Abstract

The objective was to analyze the structural characteristics, functions and attributes of bonds in the social networks of users of a Psychosocial Care Center. For this purpose, a qualitative study was developed in which 16 users of a Psychosocial Care Center participated. In-depth and semi-structured interviews were carried out based on the Network Map diagram. Extensive social networks were identified, with a concentration of intimate relationships, limited to family members and health services. After the illness, the participants reported fragile family relationships. The appropriation of spaces in the community and in friendship relationships favored the structuring of networks. The analysis of the network map comprises an analysis tool indicating the pathways for psychosocial care to reach the production of mental health care.

Psychosocial care; Mental health; Community mental health services; Social networking; Social network analysis

Introduction

Beginning in the 1970s, mental health professionals, users, and family members of people with mental disorders developed an intense mobilization in Brazil, leading to the production of a series of anti-manicomial movements. As a complex and contemporary social process, the Psychiatric Reform (PR) has produced a break from the asylum model in mental health care and can be analyzed under four dimensions - theoretical-conceptual, technical-assistance, legal-political, and sociocultural, which are evidently intertwined and interdependent¹1. Amarante P. Saúde mental e atenção psicossocial. 3a ed. Rio de Janeiro: Editora Fiocruz; 2007. .

Mental health care is based on Law no. 10,216/2001, which defends the deconstruction of psychiatric hospitals, the creation of community mental health services, and the guarantee of rights for people with mental health problems. Its operationalization is articulated to Ordinance no. 3088/2011, which establishes the Psychosocial Care Network (RAPS in the Portuguese acronym), proposing a horizontal and articulated organizational arrangement between the equipment and health actions so that the coordinated production of care meets the comprehensiveness, access, and linkages²2. Brasil. Ministério da Saúde. Legislação em saúde mental: 1990-2004. 5a ed. Brasília: Ministério da Saúde; 2005. , ³3. Brasil. Ministério da Saúde. Portaria nº 3088, de 23 de Dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde (SUS). Brasília: Ministério da Saúde; 2011. .

Through its aim to reverse the asylum and asylum-like model, mental health care in Brazil is based on the theoretical and methodological assumptions of the Psychosocial Rehabilitation in Italy⁴4. Morato GG. Reabilitação psicossocial e atenção psicossocial: identificando concepções teóricas e práticas no contexto da assistência em saúde mental [tese]. São Carlos (SP): Universidade Federal de São Carlos; 2019. , understood as a set of fundamental strategies for people to have guaranteed spaces for negotiation and exchange in the community where they live. It consists of the full exercise of citizenship through the expansion of contractual power organized in three major axes: housing, social network, and work with social value, which are incorporated into the RAPS from a micro-to-macro dimension, respectively, encompassing from the level of affectivity to the organization of services⁵5. Saraceno B. Libertando identidades: da reabilitação psicossocial à cidadania possível. 2a ed. Rio de Janeiro: Te Corá; 2001. , ⁶6. Saraceno B. Reabilitação psicossocial: uma estratégia para a passagem do milênio. In: Pitta AMF, organizadora. Reabilitação psicossocial no Brasil. 4a ed. São Paulo: Hucitec Editora; 1996. p. 13-8. .

It is argued that, in consideration of Psychosocial Rehabilitation, the production of care in mental health started to operate a clinic that integrates in an expanded and articulated manner the three axes, making it possible to take the complexity and uniqueness of the experience of mental suffering as changing processes inserted collectively⁴4. Morato GG. Reabilitação psicossocial e atenção psicossocial: identificando concepções teóricas e práticas no contexto da assistência em saúde mental [tese]. São Carlos (SP): Universidade Federal de São Carlos; 2019. .

Given the experiences of transformation and conformation of a care field consequent to the Psychiatric Reform process in Brazil, the theoretical-methodological contributions in Psychosocial Rehabilitation have been incorporated and metabolized, resulting in a new paradigm: Psychosocial Care (PC) that can be characterized by theoretical-practical, political-ideological, and ethical actions that seek to replace the asylum model and the psychiatric paradigm⁷7. Costa-Rosa A. Atenção psicossocial além da reforma psiquiátrica: contribuição a uma clínica crítica dos processos de subjetivação na saúde coletiva. São Paulo: Unesp; 2013. , ⁸8. Costa-Rosa A, Luzio CA, Yasui S. Atenção psicossocial: rumo a um novo paradigma na saúde mental coletiva. In: Amarante P, coordenador. Archivos de saúde mental e atenção psicossocial. Rio de Janeiro: Nau; 2003. p. 13-44. .

