. Brasília, DF: Ministério da Saúde; 2015..

The facilitator is the driver of this process, being in charge with the promotion of inclusive participation, making speeches being heard, prior knowledge and all forms of lore presented by those involved, stemming from their different experiences. It is part of the facilitator’s role to value and encourage participation and the development of new knowledge through critical and reflective thinking¹⁷17. Lara EMO, Lima VV, Mendes JD, Ribeiro ECO, Padilha RQ. O professor nas metodologias ativas e as nuances entre ensinar e aprender: desafios e possibilidades. Interface (Botucatu). 2019; 23:e180393. Doi: https://doi.org/10.1590/Interface.180393.
https://doi.org/10.1590/Interface.180393... . However, it should be considered that the way in which EPS facilitation is performed might provide or else hinder speech, depending on how it is crossed by institutions. If the EPS facilitators do not pay attention to the construction of knowledge in the collective, they may lose the creative and originative power of these collectives¹⁸18. Rézio LA, Fortuna CM, Borges FA. Tips for permanent education in mental health in primary care guided by the Institutional Socio-clinic. Rev Lat Am Enfermagem. 2019; 27:e3204. Doi: http://dx.doi.org/10.1590/1518-8345.3217.3204.
http://dx.doi.org/10.1590/1518-8345.3217... .

The institution is the immaterial dimension related to norms and rules constructed and established socially, i.e.: not the equipment, buildings or establishments¹⁹19. Loural R. A análise institucional. 3a ed. Petrópolis: Vozes; 2014., but for example, mental health, family and education.

Institutional Socioclinics, as a mean to question and understand social dynamics, considers that professional practice includes the relationship we establish with our work, understanding this as an institution (professional institution), thinking about these relationships²⁰20. Monceau G. Técnicas socioclínicas para a análise institucional das práticas sociais. Psicol Rev. 2015; 21(1):197-217..

The principles of Institutional Socioclinics consist of the participation of subjects in the device; order and demand analysis; analyzers’ work; restitutions’ application arrangements; analysis of the transformations that occur as the work progresses; intention in knowledge production; attention to contexts and institutional interference; and the analysis of implications²⁰20. Monceau G. Técnicas socioclínicas para a análise institucional das práticas sociais. Psicol Rev. 2015; 21(1):197-217..

The implication is the relationship (psycho-affective, historical-existential and structural-professional) that is established with the institutions (education, health, family, among others); it does not matter a priori whether this implication is something good or bad, but the fact that it produces effects that contribute and/or obstruct intervention situations, even if we don’t know¹⁹19. Loural R. A análise institucional. 3a ed. Petrópolis: Vozes; 2014.. That is why Institutional Analysis signals to the need to analyze the implication, as we will always be involved, since it is not a voluntary or conscious act¹⁹19. Loural R. A análise institucional. 3a ed. Petrópolis: Vozes; 2014.. The professional implication, on the other hand, is our relationship with the profession, understanding the profession also as an institution, with its own dynamics²⁰20. Monceau G. Técnicas socioclínicas para a análise institucional das práticas sociais. Psicol Rev. 2015; 21(1):197-217.,²¹21. Monceau G. Como as instituições permeiam as práticas profissionais. Socioclínica institucional e formação de professores. In: Pimenta SG, Franco MAS, organizadores. Pesquisa em educação: possibilidades investigativas/formativas da pesquisa-ação. São Paulo: Loyola; 2008. p. 27-73..

In this sense, the understanding of implication helped in the process of reflection on the facilitation of EPS, favoring the understanding that the analysis of the implication is not analyzing the reaction to contact with the object of analysis.

In the analysis of the implication by the facilitator and the institutional crossings in the process of developing EPS, the inclusion of the analysis of the placing system should be under consideration, the indication of the place occupied by the facilitator, what is sought to occupy, and what is assigned to occupy as a facilitator²²22. Passos E, Barros RBA. A construção do plano da clínica e o conceito de transdisciplinaridade. Psicol Teor Pesqui. 2000;16(1):71-9.. Therefore, this study aimed to analyze the process of facilitating EPS for the education in mental health in Primary Health Care.

