Abstract

Introduction

The Brazilian Psychiatric Reform movement (RPb) has made possible to advance in mental health care, with the restructuring of services and work processes so that care is directed towards humanization, comprehensiveness and respect for people in psychological distress and, therefore, is directed by the psychosocial care mode/model, which prioritizes territorialized care in community health services¹1 Oliveira LMS, Chaves MCAC. Condenados pela loucura: o impacto das diretrizes das políticas públicas para a saúde mental na dignidade da pessoa humana. Cad Grad Cienc Hum Soc Unit. 2020; 4(3):113-35.^,22 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145.. Its directives are respect for human rights, guaranteeing the patient's autonomy, freedom and citizenship, and equitable care, which takes into account the psychosocial context of the person in psychological distress¹1 Oliveira LMS, Chaves MCAC. Condenados pela loucura: o impacto das diretrizes das políticas públicas para a saúde mental na dignidade da pessoa humana. Cad Grad Cienc Hum Soc Unit. 2020; 4(3):113-35.^,22 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145..

By going against the abovementioned psychosocial care model, the manicomial mode considers the disease (the sick subject), in its organic aspect, as the object of work/care, and aims to suppress symptoms, using medication as the main means of work, without considering the subjectivity and the subject's capacity for decision and participation in this process. Working relationships are based on hierarchization and, therefore, even if there are other possibilities for means/tools of care, the division of labor model corresponding to the 'assembly line' prevails, equivalent to the common production of goods in mechanization, without shared discussion and often reducing communication between members only through the medical records³3 Costa-Rosa A. O modo psicossocial: um paradigma das práticas substitutivas ao modo asilar. In: Amarante P. Ensaios: subjetividade, saúde mental, sociedade. Rio de Janeiro: Editora Fiocruz; 2000. p. 141-68..

Even with the advances made by the RPb, it is clear that the psychosocial care model continues as an instituting movement, that is, a force for change that confronts what is set as the norm - the instituted - denying it, stressing it and seeking to transform it4. As a consequence of this instituting movement, strategies and points of care for mental health have been created which should be articulated through the Psychosocial Care Network (RAPS), with the aim of replacing mental institutions and the instituted asylum model¹1 Oliveira LMS, Chaves MCAC. Condenados pela loucura: o impacto das diretrizes das políticas públicas para a saúde mental na dignidade da pessoa humana. Cad Grad Cienc Hum Soc Unit. 2020; 4(3):113-35.^,22 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145., in other words, what is already known, the rule/order already in place4. This process is called institutionalization - a dialectical movement that promotes a union-tension capable of turning the instituting into the instituted; there is no necessarily a good or a bad side in this process⁴4 Lourau R. A análise institucional. Rio de Janeiro: Editora Vozes; 2014..

However, despite the fact that psychosocial care has become a concrete institution, in terms of the legal-political sphere, materialized through community mental health care establishments, such as the Psychosocial Care Centers (CAPS), and in the reorganization of the RAPS as a whole, it is necessary to understand that the RPb is a complex social movement, made up of four dimensions, in addition to the legal-political dimension: the socio-cultural dimension, the theoretical-conceptual dimension and the technical-assistance dimension; which are intertwined and codependent within a process of transformation⁵5 Amarante P. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora Fiocruz; 2017., encompassing aspects of basic and in-service training, everyday practices, as well as, the historical view directed at the person in psychological distress, which can be loaded with stigma.