The significant social network⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. , the object of study of this research, is concomitantly related to PC and to the three axes of Psychosocial Rehabilitation, especially the second axis that is also called social network and discusses the assumption of the quantitative and qualitative narrowing of relationships in the social network negatively impacting community insertion and affective and material exchanges⁵5. Saraceno B. Libertando identidades: da reabilitação psicossocial à cidadania possível. 2a ed. Rio de Janeiro: Te Corá; 2001. , ⁶6. Saraceno B. Reabilitação psicossocial: uma estratégia para a passagem do milênio. In: Pitta AMF, organizadora. Reabilitação psicossocial no Brasil. 4a ed. São Paulo: Hucitec Editora; 1996. p. 13-8. .

In this direction, the significant social network of users in psychological distress has central importance in the production of care in territorial and community-based services that constitute the RAPS. The Psychosocial Care Center (CAPS in the Portuguese acronym) emerges as one of the strategic equipment for users in psychic suffering and their families with the normative horizon of PC¹1. Amarante P. Saúde mental e atenção psicossocial. 3a ed. Rio de Janeiro: Editora Fiocruz; 2007. , ⁶6. Saraceno B. Reabilitação psicossocial: uma estratégia para a passagem do milênio. In: Pitta AMF, organizadora. Reabilitação psicossocial no Brasil. 4a ed. São Paulo: Hucitec Editora; 1996. p. 13-8.

7. Costa-Rosa A. Atenção psicossocial além da reforma psiquiátrica: contribuição a uma clínica crítica dos processos de subjetivação na saúde coletiva. São Paulo: Unesp; 2013. - ⁸8. Costa-Rosa A, Luzio CA, Yasui S. Atenção psicossocial: rumo a um novo paradigma na saúde mental coletiva. In: Amarante P, coordenador. Archivos de saúde mental e atenção psicossocial. Rio de Janeiro: Nau; 2003. p. 13-44. .

The expansion of the significant social network involves “professionals and all stakeholders in the health-disease process, that is, all users and the entire community”⁵5. Saraceno B. Libertando identidades: da reabilitação psicossocial à cidadania possível. 2a ed. Rio de Janeiro: Te Corá; 2001. . Thus, it is understood that the alignment of mental health care to the PC requires the partnership among the professional team, the family, and the community in the assistance to people in psychological distress, since the subjects spends most of their time outside the services, in the company of people who are part of their social networks. It has been discussed, however, that services aligned to the asylum model, such as psychiatric hospital and its updates, such as therapeutic communities, still occupy the center of the care network¹¹11. Querino RA, Borges RS, Almeida JCP, Pauli AJC, Oliveira JL, Souza J. Qual o elemento central na Rede de Atenção Psicossocial de um município de Minas Gerais? Rev Eletronica Enferm [Internet]. 2020 [citado 12 Jan 2022]; 22:59352. Disponível em: https://revistas.ufg.br/fen/article/view/59352 doi: 10.5216/ree.v22.59352.
https://revistas.ufg.br/fen/article/view... .

In the context of health care, we have identified different instruments that enable the analysis of the relationships between individuals and families with the social environment. The genogram and the ecomap comprise two instruments that help identify the functioning, interaction, and organizational patterns of the family system¹²12. Cattani AN, Ronsani APV, Welter LS, Mello AL, Siqueira DF, Terra MG. Família que convive com pessoa com transtorno mental: genograma e ecomapa. Rev Enferm UFSM. 2020; 10(6):e1-19. . The social network analysis comprises a differential approach by focusing on the subject and on the establishment of his or her social relations with other subjects and institutions, returning as a practical and theoretical-methodological reference for therapeutic interventions⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. , ¹³13. Sabot K, Wickremasinghe D, Blanchet K, Avan B, Schellenberg J. Use of social network analysis method to study professional advice and performance among healthcare providers: a systematic review. Syst Rev [Internet]. 2017 [citado 4 Abr 2022]; 6:208. Disponível em: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-017-0597-1 doi: 10.1186/s13643-017-0597-1.
https://systematicreviewsjournal.biomedc... .