Method

This is an intervention-research carried out from March 2016 to February 2017, inspired by the theoretical framework of Institutional Analysis - Institutional Socioclinics. This study is part of a PhD thesis completed by the first author and refers to a EPS process for education in mental health carried out in two ESF teams in a large city in the state of Mato Grosso, Brazil.

Twenty workers participated in the study, 11 from the ESF I team and nine from the ESF II team. Of this total, 11 were community health agents (CHA), two doctors, two nurses, two nursing technicians, two receptionists and a clerk officer.

The semi-structured interview was carried out with the workers of the two ESF teams during the entry period in field/ambience, seeking information about the work routine in health and mental health as well as experiences with and in EPS, seeking to identify needs-demands for the process EPS. The information collected along the interviews was then returned to the group, and the topics for the EPS meetings were listed, and those topics changed over the course of the training, according to the needs of the group.

The EPS process was developed over eight months. Meetings were held separately with each team (I and II), so that every fortnight there was an EPS meeting with both team I and II, i.e., there were an average of two monthly meetings, totaling 12 EPS meetings with each ESF team, taking in consideration that in some months there was just one meeting, due to team’s choice.

The group meetings were recorded with the consent of the participants and the recordings were transcribed. Additionally, the facilitators kept notes of their observations in a field diary.

In one of the restitution moments with the staff members, the first author identified the need to include other facilitators in the process. Two professionals from a Psychosocial Care Center for alcohol and other drugs (CAPSad) were then invited to participate in the facilitation process.

In order to trigger the training processes by EPS, auto-analytical devices were agreed upon with the research subjects, allowing the production of the analysis through their own execution²³23. Merhy EE. A organização não existe: uma conversa da micropolítica do trabalho, da educação permanente e da análise institucional. In: L’Abbate S, Mourão LC, Pezzato LM, organizadores. Análise institucional e saúde coletiva no Brasil. São Paulo: Hucitec; 2013. p. 579-96. (conceptual schemes, reflections from videos, dramatizations, among others).

For the purpose of data analysis, the research used thematic content analysis seeking to identify the units of meaning regrouping them later, into categories²⁴24. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.. The study was founded on Institutional Analysis - Socioclinical as its theoretical framework while using for this specific study, the concept of implication for the analysis of the facilitation process. This concept understands the implication as interaction, the analysis of commitment, the involvement (psycho-affective, historical-existential and structural-professional) with the EPS process¹⁹19. Loural R. A análise institucional. 3a ed. Petrópolis: Vozes; 2014.,²⁰20. Monceau G. Técnicas socioclínicas para a análise institucional das práticas sociais. Psicol Rev. 2015; 21(1):197-217..

The Research Ethics Committee, under the opinion of CAAE nº 53029016.2.0000.5393, approved the research. To guarantee the subjects’ anonymity and information, the staff statements were identified by the letter T, followed by Arabic numerals. The facilitators’ statements were characterized as F (1, 2 and 3) and their records were described as the facilitators’ diaries (1, 2 and 3).

Results and discussion

Collective reflection on conceptual aspects

By assuming EPS as a political-pedagogical strategy to overcome SUS shortcomings, it was recognized that EPS comprises pedagogical concepts that promote reflection-learning about work, through work and within the collective, in order to generate and produce knowledge, lore and changes²⁵25. Brasil. Ministério da Saúde. Secretaria de Gestão no Trabalho e Educação na Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem sido produzido para seu fortalecimento? Brasília, DF: Ministério da Saúde; 2018., ²⁶26. Ceccim RB. Educação Permanente em Saúde: descentralização e disseminação de capacidade pedagógica na saúde. Cienc Saude Colet. 2005; 10(4):975-86..

Through a joint construction mediated by the EPS facilitators, it was possible to learn and reflect within the collective about its conceptual aspects, for example, to provide clarification on the difference between Continuing Education (CE) and EPS.