With regard to CAPS, they were created to serve as replacement services for mental institutions, since they were supposed to provide care according to the prerogatives and guidelines of psychosocial care⁶6 Brasil. Ministério da Saúde. Centros de Atenção Psicossociais e Unidades de Acolhimento como lugares de atenção psicossocial no território: orientações para elaboração de projetos de construção, reforma e ampliação de CAPS e de UA. Brasília: Biblioteca Virtual de Saúde; 2015.. However, there is a tendency to perpetuate/maintain asylum care in establishments/services with asylum-replacement principles⁷7 Cusinato C. Reforma psiquiátrica: avanços e desafios das práticas dos profissionais de um Centro de Atenção Psicossocial (CAPS) [dissertação]. Botucatu: Faculdade de Medicina, Universidade Estadual Paulista; 2016.. Furthermore, as they are one of the main services of the RAPS, the daily life of the CAPS can reveal to us, through professional practices and the work process, details about this continuous dialectic between the instituting and the instituted. Despite this, there are only studies that problematize the weaknesses and difficulties of psychosocial care, but which do not directly discuss the process of institutionalization of psychosocial care, based on institutional analysis⁸8 Severo AK, L’abbate S. Uma supervisão clínico-institucional na reforma psiquiátrica na perspectiva da análise institucional. Trab Educ Saude. 2019; 17(3):e0021646.^,99 Mesquita-Lago LP, Matumoto S, Silva SS, Mestriner SF, Mishima SM. Analysis of professional practices as a multiprofessional residency education tool. Interface (Botucatu). 2018; 22(2):1625-34. doi: 10.1590/1807-57622017.0687.
https://doi.org/10.1590/1807-57622017.06... .

Against this backdrop, this study sought to analyze the process of institutionalizing psychosocial care through the professional practices of a CAPS, since, given the complexity of this process, it is pertinent to discuss its effects and repercussions on mental health care and on the materialization of the mental health policies proposed by the RPb.

Method

This is a descriptive and qualitative study, part of the exploratory stage of an intervention-research entitled "Interprofessionality and mental health care", which was divided into three stages: entry into the field, exploratory moment and intervention moment with data analysis. The matrix research aims to analyze interprofessional care in mental health care, which covers the CAPS, and also two family health units in the same municipality, and which began during the Covid-19 pandemic. Participants included professors and students from the postgraduate and undergraduate nursing programs at a public university, all linked to a mental health research group, as well as health professionals from the services, who freely chose to contribute to the research as study participants.

Intervention-research takes on the political character of seeking transformations by questioning the various meanings crystallized in institutions¹⁰10 Galvão EFC, Galvão JB. Pesquisa intervenção e análise institucional: alguns apontamentos no âmbito da pesquisa qualitativa. Rev Cienc Soc. 2017; 1(1):54-67.. The qualitative method proposes a subjective analysis, where motivation, aspirations, beliefs and values must be understood as part of social reality, observing situations through different interpretations, considering the individuality of the subjects¹¹11 Minayo MCS, Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. São Paulo: Vozes; 2011..

The setting for this study was a type I CAPS in a state capital of Brazil. All CAPS health professionals were included in the study, and inactive professionals due to illness, vacations or other types of leave were excluded. Of the 24 professionals at the service, only 11 were active, and only nine agreed to take part: two nurses, two psychologists, three social workers, a pharmacist and a journalist, who worked as the service manager.

Data collection took place between June and September 2020, based on participant observation, in which individual appointments, case discussions and everyday situations were observed, recorded in a researcher's diary, and individual semi-structured interviews, with questions about the work routine and mental health care, which were carried out in the service itself during working hours, lasting approximately 50 minutes and recorded with an electronic recorder. To guarantee the anonymity of the participants, they were identified by the letter P, referring to professional, followed by cardinal numbers, chosen at random.

The analysis was carried out according to Bardin's thematic content analysis¹²12 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2016., which consists of three chronological stages: pre-analysis - where the data collected was subject to free-floating reading and then read exhaustively; exploration of the material, in which coding units, classification and categorization are defined; and treatment of the results, in which inferences and interpretations of the data are made in the light of the theoretical framework of Institutional Analysis and psychosocial care⁴4 Lourau R. A análise institucional. Rio de Janeiro: Editora Vozes; 2014.^,55 Amarante P. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora Fiocruz; 2017.. Based on the thematic content analysis of the participants' statements and the researcher's diary, two categories were formed: 1) Established practices in the organization of work and mental health care at the CAPS; 2) Training, management and working conditions: aspects that put pressure on the institutionalization of psychosocial care.