The significant social network is an open system that gathers together all the relationships; individual, family, community, and institutional, that influence a person’s recognition as a subject. They function as a social buffer by providing real and lasting help and support at the intermediary level of the social structure that deals with social integration and identity development in dynamic processes. When inserted into a diagram, it configures a network map and serves as an intervention instrument, showing the degree of closeness and commitments available to the subject in a given context and situation⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. , ¹⁴14. Lavall E, Olschowsky A, Kantorski LP. Avaliação de família: rede de apoio social na atenção em saúde mental. Rev Gauch Enferm. 2009; 30(2):198-205. .

There is a strong relationship between social network and health, its positive aspects affirming the potentiality of large and solid significant social networks. Investigations indicate that the lack of support can be one of the factors that contribute to the development or worsening of psychological distress¹³13. Sabot K, Wickremasinghe D, Blanchet K, Avan B, Schellenberg J. Use of social network analysis method to study professional advice and performance among healthcare providers: a systematic review. Syst Rev [Internet]. 2017 [citado 4 Abr 2022]; 6:208. Disponível em: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-017-0597-1 doi: 10.1186/s13643-017-0597-1.
https://systematicreviewsjournal.biomedc...

14. Lavall E, Olschowsky A, Kantorski LP. Avaliação de família: rede de apoio social na atenção em saúde mental. Rev Gauch Enferm. 2009; 30(2):198-205. - ¹⁵15. Cardoso HF, Baptista MN. Escala de Percepção do Suporte Social (versão adulta) - EPSUS-A: estudo das qualidades psicométricas. Psico USF. 2014; 19(3):499-510. . Several studies have used the Network Map to assess the social network of subjects in various care settings, especially among those dealing with psychological distress¹⁶16. Leônidas C, Santos MA. Redes sociais significativas de mulheres com transtornos alimentares. Psicol Reflex Crit. 2013; 26(3):561-71.

17. Machado MS, Pereira CRR. Redes pessoais significativas de mulheres responsáveis por famílias monoparentais em vulnerabilidade social. Estud Psicol (Natal). 2020; 25(4):399-411.

18. Silva MA, Azevêdo AVS. Mulheres em projetos comunitários: redes sociais significativas e a promoção da saúde. Estud Psicol (Natal). 2020; 25(4):436-48.

19. Reis TCM, Azevêdo AVS. Redes sociais significativas de homens em situação de rua no sul do Brasil. Estud Psicol (Natal). 2020; 25(3):324-34.

20. Wyngaerden F, Nicaise P, Dubois V, Lorant V. Social support network and continuity of care: an ego-network study of psychiatric service users. Soc Psychiatr Psychiatr Epidemiol [Internet]. 2019 [citado 5 Abr 2022]; 54:725-35. Disponível em: https://link.springer.com/article/10.1007%2Fs00127-019-01660-7
https://link.springer.com/article/10.100... - ²¹21. Park NS, Jang Y, Lee BS, Chiriboga DA, Chang S, Kim SY. Associations of a social network typology with physical and mental health risks among older adults in South Korea. Aging Ment Health [Internet]. 2017 [citado 5 Abr 2022]; 22(5):631-8. Disponível em: https://www.tandfonline.com/doi/full/10.1080/13607863.2017.1286456 doi: 10.1080/13607863.2017.
https://www.tandfonline.com/doi/full/10.... .

Therefore, the analysis of significant social networks makes it possible to understand the relationships established by the subjects and their conditions, informing the health services workers about the processes of psychosocial integration¹³13. Sabot K, Wickremasinghe D, Blanchet K, Avan B, Schellenberg J. Use of social network analysis method to study professional advice and performance among healthcare providers: a systematic review. Syst Rev [Internet]. 2017 [citado 4 Abr 2022]; 6:208. Disponível em: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-017-0597-1 doi: 10.1186/s13643-017-0597-1.
https://systematicreviewsjournal.biomedc... and subsidizing elements for the conformation of psychotherapeutic interventions¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. . Moreover, it potentially acts as an analyzer of the work processes in relation to the PC proposal. In this sense, we aimed to analyze the structural characteristics, functions, and attributes of the bonds in the social networks of users of a Psychosocial Care Center.