The facilitation process allowed differentiating the concepts between EPS and CE from the collective work and previous problematized knowledge using the guiding questions that provided the reflection of the participating professionals:

By questioning the professionals, in the sense of producing knowledge in and by the collective, seeking to problematize the difference between EPS and CE, the team understood, through its own process and movement, that CE is configured as a continuity of the school model, centralized in knowledge updating, through the transmission of knowledge, most of the time limited, disjointed from the context, from collective participation and social control. It is characterized as a training strategy with temporary breaks, for example, with periodic courses focused on technical-scientific knowledge in specific areas¹³13. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde; 2009.,²⁷27. Peduzzi M, Guerra DAD, Braga CP, Lucena FS, Silva JAM. Atividades educativas de trabalhadores na atenção primária: concepções de educação permanente e de educação continuada em saúde presentes no cotidiano de Unidades Básicas de Saúde em São Paulo. Interface (Botucatu). 2009; 13(30):121-34.,²⁸28. Figueredo RC, Celestino KAA, Moraes CRF, Figueiredo IIS. Desafios e perspectivas na educação permanente em saúde desenvolvida na atenção primária: uma revisão bibliográfica. Rev Cientif ITPAC. 2014; 7(4):255-66..

Even when CE is carried out using active methodologies, there is no progress towards the production of reflections and self-analysis of work, based on the hardships experienced in daily work, being only formal spaces for the production of knowledge. It is not training as a process linked to situations arising from work and its problematization for the production of new knowledge²⁹29. Fernandes RMC. Educação permanente e políticas sociais. Campinas: Papel Social; 2016..

Consequently, there was an understanding that EPS represents an important advance in care workers formative process, since it incorporates teaching and learning in the real context, transforming practice and daily life into a source of knowledge and problematization of doing, enabling workers to take the place of actors instead of recipients and producing reflections about the context¹³13. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília, DF: Ministério da Saúde; 2009.,³⁰30. Brasil. Ministério da Saúde. Secretaria-Executiva. Subsecretaria de Assuntos Administrativos. Educação permanente em saúde: um movimento instituinte de novas práticas no Ministério da Saúde: Agenda 2014. Brasília, DF: Ministério da Saúde; 2014.. It is focused on the potential of daily practice, in which work is the object of formation and transformation, problems and solutions emerge from the daily practice of professionals, in a context of shared -and not centralized- responsibility.

The facilitator’s posture and the restitution towards the group may foster new paths, directed to knowledge built in the group, affection, desire, cooperation and solidarity. No “me” may be constituted without a “no me”, as learning in daily life is linked to contacts with the other and the in-service training process by EPS³¹31. Freire P. Pedagogia do oprimido. 47a ed. Rio de Janeiro: Paz e Terra; 2005.,³²32. EPS em Movimento. Um mergulho no mundo do trabalho em saúde [Internet]. 2014 [citado 4 Jan 2020]. Disponível em: http://eps.otics.org/material/entrada-textos-em-cena/um-mergulho-no-mundo-do-trabalho-em-saude
http://eps.otics.org/material/entrada-te... . Therefore, the restitution was an opportunity to look at the work process, sharing reflections within the collective, putting them under analysis, close to work self-management processes¹⁸18. Rézio LA, Fortuna CM, Borges FA. Tips for permanent education in mental health in primary care guided by the Institutional Socio-clinic. Rev Lat Am Enfermagem. 2019; 27:e3204. Doi: http://dx.doi.org/10.1590/1518-8345.3217.3204.
http://dx.doi.org/10.1590/1518-8345.3217... ,²⁰20. Monceau G. Técnicas socioclínicas para a análise institucional das práticas sociais. Psicol Rev. 2015; 21(1):197-217..

The facilitation process also allowed workers to verbalize definitions referring to EPS, not only linked to the cognitive process, but also to other elements present in the relationship with the other. This is due to the fact that the reflection does not happen individually but rather contextualized, beginning to make sense for the group, often caused by the analysis of the life experiences of those involved³³33. Ferreira L, Barbosa JSA, Eposti CDC, Cruz MM. Educação permanente em saúde na atenção primária: uma revisão integrativa de literatura. Saude Debate. 2019; 43(120):223-39. Doi: https://doi.org/10.1590/0103-1104201912017.
https://doi.org/10.1590/0103-11042019120... .