This study began after it was registered on the Brazil Platform and cleared by the Research Ethics Committee under opinion No. 4.199.950/2020, and the interviews and observations were carried out after signing the Informed Consent Form (ICF).

Results

Practices established in the organization of work and mental health care at CAPS

When working/caring people in psychological distress, some professionals use terms linked to infantilization or reduce mental health care to the empirical task of motherhood, far removed from scientific knowledge. In addition, one of the participants mentioned the need to be close to the user, more in the sense of guardianship than strengthening the bond.

On the other hand, the majority of professionals show that they have a broader view of the subject, beyond the diagnosis presented, in which the objective of the work is also to prevent hospitalization, to welcome the patient and to guarantee the patient's autonomy and social reintegration, even though one of the professionals mentioned cure as the purpose of the work.

It should be noted that the conceptions and practices of asylum and psychosocial care in the institutionalized-instituting relationship encompass continuous/articulated and non-polarized movements.

Regarding the work instruments established in the service routine, home visits, matrix support, groups and individual care were the most repeated in the professionals' responses, even considering that most of these activities were suspended during data collection, which took place in the context of the Covid-19 pandemic. The inclusion of leisure activities was also mentioned by the participants as a working tool to be adopted by the service.

On the other hand, the Personalized Therapeutic Project (PTS) is scarcely used in everyday work and, when it is used, it is conducted in a fragmented way by the team. In addition, there was no reference in the data to user participation in the construction of the PTS.

This fragmentation of work is not limited to the realization/construction of the PTS and is present, more intensely, in the work process and in the misuse of opportunities for interprofessional action, such as conducting case study meetings. It can be seen that the segmentation of work is sometimes recognized and criticized by the team professionals themselves.

Another relevant aspect is the overlap between medicine and other professions. The professionals say that many users seek medication as a treatment, therefore the medical professional is their first choice, to the detriment of the work of other categories, which favors the centralization of care based on the biomedical model. However, this attitude is not unilateral, since the team also naturalizes the medical hierarchy within the service and works from this perspective.

Despite the obvious fragmentation, there are some interprofessional practices instituted in the daily routine of the service, such as the discussion of conducts and some shared care, which lead to the institutionalization of interprofessionality, as well as demonstrating the recognition of the benefits of this type of work.

Training, management and working conditions: aspects that strain the institutionalization of psychosocial care

This study also identified that most professionals, despite the discourse of an expanded view of the subject, have weaknesses in some concepts and theoretical-practical knowledge closely linked to mental health care, as well as laws, ordinances and regulations that guide work in psychosocial care.

Several precarious working conditions were also identified, such as a lack of materials and structure, temporary contracts and disparity in salaries. In addition, there is dissatisfaction with local management, specifically the municipal mental health coordination, due to the distance and little support for the development of actions that go beyond individual care.

Even though care is centered on the physician, the professionals also denounce the precariousness of human resources, high turnover of workers, little or no space for permanent health education/in-service training and lack of supervision and/or clinical and institutional support.

Despite the established practices that strain the process of institutionalizing psychosocial care, it is worth noting that there are professionals with knowledge and commitment to the anti-asylum struggle and that they recognize the weaknesses and problems of the service and local management, such as the fragmentation of work, the centralization of care based on medical knowledge, insufficient theoretical training and, in this way, shed light on the practices that establish psychosocial care within the CAPS.

Discussion

The Brazilian Psychiatric Reform was an enabler of movements in the theoretical and practical fields, stressing the paradigm shift in mental health care, through practices and services that replace the medical-psychiatric/manic model¹³13 Trindade JNR. A emergência do acompanhamento terapêutico como dispositivo clínico-político no processo da reforma psiquiátrica [trabalho de conclusão de curso]. São Paulo: Faculdade em Ciências da Saúde, Pontifícia Universidade Católica de São Paulo; 2020.. However, this study reveals that professionals are also crossed by the "asylum" institution as they reproduce asylum/medical-psychiatric practices, by having care based on infantilization, reducing it to the empirical task of motherhood and the tutelage of users. In other words, they reproduce attitudes that seek to preserve what has already been established and, therefore, hinder not only the institutionalization of psychosocial care but also the process of analysis and self-reflection14.