Method

This was a descriptive and exploratory study of a qualitative nature. By considering the objective and the object of study, qualitative research; by referring to people’s lives and their lived experiences, favors the description, understanding, and interpretation of social phenomena perceived by the subjects²²22. Creswell JW, Creswell JD. Projeto de pesquisa: métodos qualitativo, quantitativo e misto. 5a ed. São Paulo: Editora Penso; 2021. . The items of the Consolidated Criteria for Reporting Qualitative Research were followed as criteria for organizing the data²³23. Tong A, Sainsbury P, Craig J. Critérios consolidados para relatar pesquisa qualitativa (COREQ): uma lista de verificação de 32 itens para entrevistas e grupos focais. Int J Qual Health Care. 2007; 19(6):349-57. .

The research was developed in a Psychosocial Care Center, type III, located in a city in the interior of São Paulo, which belongs to a care complex administered by the state. This particularity gives the service a regional character, acting as a reference of specialized care for municipalities located in the Center-West of São Paulo, belonging to the VI Regional Health Department of Bauru.

We used convenience sampling²⁴24. Minayo MCS. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Rev Pesqui Qualitativa. 2017; 5(7):1-12. to select the participants, considering as inclusion criteria: age of majority, being under follow-up for more than six months, living in the same municipality as the service. Cognitive deficit that impacted data collection was the only exclusion criterion. Thus, 24 users were invited to participate in the research, of which eight refused due to incompatibility of schedules for data collection or unwillingness to report on their experience and their networks. Thus, the sample of participants consisted of 16 users.

Data collection was conducted between the months of November and December 2019. The technique used was the individual semi-structured in-depth interview guided by a script divided into two parts: the first with closed questions in order to raise sociodemographic information of the participants, and the second with open questions, prepared by the authors and based on the theoretical framework, guiding the completion of the Network Map diagram¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

The interviews were scheduled, prioritizing times and dates that users would be at the service for their therapeutic activities. They were carried out in a private room in the service itself, audio-recorded, and later transcribed in full. The duration of the interviews varied between 40 and 50 minutes. In case there were any gaps in the users’ network composition, the institutional records were consulted as complementary collection instruments.

The network map is organized by a diagram with three concentric circles (internal, intermediate, external) divided into four quadrants: the first is focused on family relations, the second on health services relations, the third on community relations, and the fourth on friendship relations. Regarding the organization of the circles, the inner circle symbolizes the relationships that the individual has the best bonds (intimate relationships); the intermediate circle indicates the relationships with a lower degree of relational commitment, such as social and/or professional relationships and even family ones (contact relationships); the outer circle represents occasional relationships, such as acquaintances from the community in general (occasional relationships)⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

We analyzed the structural characteristics of the networks in terms of their size, density, composition, and homogeneity/heterogeneity, observing the functions of network ties, taking into account social companionship and emotional support⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

To evaluate the network in its structural characteristics, we measure its size, which is linked to the number of people included in the participant’s network. The networks that have more effectiveness are those of medium size, since the networks characterized as small are less effective in times of overload or periods of long tension, and the larger ones have the idea that the “other” family member is taking care of the problem⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

Density indicates the quality of the relationship, demonstrating the influence that person can exert on the individual. In relation to the composition, pointing out the place that each member occupies in the quadrants; analyzing the dispersion refers to the geographical distance between the members of the network, and finally, there is an analysis about the homogeneity/heterogeneity that relate to gender, age, culture, and the socioeconomic level⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

In order to know the functions of the bonds exercised by the network, we analyzed some items such as: social companionship, which will indicate the performance of activities in the social environment, and the emotional support that involves the individual⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

The network map analysis used Sluzki’s⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. method, which proposes that from the layout and characteristics of the network it is possible to identify structure, functions, and attributes of the ties of significant social networks. This construction of the network map represents an graphic view of the significant social network, from which one can understand its structure, its composition, the functions performed by the network members, and the attributes of the existing ties¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

The analysis of qualitative data from semi-structured interviews that guided the construction of the network maps took as methodological reference the content analysis in its thematic representational aspect²⁵25. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2016. . This research applied the network map as the main instrument to achieve the proposed objectives, thus, the nomination process of categories and subcategories of analysis respected, respectively, the quadrants of the network map and the characteristics, functions and attributes of each quadrant⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

This study was cleared by the Ethics Committee on Research with Human Beings of the Botucatu Medical School - Universidade Estadual Paulista “Júlio de Mesquita Filho”, under opinion no. 057382/2019, complying with Resolution no. 466/12²⁶26. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 466, de 12 de Dezembro de 2012 [Internet]. Aprova diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Brasília: Ministério da Saúde; 2012 [citado 23 Ago 2020]. Disponível em: http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf
http://conselho.saude.gov.br/resolucoes/... . To guarantee the anonymity of the participants, the speeches were identified with the letter ‘E’ for Interviewee, followed by numerical numerals, according to the increasing order of the interviews.