As the EPS integrates active teaching-learning methodologies that are known to occur in a dynamic, problematic, non-linear way, ensuring the deepening of knowledge and the expansion of its meanings³⁴34. Ceccim RB, Ferla AA. Educação permanente em saúde. In: Pereira IB, Lima JCF. Dicionário de educação profissional em saúde. 2a ed. Rio de Janeiro: EPSJV; 2008. p. 162-8., the facilitator must then promote more democratic relationships, allowing a rupture with traditional models of learning.

The facilitators were able to provide a embracing environment and the development of affection by understanding that, in EPS the facilitator must provide an educational practice that adds knowledge and technical mastery, that is at the same time, articulated to joy, affection, listening ability, perception of another and thoughtfulness³⁵35. Azevedo CRF, Gomes R. Use of narrative in continuing Health education: educational directions, successes and limits. Interface (Botucatu). 2019; 23:e170957. Doi: https://doi.org/10.1590/interface.170957.
https://doi.org/10.1590/interface.170957... .

The ability to listen includes verbal and non-verbal language to understand and process information, something only made possible through attentive and reflective listening, which will favor the perception and understanding³⁶36. Broca PV, Ferreira MA. Communication process in thenursingteamabasedonthe dialogue between Berloand King [Internet]. Esc Anna Nery. 2015; 19(3):467-74. Doi: https://doi.org/10.5935/1414-8145.20150062.
https://doi.org/10.5935/1414-8145.201500... not only of concepts and contents, but also of people.

EPS, as an in-service education strategy, should provide experimentation in context, in affectivity, therefore being affected by reality³⁷37. EPS em Movimento. Caixa de Afecções [Internet]. 2014 [citado 4 Jun 2020]. Disponível em: http://eps.otics.org/material/entrada-experimentacoes/caixa-de-afeccoes?searchterm=caixa+de+afe
http://eps.otics.org/material/entrada-ex... . For Spinoza³⁸38. Spinoza B. Ética. Belo Horizonte: Autentica; 2009., affection is related to the force of existing, or the power to act, in which it can be increased or decreased.

Therefore, ideas, sensations, words and materials that are meaningful, that provoke affections, questions or serving as memory support for experiences are also sources of learning³⁷37. EPS em Movimento. Caixa de Afecções [Internet]. 2014 [citado 4 Jun 2020]. Disponível em: http://eps.otics.org/material/entrada-experimentacoes/caixa-de-afeccoes?searchterm=caixa+de+afe
http://eps.otics.org/material/entrada-ex... .

As a mediator of learning that integrates subjects, knowledge and lore, the facilitators must place themselves in this relationship in a respectful and ethical stance, promoting critical reflection on the practice and the experiences, lives and knowledge³⁹39. Hospitais PROADI-SUS. Desenvolvimento da gestão de programas de residência e preceptoria no SUS- DGPSUS 2018-2010 [Internet]. 2019 [citado 17 Jan 2020]. Disponível em: https://hospitais.proadi-sus.org.br/projetos/107/dgpsus
https://hospitais.proadi-sus.org.br/proj... , while accepting the affective demands arising in the educational process:

The effect that a certain experience has on us, interrogating experiences, challenging us to think and make connections with what has been experienced, re-contextualizing the experience, producing displacements and affections³⁷37. EPS em Movimento. Caixa de Afecções [Internet]. 2014 [citado 4 Jun 2020]. Disponível em: http://eps.otics.org/material/entrada-experimentacoes/caixa-de-afeccoes?searchterm=caixa+de+afe
http://eps.otics.org/material/entrada-ex... , as there are questions directed to what is done with what affects me, in order to a collective revisiting of the knowledge produced by the experience.