The infantilization of the subject in psychological distress is extremely closely linked to the process of institutionalizing the patient within asylum services. In these environments, it is a method of removing civil autonomy, freedom and the ability to make decisions about oneself; guardianship, arising from this infantilization, is seen as inevitable and seen as a form of protection¹⁵15 Amaral RB, Silva SAH. O direito à moradia de pessoas com sofrimento psíquico. Braz J Health Rev. 2020; 3(3):6309-29.. In this sense, linking the guardianship of users with motherhood can be a way of minimizing the bad effects of this attitude, reinforcing it as an act of affection, which makes it difficult for professionals and society itself to perceive the harm¹⁶16 Amorim RG, Lavrador MCC. A perspectiva da produção de cuidado pelos trabalhadores de saúde mental. Psicol Cienc. 2017; 37(2):273-88. and violence of this castrating guardianship16 of desires and movements, producing investment paths in the world in order to take it over and make it their own, as well as curtailing the rights and autonomy of the person in psychological distress¹⁶16 Amorim RG, Lavrador MCC. A perspectiva da produção de cuidado pelos trabalhadores de saúde mental. Psicol Cienc. 2017; 37(2):273-88.. In contrast to the paradoxical autonomizing guardianship, which provokes a movement to produce autonomy and the possibility of life, where from dependence, liberation and accountability are sought through the use of instruments that increase the degree of governability and enable the subject to manage their decisions, where the living action of one triggers the production of life in the other16.

The castrating guardianship is linked to the asylum model, annulling any existence of desiring subjectivity, which results in the subject not being mobilized as a participant in their treatment, with the body/ organism being the object for which actions are directed and, thus, the individual continues to be seen as sick, with few possibilities for active participation, playing the role of merchandise, in which not only the tasks are fragmented, but also the subject, in which even in a job made up of several professionals, the castrating tutelage is intensified, by the determination based on problems as a biological order and, therefore, the efficacy is expected to come from chemistry, with medication being the main means/instrument of care³3 Costa-Rosa A. O modo psicossocial: um paradigma das práticas substitutivas ao modo asilar. In: Amarante P. Ensaios: subjetividade, saúde mental, sociedade. Rio de Janeiro: Editora Fiocruz; 2000. p. 141-68.^,1616 Amorim RG, Lavrador MCC. A perspectiva da produção de cuidado pelos trabalhadores de saúde mental. Psicol Cienc. 2017; 37(2):273-88.^,1717 Merhy EE. Cuidado com o cuidado em saúde. Saiba explorar seus paradoxos para defender a vida. O ato de cuidar é um ato paradoxal: pode aprisionar ou liberar [Internet]. Campinas: [place unknown]; 2004 [citado 18 Jan 2024]. Disponível em: https://docplayer.com.br/20994959-Cuidado-com-o-cuidado-em-saude-saiba-explorar-seus-paradoxos-para-defender-a-vida-o-ato-de-cuidar-e-um-ato-paradoxal-pode-aprisionar-ou-liberar.htmlHess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63..

The reproduction of asylum practices in substitute services such as CAPS, for example, reveals the inevitable contradiction for institutional analysis, in which the practices instituted by professionals falsify the initial principles of the founding spirit of the "psychosocial care" institution, in which workers often forget why they work¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63.. In this case, the instituted is represented by practices linked to tutelage, infantilization, hyper medicalization, among others, which are reproduced in the daily work of the CAPS, covering up and denying the initial objectives in the foundation of that service, that is, (re)building the autonomy of people in pain, social reinsertion, co-management and co-participation, which enable psychosocial rehabilitation. In this way, we can see what we call the principle of falsification¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63., since the service is implemented to put the principles of psychosocial care into practice, but its actions are asylum-like.