Results and discussion

Regarding the participants, ten were men and six were women. Age ranged from 25 to 59 years, with an average age of 44 years. Regarding marital status, the majority declared themselves unmarried and of the remaining three, two were married and one was in a stable union. The majority declared themselves white, two declared themselves brown, and one black. Ten reported living with a family member, five reported living alone, and one resided in a nursing home. All participants said they professed some religion, Christianity was the one that stood out the most, and one participant declared his religion was Jehovah’s Witness. The totality is in treatment in the service for more than two years and 15 participants reported using psychotropic drugs daily.

As general aspects, the participants’ network map showed that the quadrants with the largest number of people and institutions were related to family relations and work/health services relations. Consequently, the quadrants pertaining to community relations and friendship had the fewest people and institutions. Regardless of the quadrant, most of the relationships considered in the 16 network maps were considered intimate, that is, they were located in the inner circle. Compared to networks built by users of CAPS Alcohol and Other Drugs²⁷27. Borges CD, Scheneider DR. Rede social significativa de usuários de um CAPSad: perspectivas para o cuidado. Pensando Fam. 2017; 21(2):167-81. , ²⁸28. Siniak DS, Pinho LB, Maidana JN Jr, Avila MB, Silva VAM. Análise da rede social de um Centro de Atenção Psicossocial Álcool e Drogas. Rev Enferm UFSM. 2021; 10(e32):1-20. , we noticed more structurally diverse network maps.

The extent of the networks can be visualized through Figure 1 - Collective Network Map, which illustrates the composition built by each participant. In this map are inserted the people and institutions that were considered as elements of the participants’ networks, whether family relationships, community relationships, friendship relationships, or relationships with health services.

We started the analysis of the structural characteristics of the maps, considering the size of the networks and their homogeneity. The former is related to the number of people who make up the network map, and the latter, to the similarities between the socioeconomic, demographic, and cultural characteristics of the people inserted in the map⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. .

In regards to the size, we noticed more often extensive social networks (E3, E7, E8, E9, E10, E11, E12, and E15), followed by intermediate networks (E1, E2, E4, E5, E6, E14) and small networks (E13 and E16). As for the homogeneity of the network maps, in general, the majority are adults. Children were exceptions among maps, and when highlighting the feelings aroused in the participants when mentioned, we found that they produce positive affections:

We identified that the functions of the bond was the most used criterion for the insertion of individuals in the network map. Among the functions, emotional support was the most cited, and participants attributed reciprocity and degree of commitment. In general, the relationships that offer emotional support were expressed through key words and experiences related to care, help, support, availability, and commitment established in these relationships, and these are the people participants seek out when they need them.

In the quadrant that refers to family relationships, excerpts allow us to affirm the presence of people with whom the density of relationships was considered strong and significant, and the function of these bonds exercised social companionship, emotional support, and material help:

Family relationships exert, positively or negatively, a strong influence on the mental health of individuals. The conviviality, satisfaction, and connection of effective relationships decrease the expression of psychological suffering, while distant or abusive relationship styles lead to worse psychological outcomes²⁹29. Alegría M, NeMoyer A, Bagué IF, Wang Y, Alvarez K. Social determinants of mental health: where we are and where we need to go. Curr Psychiatry Rep [Internet]. 2018 [citado 5 Abr 2022]; 20:95. Disponível em: https://link.springer.com/article/10.1007/s11920-018-0969-9. doi: 10.1007/s11920-018-0969-9.
https://link.springer.com/article/10.100... . The fragility of family bonds reveals another extreme of the density and function of these relationships in the participants’ network map. We noticed that the geographical territory, proposed in the referential as dispersion, was considered adjunct to density and that the follow-up in the service influenced the quality of the relationship⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98.:

The density was characterized by a larger number of people and institutions in the inner circle, evidencing the weakness in the participants’ networks ( Figure 1 )⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. . Family relationships represent one of the first contexts that are interfered with by the psychic illness and go through intense and diverse dynamics, reconfiguring the conviviality of the members in the family context. From symbolic mourning to overloads, the coexistence among family members experiences conflicting situations that can lead to atrophy in this quadrant, as was characterized in the composition of the participants’ network map³⁰30. Ramos AC, Calais SL, Zotesso MC. Convivência do familiar cuidador junto a pessoa com transtorno mental. Contextos Clin [Internet]. 2019 [citado 9 Abr 2022]; 12(1):282-302. Disponível em: https://revistas.unisinos.br/index.php/contextosclinicos/article/view/ctc.2019.121.12/60746848 doi: 10.4013/ctc.2019.121.12.
https://revistas.unisinos.br/index.php/c... , ³¹31. Oliveira EM, Eloia SMC, Lima DS, Eloia SC, Linhares AMF. A família não é de ferro: ela cuida de pessoas com transtorno mental. Rev Pesqui (Univ Fed Estado Rio J). 2017; 9(1):71-8. doi: 10.9789/2175-5361.2017.v9i1.71-7816.
https://doi.org/10.9789/2175-5361.2017.v... .

Regarding the frequency of contacts, we perceived that the geographical distance led to a greater need to maintain contact in order to sustain the intensity of the relationship. In another case, the perception was of an occasional relationship, of little commitment⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. .

It may be affirmed that the emotional and material support offered by family relationships had positive repercussions for health promotion, specifically in solidarity and co-responsibility¹⁷17. Machado MS, Pereira CRR. Redes pessoais significativas de mulheres responsáveis por famílias monoparentais em vulnerabilidade social. Estud Psicol (Natal). 2020; 25(4):399-411. , ¹⁸18. Silva MA, Azevêdo AVS. Mulheres em projetos comunitários: redes sociais significativas e a promoção da saúde. Estud Psicol (Natal). 2020; 25(4):436-48. . In this sense, the material help was attributed only in the family quadrant in the participants’ network map, was characterized by financial help and was independent of the affective characteristic of the relationship. Owing to the absence or insufficiency of social security benefits for the maintenance of expenses and survival, in several moments, material help was the justification for the inclusion of some relative in the network map:

Building the network map together with the participants made it possible to understand the conditions of a certain lived context that influenced them. The material help, represented in the speeches, illustrates such a result. It is warned that economic difficulties generated by insufficient income, currently considered factors in the social determination in mental health, are associated with worse health outcomes in young people and adults²⁹29. Alegría M, NeMoyer A, Bagué IF, Wang Y, Alvarez K. Social determinants of mental health: where we are and where we need to go. Curr Psychiatry Rep [Internet]. 2018 [citado 5 Abr 2022]; 20:95. Disponível em: https://link.springer.com/article/10.1007/s11920-018-0969-9. doi: 10.1007/s11920-018-0969-9.
https://link.springer.com/article/10.100... , ³²32. Affleck W, Carmichael V, Whitley R. Men’s mental health: social determinants and implications for services. Can J Psychiatr [Internet]. 2018 [citado 5 Abr 2022]; 63(9):581-9. Disponível em: https://journals.sagepub.com/doi/epub/10.1177/0706743718762388 doi: 10.1177/0706743718762388.
https://journals.sagepub.com/doi/epub/10... , ³³33. Pevalin DJ, Reeves A, Baker E, Bentley R. The impact of persistent poor housing conditions on mental health: a longitudinal population-based study. Prev Med. 2017; 105:304-10. .

The composition of the second quadrant of the network map, health services, was concentrated between Basic Health Units (BHU) and CAPS, which were distributed among the three circles of the participants’ maps ( Figure 1 ). We observed that the intermediate quadrant had a greater number of relationships when compared to the familiar one. The following excerpts characterize these qualities:

The fact that two services of the RAPS, CAPS and BHU, evidence a small quadrant, considering the structural characteristic of the social networks⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98. , ²⁷27. Borges CD, Scheneider DR. Rede social significativa de usuários de um CAPSad: perspectivas para o cuidado. Pensando Fam. 2017; 21(2):167-81. , ²⁸28. Siniak DS, Pinho LB, Maidana JN Jr, Avila MB, Silva VAM. Análise da rede social de um Centro de Atenção Psicossocial Álcool e Drogas. Rev Enferm UFSM. 2021; 10(e32):1-20. . We emphasize this positive aspect, because they are community mental health services that, besides having strategies to deal with the mental illness, include in their actions the collaboration and the active participation of family members and other members of the social network of the user, with the objective of instrumentalizing the management in the welcoming and care of the various difficulties that may occur. These services have the ethical, technical, and political commitment to produce emancipation and autonomy for users, building spaces for dialogue to deconstruct stigmas and prejudices²⁸28. Siniak DS, Pinho LB, Maidana JN Jr, Avila MB, Silva VAM. Análise da rede social de um Centro de Atenção Psicossocial Álcool e Drogas. Rev Enferm UFSM. 2021; 10(e32):1-20. , ³⁴34. Silva AP, Soares PFC, Costa ES, Silva LGS, Silva RG, Braga LS. O cuidado a pessoa em sofrimento mental: sob a ótica dos familiares. Nursing (São Paulo). 2021; 24(281):6280-9. .