The facilitation process then presented itself as an important pedagogical element, since it added affection, meaningful learning and the mobilization of concerns, valuing the singular movement of the group and each participant. The de-territorializations and affections mobilized in this movement were based on the sensitivity of speech and the ability to see oneself in the other and in the collective, with some effects derived from looking at oneself, perceiving undesirable acts and actions, finding potentialities to follow and transform practice and daily life.

Therefore, we were able to provide potent collective spaces to think about the work process and health care and, in addition, the individual and collective transformations resulting from this process⁴⁰40. Figueiredo MD, Campos GWS. O apoio Paideia como metodologia para processos de formação em saúde. Interface (Botucatu). 2014; 18(1):931-43..

Learning and experiencing are processes that happen within head, body and the vibrations that affect us through encounters, i.e., they are experiences that make up our experiences that can also produce learning. It is in the encounter that the mutual capacity to affect and be affected occurs. To look for self advances whenever we are also able to recognize ourselves in the other in a production process³²32. EPS em Movimento. Um mergulho no mundo do trabalho em saúde [Internet]. 2014 [citado 4 Jan 2020]. Disponível em: http://eps.otics.org/material/entrada-textos-em-cena/um-mergulho-no-mundo-do-trabalho-em-saude
http://eps.otics.org/material/entrada-te... .

Revisiting daily work as a strategy of detaching from one’s own truths and opening oneself to new knowledge³²32. EPS em Movimento. Um mergulho no mundo do trabalho em saúde [Internet]. 2014 [citado 4 Jan 2020]. Disponível em: http://eps.otics.org/material/entrada-textos-em-cena/um-mergulho-no-mundo-do-trabalho-em-saude
http://eps.otics.org/material/entrada-te... foster the translation of the practices and knowledge inherent in daily work into new meanings of learning and care.

Traditionally, mental health care has always been directed to healing, care was aimed towards illness and medication is its main work tool, based on the social isolation of the person in mental distress⁴¹41. Amarante P. Saúde mental e atenção psicossocial. Rio de Janeiro: Fiocruz; 2017..

To transform mental health care, we understand that first it is necessary that the discussions and reflections on this topic should make sense for the professionals and for the community in general, that is, the training needs to make sense, and to be in service, discussing and learning by work and for work.

Throughout the mental health training process done through EPS, the experienced situations were problematized, as well as the concepts, terms and nomenclatures used, allowing the practitioners to also share their fears and insecurities with the group, both as space for the production of affections as well as the learning produced from the unusual, problematizing realities, questioning and reflecting on daily life, being able to reframe practices, collectively retrieving experiences, also collectively building new knowledge and confrontations/resolutions for the situations that are experienced³⁵35. Azevedo CRF, Gomes R. Use of narrative in continuing Health education: educational directions, successes and limits. Interface (Botucatu). 2019; 23:e170957. Doi: https://doi.org/10.1590/interface.170957.
https://doi.org/10.1590/interface.170957... ,⁴²42. Pinheiro MCC, Hypólito ALM, Kantorski LP. Educação permanente no processo de trabalho em saúde mental. J Nurs Health. 2019; 9(2):e199203. Doi: http://dx.doi.org/10.15210/jonah.v9i2.13661.
http://dx.doi.org/10.15210/jonah.v9i2.13... .

The hoe went from a routine experience and experimentation fraught with meanings, restricted to fear and danger, to the provocation of change, of transformation, as the EPS facilitator manages to find something that functions as a factor of affection and awakens new meanings in the collective, a new look at instituted and naturalized practices.

EPS should start from the experience of discomfort with the reality lived in the act and consider the previous knowledge of each subject, making it both possible and necessary a learning called significant⁴³43. Slomp HJ, Feuerwerker LCM, Poirot LMG. Educação em saúde ou projeto terapêutico compartilhado? O cuidado extravasa a dimensão pedagógica. Cienc Saude Colet. 2015; 20(2):537-46..