In this sense, we can see the infantilized view of the person in psychological distress and the hierarchization of biomedical-psychiatric practice over others as a manifestation of this principle in the daily work of these substitutive services. The political and biopsychosocial factors as determinants, as well as the investment in mobilizing the subject as the main participant in treatment, with emphasis on the individual and the social and family group in the process of care and understanding of mental suffering, according to the psychosocial mode/model³3 Costa-Rosa A. O modo psicossocial: um paradigma das práticas substitutivas ao modo asilar. In: Amarante P. Ensaios: subjetividade, saúde mental, sociedade. Rio de Janeiro: Editora Fiocruz; 2000. p. 141-68., materialized in substitutive equipment, such as the CAPS, for example, created and planned to replace the asylum, sometimes works from the perspective of the established asylum model, with regard to the professionals' perception of the object and instruments of work²2 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145..

The sovereignty of the psychiatrists and their practices over the knowledge and autonomy of other professionals, such as nurses and psychologists, is also historically sustained by the culture. This culture in terms of mental health, is closely related to the strengthening of the asylum logic, where the insane individuals need to have their behavior controlled by physical and chemical methods, rather than being understood as subjects with basic human needs, or seeking to promote care that provides more safety, less organic risk and guarantees these needs in a comprehensive and humanized way²2 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145..

These instituted practices in the CAPS demonstrate an effect of the institutionalizing process, which we call the Mühlmann Effect, in which the institution tends to be formed from the negation of the initial prophecy¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63.. Prophecy, in this sense of institutional analysis, distances itself from the religious concept and is understood from the initial objectives of the instituting movement. In this study, it is characterized by the Psychiatric Reform/anti-asylum struggle, which has as its principle the reorientation of the mental health care model, as well as the construction of a new social place for madness, aiming at comprehensive care for the subject, in order to promote their autonomy and social reintegration²2 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145.,¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63..

This contradiction is inevitable and results from the action of the principle of equivalence, in which the instituted only "accepts" the instituting movement to the extent that it becomes equivalent to the norm already established¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63.. In other words, the mental health/psychosocial care institution can use working tools that were initially created with the aim of replacing asylum practices, but which are used for the benefit of the instituted.

In this sense, the manifestation of the principle of falsification, linked to the Mühlmann Effect, is also identified in this study, when other practices instituted in the CAPS relate to the dialectical aspects of the institution and the effects of the institutionalizing process. The use of instruments that are specific to the psychosocial care model, such as groups, home visits and the PTS, in a territorial and free care service, are only possible thanks to the strength of the institutionalizing movement of the RPb. However, the data shows that professionals often apply the tools of the psychosocial model, but distort their purposes and use them to maintain the established²2 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145.^,1818 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63., with care being reduced to the purpose of control, tutelage and even cure.

In this way, the initial prophecy is denied by the established through the practices of professionals¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63.. This happens, for example, when the PTS, which is fundamentally an interprofessional work tool, based on collective construction, with the active participation of users and the promotion of their autonomy over their health-disease process, is used by professionals without actually including users/people in psychological distress in therapeutic planning and without encouraging their autonomy over their health decisions¹⁹19 Lima LVC, Andrade FCB. O projeto terapêutico singular como estratégia de cuidado na atenção básica em saúde: uma proposta de implementação no município de São Pedro do Piauí [trabalho de conclusão de curso]. Teresina: Universidade Aberta do SUS; 2020..

This falsification may also happen in the use of case study meetings, when they are limited to referrals or discharges, with little or no discussion between the team, without shared decision-making, or even when therapeutic activities are restricted to the internal environment of the CAPS. Instead, they don't value the integration of these users with society and the territory in which they live, and don't promote the reinsertion and social autonomy of people suffering from mental illness, objectives initially professed by the movement that established the RPb.