In the view of the study participants, the functions performed by health services are similar to those performed by families, being points of comparison for the participants. In this exercise, different densities can be observed, as well as, multidimensionality is identified as an attribute of these bonds⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. , ¹⁰10. Moré CLOO, Crepaldi MA. O mapa de rede social significativa como instrumento de investigação no contexto da pesquisa qualitativa. Nova Perspect Sist. 2012; 21(43):84-98.:

When the health services and their professionals were approached, we noticed the concentration of statements related to emotional support due to the quality of the bonds established with the participants. We visualized these results when participants referred to seek services when they do not feel well, emphasizing that the service is the place where they find support and care, a characteristic that concretizes the variables of the micro-dimension that determine rehabilitative results⁶6. Saraceno B. Reabilitação psicossocial: uma estratégia para a passagem do milênio. In: Pitta AMF, organizadora. Reabilitação psicossocial no Brasil. 4a ed. São Paulo: Hucitec Editora; 1996. p. 13-8.:

In the quadrant that discusses the insertion of the community in the network map, we observed the circulation of participants through various spaces in the territory. Most people and institutions were inserted in the closest relationships that were linked to religious issues and citizenship:

In the community, emotional support was characterized by participants pointedly when referring to how they are welcomed, how they perceive the affection and consideration received in religious institutions:

We identified the appropriation of territory by the participants when they reported the places they frequent as leisure options such as the square, the snack bar, and the mall:

We noticed in the community network, an institution that performs several functions in the lives of the subjects, the most cited was an association of mental health users with a focus on work, as reported below:

Associations of users of mental health services showed to have a fundamental role in the defense of rights, are focused on work, sociability and empowerment of users and their families. It can have five profiles, being them: of mutual help; of mutual support; of defense of rights; of transformation of stigma and dependence in the relationship with madness and the crazy in society; and of participation in the health/mental health system and wider social militancy³⁵35. Cunha CN, Goulart MSB. A participação política de pessoas com sofrimento mental: a Associação dos Usuários de Serviços de Saúde Mental de Minas Gerais (Asussam-MG). Psicol Rev. 2015; 21(3):513-33. , ³⁶36. Luiz CCA, Leal EM, Galletti MC. Desafios enfrentados por usuários da saúde mental: reflexões sobre narrativas acerca do trabalho dentro e fora de oficinas de geração de trabalho e renda. Rev Ter Ocup. 2018; 29(1):63-9. .

Psychic illness resonated negatively in the community quadrant of the network for some participants:

We observed, when analyzing the third quadrant, its power in the production of care in spaces beyond the health services, bringing together principles and guidelines that make interlocutions with the social network axis of psychosocial rehabilitation and with the sociocultural dimension of the psychiatric reform. The circulation through the different spaces of the territory favors the expansion of the pari-passu contractuality with the deconstruction of the social imaginary that sustains the stigma of madness³⁷37. Yasui S, Luzio CA, Amarante P. Atenção psicossocial e atenção básica: a vida como ela é no território. Rev Polis Psique [Internet]. 2018 [citado 13 Ago 2018]; 8(1):173-90. Disponível em: https://seer.ufrgs.br/index.php/PolisePsique/article/view/80426 doi: 10.22456/2238-152X.80426.
https://seer.ufrgs.br/index.php/PolisePs... .