Even though still incipient, EPS may in this study initiate an instituting movement to change the theoretical-conceptual, technical-assistance and sociocultural dimension, components of the Psychiatric Reform, as a complex social process⁴¹41. Amarante P. Saúde mental e atenção psicossocial. Rio de Janeiro: Fiocruz; 2017., promoted by the process of facilitation and professional involvement, ethical, political-ideological and affective of the facilitators with the object of study: EPS and mental health.

Although this research is restricted to a local context, it is essential to expand the field of intervention for the whole field of analysis. This means that this production is not only a product of the local dynamics and of the interactions solely regarding the individuals who are part of this study⁴⁴44. Fortuna CM, Monceau G, Valentim S, Mennani KLE. Uma pesquisa socioclínica na França: notas sobre a Análise Institucional. Fractal Rev Psicol. 2014; 26(2):255-66..

The control of the learning process and the institutional crossings

The EPS facilitator should promote and “facilitate” collective analyzes supplying answers and new questions formulated in the group. Therefore, it is desirable that to facilitate should evade the position of specialist and of those who have and are able to “give answers”³⁵35. Azevedo CRF, Gomes R. Use of narrative in continuing Health education: educational directions, successes and limits. Interface (Botucatu). 2019; 23:e170957. Doi: https://doi.org/10.1590/interface.170957.
https://doi.org/10.1590/interface.170957... ,⁴⁴44. Fortuna CM, Monceau G, Valentim S, Mennani KLE. Uma pesquisa socioclínica na França: notas sobre a Análise Institucional. Fractal Rev Psicol. 2014; 26(2):255-66..

The process of facilitating EPS implies encouraging reflection with the development of cognitive, psychomotor and attitudinal capacities to create new practices and knowledge. However, the position of specialist in mental health, occupied by the facilitators, resulted, in some moments, in a control of the creative process.

In the same way that EPS has the potential to reflect around what is instituted and naturalized as a practice in the daily work, at the same time it can also reproduce learning modes controlled by forces and/or instituted training / in-service practices⁴⁵45. Rocha D, Deusdará B. Contribuições da análise institucional para uma abordagem das práticas linguageiras: a noção de implicação na pesquisa de campo. Cad Letras UFF. 2010; 40:47-73..

In this case, although there is experience in EPS or theoretical knowledge, the practice of instituted training and therefore with the greatest risk of being reproduced, is the practice in which there is someone who has the knowledge and is responsible for passing on this knowledge/information, most of the time in a less democratic and participatory way.

This capture occurs through training as a continuation of the “school” model centered on updating knowledge through the transmission of knowledge, most of the time pinpointed and fragmented, disjointed from the context and from collective participation and social control⁴⁰40. Figueiredo MD, Campos GWS. O apoio Paideia como metodologia para processos de formação em saúde. Interface (Botucatu). 2014; 18(1):931-43..

The educational institution, as well as traditional and conservative characteristics, often crosses our practice, enabling the risk of reducing EPS spaces to simple information transfer. In the abovementioned situation, the facilitators centralized the analysis of the dramatization scene from the point of view of specialists in mental health, but also of teachers (place of speech of one of the facilitators), with few guiding questions that could be able to allow the team to reflect about why they presented a scene that described attitudes that they disapproved in another team.

Crossings, as a concept of Institutional Analysis, are those interpenetrations and attitudes that reproduce what is instituted according to the conservative¹⁹19. Loural R. A análise institucional. 3a ed. Petrópolis: Vozes; 2014.. Institutional crossings will always consist of the conservation of the instituted, of something previously existing, making the analysis process difficult⁴⁵45. Rocha D, Deusdará B. Contribuições da análise institucional para uma abordagem das práticas linguageiras: a noção de implicação na pesquisa de campo. Cad Letras UFF. 2010; 40:47-73..