It's worth pointing out that practices linked to the psychosocial care model are only an effective substitute for the medical-psychiatric model if they are carried out with the aim of (re)building autonomy, social reintegration and care in freedom, where the user is the center of care. Otherwise, there are just new costumes and names for practices that have already been instituted and are permeated by the asylum model²⁰20 Campos DB, Bezerra IC, Jorge MSB. Produção do cuidado em saúde mental: práticas territoriais na rede psicossocial. Trab Educ Saude. 2020; 18(1):e0023167..

Despite the instituted practices mentioned above, there are instituting movements that put pressure on the institutionalization of psychosocial care, as many professionals mention humanized care, which promotes the protagonism of the suffering person, considers the subject as a whole, and takes a critical stance in relation to the centralization of care in doctors and medication, as well as vertical and hierarchical relationships. When the professionals point out the importance and need for interprofessional work, recognizing that they still reproduce a fragmented way of working that hinders the institutionalization of psychosocial care, there is a tension in relation to what has been established and, therefore, a possibility for change.

The theoretical-conceptual framework of the complex social process, which encompasses university and in-service training, plays a fundamental role in the paradigm shift and, therefore, in the teamwork approach, which leads to interprofessionality (technical and care sphere). Interprofessional work can foster the institutionalization of psychosocial care and promote efficient and respectful professional practices among health categories²¹21 Cervo EB, Caumo MA, Cerdótes ALP, Jaeger FP. Interprofissionalidade e saúde mental: uma revisão integrativa. Rev Psicol Saude Deb. 2020; 6(2):260-72.. Therefore, university training, residencies and the Permanent Education in Health (EPS) are ways to overcome uni-professionalism and possibilities to promote discussion on the subject and better prepare professionals who work in caring for people suffering from mental illness.

Professionals' distance from the National Permanent Education in Health Policy (PNEPS) and the lack of in-service training spaces can strengthen established practices and put a strain on the process of institutionalizing psychosocial care. EPS spaces generate reflection on established professional practices, enabling collective mobilization for change and overcoming obstacles to psychosocial care²²22 Santos ACP, Cortez EA, Valente GSC, Assad SGB. Educação permanente visando à integralidade do cuidado na rede de saúde mental. Res Soc Dev. 2021; 10(1):e23810111648..

It is important to note that the reproduction of the asylum model by professionals and the distancing from EPS are also the result of political setbacks, such as the strengthening of asylum instruments and establishments, through recommendations and funding from the federal government and the 2017 National Mental Health Policy, which provides for an increase in beds in psychiatric hospitals, including them as components of the RAPS, as well as the Technical Note 87 CGMAD/DAPES/SAS/MS no. 11/2019, which redirects beds in psychiatric hospitals. No. 11/2019, which redirected resources to the purchase of electroconvulsive therapy equipment and advocated psychiatric hospitalization and therapeutic communities for alcohol and drug users²³23 Brasil. Ministério da Saúde. Resolução nº 32, de 14 de Dezembro de 2017. Estabelece as diretrizes para o fortalecimento da Rede de Atenção Psicossocial (RAPS). Diário Oficial da União. 22 Dez. 2017.^,2424 Brasil. Ministério da Saúde. Nota Técnica Nº 11/2019-CGMAD/DAPES/SAS/MS. Brasília: Ministério da Saúde; 2019..

This political setback is accompanied by precarious working conditions, which blocks or hampers the provision of care based on the psychosocial care model and, consequently, strains and weakens the movement to transform practices²2 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145.^,2525 Nóbrega MPSS, Mantovani GS, Domingos AM. Recursos, objetivos e diretrizes na estrutura de uma Rede de Atenção Psicossocial. Rev Bras Enf. 2020; 73(1):e20170864..

To the extent that professionals use work tools created from the RPb/psychosocial care model, but used for psychiatric purposes, a contradiction and tension is identified between the instituted and the instituting, strengthening the instituted modus operandi, i.e. the Mühlmann Effect and the principle of falsification¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63.. But if the transformation of the practices instituted in the daily life of mental health services is the goal of the social movement of the RPb, it is natural that, in the face of these principles, the question arises: is it possible to resist the falsification of prophecy and the principle of equivalence?