In the last quadrant, friendship relations, there was again the insertion of professionals and other users in the CAPS that were related to the experiences and the welcoming performed by professionals. This finding corroborates data from research conducted with users of CAPS-Alcohol and other Drugs²⁷27. Borges CD, Scheneider DR. Rede social significativa de usuários de um CAPSad: perspectivas para o cuidado. Pensando Fam. 2017; 21(2):167-81.:

Similar to the community, in the quadrant referring to friendship the participants included people linked to religion and were related to critical episodes of the illness:

The relationship between intensity and dispersion of the people inserted in the participants’ network maps also appeared illustrated in the quadrant referring to friendship. It is characterized that there is a relationship between geographical distance and intensity of the relationship:

Even though the inner circle in the friendship quadrant ( Figure 1 ) has a greater density of relationships, it can be noticed that in comparison with the community and health services quadrants, there was a greater distribution among the outer circles of the network map. The participants, however, presented some difficulty in expressing the reason for insertion or stated that they did not have friends, these relationships being linked to illness and treatment:

Isolation from friendship relationships in an elderly population was associated with worse outcomes for stress and depression symptoms³⁸38. Taylor HO, Taylor RJ, Nguyen AW, Chatters L. Social isolation, depression, and psychological distress among older adults. J Aging Health. 2018; 30(2):229-46. , also functioning as protective factors for the population with severe and persistent mental disorders²⁹29. Alegría M, NeMoyer A, Bagué IF, Wang Y, Alvarez K. Social determinants of mental health: where we are and where we need to go. Curr Psychiatry Rep [Internet]. 2018 [citado 5 Abr 2022]; 20:95. Disponível em: https://link.springer.com/article/10.1007/s11920-018-0969-9. doi: 10.1007/s11920-018-0969-9.
https://link.springer.com/article/10.100... . With this characteristic, it dialogues with the perception of loneliness as a social network factor that most negatively influenced health in the population of three European countries³⁹39. Rico-Uribe LA, Caballero FF, Olaya B, Tobiasz-Adamczyk B, Koskinen S, Leonardi M, et al. Loneliness, social networks, and health: a cross-sectional study in three countries. PLoS One. 2016; 11(1):e0145264. .

The functions of attachment in the fourth quadrant, social companionship is evidenced:

During the configuration of the participants’ network map, it was identified that the psychological illness triggered a process of reduction of the social network, a phenomenon called vicious circle⁹9. Sluzki C. A rede social na prática sistêmica: alternativas terapêuticas. São Paulo: Casa do Psicólogo; 1997. . This fact, operating under the aegis of PC⁴4. Morato GG. Reabilitação psicossocial e atenção psicossocial: identificando concepções teóricas e práticas no contexto da assistência em saúde mental [tese]. São Carlos (SP): Universidade Federal de São Carlos; 2019. , ⁷7. Costa-Rosa A. Atenção psicossocial além da reforma psiquiátrica: contribuição a uma clínica crítica dos processos de subjetivação na saúde coletiva. São Paulo: Unesp; 2013. , ⁸8. Costa-Rosa A, Luzio CA, Yasui S. Atenção psicossocial: rumo a um novo paradigma na saúde mental coletiva. In: Amarante P, coordenador. Archivos de saúde mental e atenção psicossocial. Rio de Janeiro: Nau; 2003. p. 13-44. , creates different opportunities for intervention for the equipment and professionals working in the RAPS. Interpreted in a complex way, the network calls for a set of actions from promotion to care production to support the user in weaving networks based on circles that expand and are, in their territories, at their disposal⁵5. Saraceno B. Libertando identidades: da reabilitação psicossocial à cidadania possível. 2a ed. Rio de Janeiro: Te Corá; 2001. .

Final considerations

It was possible to understand the structure of the social network of CAPS III users, how the relationships are established, and their functions. In general, we affirm that the networks were characterized as large, with distinct densities and better-quality prevailing in family relationships and among health services, specifically in CAPS. Regarding the composition, in all areas intimate relationships prevailed, highlighting the family quadrant. Regarding the dispersion of the network, it was mostly made up of people geographically close, influencing the frequency of contact. There was no high heterogeneity in the composition of the networks. The most evident functions of the bonds were social companionship, emotional support, and material help, and the functions of cognitive guidance, social regulation, and stimulation of new contacts were not observed.

We noticed that users have appropriated the spaces in the community and seek friendships beyond the health services, most of them related to religion. Some family relationships, especially after the illness of the subject, have become fragile, indicating the need for health professionals, especially from CAPS, to support and work with family members during the process of psychosocial rehabilitation of users.

Through these data, the health services can reflect the paths they are following, when the horizon of psychosocial care is taken as a reference, since the expansion of significant social networks moves the rehabilitation triad and advances the project of building an anti-manicomial institution and democratic society.

References

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