It is important to place in evidence those institutional crossings through the analysis of implications as a powerful analytical and operative device for the development of EPS among the supporters, articulators and facilitators of EPS¹⁸18. Rézio LA, Fortuna CM, Borges FA. Tips for permanent education in mental health in primary care guided by the Institutional Socio-clinic. Rev Lat Am Enfermagem. 2019; 27:e3204. Doi: http://dx.doi.org/10.1590/1518-8345.3217.3204.
http://dx.doi.org/10.1590/1518-8345.3217... ,⁴⁶46. Borges FA, Fortuna CM, Feliciano AB, Silva MV, Kasper MS, Ogata MN. Analysis of professional implication as a tool of permanent education in health. Rev Lat Am Enferm. 2019; 27:e3189. Doi: http://dx.doi.org/10.1590/1518-8345.3114.3189.
http://dx.doi.org/10.1590/1518-8345.3114... .

These crossings may preclude opportunities to problematize what the team really wants to show about itself or allow the dramatization process to function as the analyzer.

The effect of the analyzer is to reveal something “hidden”, to disorganize what was somehow organized, giving new meanings to naturalized practices, revealing contradictions of a group moment. In this sense the analyzer replaces the analyst, directing and provoking the analysis by itself⁴⁷47. L’Abbate S. O analisador dinheiro em um trabalho de grupo realizado num hospital universitário em Campinas, São Paulo: revelando e desvelando as contradições institucionais. In: Rodrigues HBC, Altoé S, organizadores. Saúde Loucura: Análise Institucional. n. 8. São Paulo: Hucitec; 2004. p. 79-99.,⁴⁸48. Lourau R. Implicação e sobreimplicação. In: Altoé S, organizador. René Lourau: analista institucional em tempo integral. São Paulo: Hucitec; 2004. p. 186-98..

In spite of our position in the group, having the intention of proposing collective reflections, of enunciating things, in the group we often remained over-implicated in relation to the affective and organizational dimension, dividing and sharing in a restricted way the speech and reflection, mobilized by the desire to modify/transform mental health care.

It is important to point out that these perspectives are important for us to understand our places of speech and, consequently, the institutions that cross/speak for us, such as the educational institution and the mental illness/insanity/mental suffering institution. Analyzing these institutional crossings and our relationship with the object of study (EPS) enabled us to identify our over-implications in the facilitation process, in which, even after the completion of the intervention, it was possible to have repercussions in changing our practices and in facilitating other groups for in-service training.

From the perspective of Institutional Analysis/ Institutional Socioclinical Analysis, there is a need for the researchers to put themselves in analysis/analyze their own implications, their relations with the object of study, and not as analysts of data/facts, as in other research²⁰20. Monceau G. Técnicas socioclínicas para a análise institucional das práticas sociais. Psicol Rev. 2015; 21(1):197-217..

Even though the analysis of the facilitators’ involvement took place at a different time, even because two facilitators participated only in the final meetings, to be in a training process in and by the collective favored the perception that the movement of creation and reflection was, in some moments, captured by the control of learning.

To put it in other words, it was identified that there were moments of control, but their analysis became more meaningful when we (we, facilitators) analyzed our implications, observing the institutional crossings:

I could have allowed them to come to a conclusion [...], they talked about the case and I already said what I had to do. (Facilitator’s Diary F3)

The process started from control and over-implications were revised/transformed from stimulus to reflection, provided by the two facilitators entering at the end of the process.

Although there was no sharing/analysis with the workers regarding the implications of each one, the understanding about the implications and over-implications allowed us as facilitators, to understand that the need for control or destabilization in the face of “non-control” was related to our structural-professional involvement with the training process and specialty in mental health¹⁸18. Rézio LA, Fortuna CM, Borges FA. Tips for permanent education in mental health in primary care guided by the Institutional Socio-clinic. Rev Lat Am Enfermagem. 2019; 27:e3204. Doi: http://dx.doi.org/10.1590/1518-8345.3217.3204.
http://dx.doi.org/10.1590/1518-8345.3217... . We all spoke of a “place” of the known, holders of knowledge regarding the specialty/specificity of mental health, as well as group coordinators in mental health services. From the analysis of this crossing, it was possible to acknowledge the relevance of “non-control” in a training process based on EPS¹⁸18. Rézio LA, Fortuna CM, Borges FA. Tips for permanent education in mental health in primary care guided by the Institutional Socio-clinic. Rev Lat Am Enfermagem. 2019; 27:e3204. Doi: http://dx.doi.org/10.1590/1518-8345.3217.3204.
http://dx.doi.org/10.1590/1518-8345.3217... .