According to Hess, it is possible to form micro-nuclei of resistance to the falsification of prophecy, in order to transform established practices¹⁸18 Hess R. Do efeito Mühlmann ao princípio de falsificação: instituinte, instituído, institucionalização. Mnemosine. 2007; 3(2):148-63.. Still on this subject, it is logical to conclude that, if we consider RPb to be a complex and multifaceted movement, so too must these actions of resistance⁵5 Amarante P. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora Fiocruz; 2017..

Therefore, beyond the legal-political area, it is important to strengthen and encourage research, especially intervention research, because for professionals who are immersed in the established logic of the service, this type of study challenges them to look at the context and produce new knowledge and working tools while transforming everyday practices by getting to know them. The principle of institutional analysis - transforming in order to know - directs the subject to participate in the institutional dynamics4 and, therefore, with the possibility of taking a critical look at the instituted processes, favoring the strengthening of the institutionalization of psychosocial care. In addition, extension projects, in-service training based on EPS, co-management and co-participation spaces for users and professionals, the implementation of interprofessional residencies and internships at universities, are also some of the options for changing social, care and educational practices and attitudes towards mental health care in Brazil²2 Sampaio ML, Bispo JP Jr. Entre o enclausuramento e a desinstitucionalização: a trajetória da saúde mental no Brasil. Trab Educ Saude. 2021; 19:e00313145.^,2626 Radke MB, Ceccim RB. Educação em saúde mental: ação da reforma psiquiátrica no Brasil. Saude Redes. 2018; 4(2):19-36.^,2727 Nunes JMS, Guimarães JMX, Sampaio JJC. A produção do cuidado em saúde mental: avanços e desafios à implantação do modelo de atenção psicossocial territorial. Rev Saude Colet. 2016; 26(4):1213-32..

Faced with various tools that strengthen the established and the denial of the initial prophecy of the institutionalization of psychosocial care, such as poor professional training, the permeation of the asylum model in the practices of CAPS professionals, precarious working conditions and, above all, the still recent setbacks in the Mental Health Policy, it is understood that the RPb is and should be a permanent movement of resistance and, therefore, can promote the transformation of practices.

Conclusions

The study allowed to analyze the process of institutionalization of psychosocial care through the professional practices of the CAPS, revealing the dialectical reality of tensions between the instituted asylum and the instituting movement of the RPb, which produces the Mühlmann Effect in the daily life of the service and, therefore, the falsification of the prophecy of the psychosocial care model and the CAPS itself, since strongly instituted asylum practices and the distortion of the purpose of work instruments initially designed to meet the purpose of psychosocial care were identified.

The research-intervention in which this study is inserted has also produced, from the restitution of the exploratory stage and the articulation with the current needs of the service, fortnightly meetings for in-service training, with the active participation of six professionals from the service, lasting approximately two hours, which makes it possible to strengthen instituting practices based on psychosocial care. In this sense, it is important to value the team's openness to looking at everyday work with the possibility of creation and resistance to the Mühlmann Effect.

Despite the limitations of the study caused by the pandemic and the reduction in the number of professionals at the time of collection, it was possible to reflect through the results on the practices of strengthening the asylum instituted within the CAPS, and on the strategies of precariousness and weakening of the institutionalization of psychosocial care, in the four areas of the complex social process of RPb, and the need to promote and strengthen devices for reflection and transformation of practices, whether through research that brings contributions to the services, through in-service training, or university extension projects, public hearings with popular participation, among other forms of continuous resistance to the falsification of prophecy.

Acknowledgments

We would like to thank the reviewers for their time in analyzing and suggesting improvements to our work, and the editorial team for their professionalism, dedication and attention during the publication process. We would also like to thank our friends and co-workers who helped us during the research and, in particular, we would like to thank Dr. Marina Nolli Bittencourt, Dr. Luana Pinho de Mesquita Lago and Dr. Valéria De Carvalho Araújo Siqueira for their guidance during the writing process.

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