The structural-professional implication with the training process is linked to the way we, the facilitators, build our training throughout life, based on a positivist, hierarchical and scarcely creative model, in which there is control; there are instituted ways that control and capture the process of teaching problematizing. Over-implication is only perceived based on the analysis of implication²⁰20. Monceau G. Técnicas socioclínicas para a análise institucional das práticas sociais. Psicol Rev. 2015; 21(1):197-217..

The fact that we are/occupy the place of specialist and activist in anti-asylum and psychosocial care, we believe that mental health care is part of any kind of care for human beings, our empathy with users in psychological distress, that is, the sensitization and recognition of the other in its uniqueness and complexity, as well as the form of militant work, kept us over-involved in an affective-libidinal and structural-professional way.

In the same way of the experience reported by Dubois⁴⁹49. Dubois A. Leseffets d’une recherchesur um dispositif d’analyse de pratiques professionnelles. In: Monceau G, organizador. Enquêter ou intervenir? Effets de larecherchesócio-clinique. Nîmes: Champ Social éditions; 2017. p. 30-9., we were (mainly Facilitator 1) inhabited by the “ghost of a model” in this situation: an ideal and single mental health care model, through which we also believed that we were able to change and do a revolution in local mental health care.

We are always involved, since the implication is not a matter of will, of conscious decision: it is a sign of the place that it occupies or is designated to occupy with risks that this implies in a voluntary act. Due to this, the Institutional Analysis proposes that we should analyze our implications, and not merely talk about implication⁵⁰50. Barros RB. Grupo: a afirmação de um simulacro. 3a ed. Porto Alegre: Sulina, Editora da UFRGS; 2013..

Analyzing this implication is a movement of looking at oneself, looking at which institutions are speaking on behalf of us, being, necessarily, a collective work, since the implications are not analyzed alone, in a secluded corner²¹21. Monceau G. Como as instituições permeiam as práticas profissionais. Socioclínica institucional e formação de professores. In: Pimenta SG, Franco MAS, organizadores. Pesquisa em educação: possibilidades investigativas/formativas da pesquisa-ação. São Paulo: Loyola; 2008. p. 27-73., but from being immersed in the field, looking at others, from self-analysis and encounters. In this way, it is feasible to reflect around the echoes of our actions.

Final considerations

The present study aimed to analyze the process of facilitating EPS for education in mental health in Primary Care. We point out how much this analytical movement can enhance the spaces for in-service education, expanding the analysis for our relationship with work and health/mental health care; learning and teaching; with in-service education as well as facilitating learning movements. This enables new ways of doing health and, in particular, of producing knowledge full of meanings, based on the valuation of the most different experiences and knowledge.

To this end, it is necessary that the facilitation process be based on the encouraging of the reflection/self-reflection of the worker about the daily practices with attention to the control of the learning process and institutional crossings.

The potential of this research is related to the analysis of the EPS facilitation process, using Institutional Analysis - Socioclinical, identifying the institutional crossings and the implications / over-implications, linked to the EPS, from the critical-reflective look about over-implication.

After the end of the EPS process and already leaving the field of intervention of the study, it was understood that the collective did not exhaust the learning process. Instead, it started an instituting movement to change the paradigm of care for people in mental distress and education by work and for work in an interprofessional, dialogued, reflective, contextualized and collective perspective.

Despite its boundaries as a local research, it was understood that the expansion of the analysis field contributes from the perspective of the need to analyze the process of facilitating EPS, considering the institutional crossings and analysis of the implication of the facilitators that help to potentiate other processes of learning.

Acknowledgments

To the State Department of Health and the Psychosocial Care Center for alcohol and other drugs for allowing two professionals to collaborate in the research, as well as for the partnership in other projects.

References

Publication Dates

History