Rev. Latino-Am.

Enfermagem
2019;27:e3204
DOI: 10.1590/1518-8345.3217.3204
www.eerp.usp.br/rlae

Original Article

Tips for permanent education in mental health in primary care guided

by the Institutional Socio-clinic*

Larissa de Almeida Rézio1,2 Objective: to analyze a process of Permanent Education

https://orcid.org/0000-0003-0750-8379
in Health about mental health with Family Health teams.
Cinira Magali Fortuna3
Method: research-intervention performed with 20 workers
https://orcid.org/0000-0003-2808-6806

Flávio Adriano Borges4 from two teams of the Family Health Strategies. Semi-
https://orcid.org/0000-0001-5941-4855 structured interviews and 12 reflection meetings were carried
out with each team. The principles of Institutional Socio-clinic
were used to guide the meetings and the analysis of the data.
Results: seven beaconing tips were identified for the Process
of Permanent Education in Health: effects produced from the
choices of inclusion of the management in the planning of the
meetings, revealing established ways of working; attention
to non-control in training movements; use of restitution
at meetings, reducing stiffness and tensions; attention to
* Paper extracted from doctoral dissertation “A educação
permanente em saúde para formação em saúde mental the institutions that cross us; analysis of the facilitator’s
na atenção básica, guiada pelos princípios da socioclínica
involvement in the training, redirecting behaviors and
institucional”, presented to Universidade de São Paulo,
Escola de Enfermagem de Ribeirão Preto, PAHO/WHO attitudes; problematization about the object, instrument and
Collaborating Centre for Nursing Research Development,
Ribeirão Preto, SP, Brazil.
purpose, which favored the reflection about the mental health
1
Universidade Federal do Mato Grosso, Faculdade de care and to learn to facilitate and experience the Permanent
Enfermagem, Cuiabá, MT, Brazil.
2
Scholarship holder at the Coordenação de Aperfeiçoamento Education in Health in the act of making. Conclusions:
de Pessoal de Nível Superior (CAPES), Brazil, and at the
socio-clinic assisted the experience of facilitating in-service
Fundação de Amparo à Pesquisa do Estado de Mato
Grosso (FAPEMAT), Brazil. training, pointing out tips for the collective construction of
3
Universidade de São Paulo, Escola de Enfermagem de
Ribeirão Preto, PAHO/WHO Collaborating Centre for
contextualized, reflexive and problematizing knowledge.
Nursing Research Development, Ribeirão Preto, SP, Brazil. Descriptors: Permanent Education; Professional Training;
4
Universidade Federal de São Carlos, Departamento de
Enfermagem, São Carlos, SP, Brazil. Public Health; Mental Health; Primary Health Care; Nursing
in Public Health.

How to cite this article

Rézio LA, Fortuna CM, Borges FA. Tips for permanent education in mental health in primary care
guided by the Institutional Socio-clinic. Rev. Latino-Am. Enfermagem. 2019;27:e3204. [Access ___ __ ____];
Available in: ___________________ . DOI: http://dx.doi.org/10.1590/1518-8345.3217.3204. month day year

URL
2 Rev. Latino-Am. Enfermagem 2019;27:e3204.

Introduction necessary that the training be based on the reflection of

the work process and that it is a collective construction,
The National Health Council (NHC) approved the not taxation and encompasses psychosocial attention
Training and Development Policy for the Unified Health as a guideline.
System (UHS): Pathways to Permanent Education in Although there is this need for training, most of
Health, establishing the National Permanent Education the international studies point to a formative logic still
Policy (NPEP) as a UHS strategy for training and focused on the traditional training and capacities, with
work development, considering the constitutional measurements of their impacts in the daily work(13-17).
responsibility of the Ministry of Health to order the Another relevant point refers to the fact that
formation of human resources for the health area . (1)
Mental Health training is often based on the biomedical /
It is understood that the Permanent Education psychiatric model, emphasizing the diagnosis of mental
in Health (PEH) is a proposal of relevant learning disorders and drug treatments, besides happening in a
to contemplate the worker as protagonist of the decontextualized way of the daily work of health(18).
formation process. The latter - also focused on the Brazil has stood out in terms of training that takes
problems and difficulties experienced in the daily place from the context of health work, dialoguing with
production of care, management and participation it, in a permanent perspective, seeking to propitiate
and social control – makes it possible to construct reflection, problematizations, denaturalization of
collective spaces for reflection and evaluation of the concepts and hegemonic practices in Mental Health,
daily actions of the health services, decentralizing in addition to discussions on the different perspectives
and disseminating the pedagogical capacity between regarding psychic suffering and psychosocial attention,
managers and workers, operating in the micro-politics incorporation of the discussion of interventions present
of the work process. In this way, professional training in the daily routine of the practice as the reception and
is offered at the same time as the changes in health qualified listening, expanding the ways of caring for the
practices are produced (2-4)
. health of the population(19-20).
PEH is one of the strategies that can favor the Given this context, it is understood that the training
expansion of mental health care in relation to health is not effective to enable the change of practice and the
services and the care network, as well as highlighting incorporation of new concepts, by de-contextualization
various possibilities of work tools to be used in the and based only on the transmission of knowledge in a
psychosocial context, since new policies and guidelines unidirectional perspective(3).
guide the care network and, therefore, involve workers Like PEH, one of the structuring axes of Institutional
from different services and, necessarily, the Family Socio-clinic is also work. For this, the professional
Health Strategy (FHS), seeking the construction of practice includes ways of relating to the collective of
autonomy and social reintegration of the subjects (5-6)
. work, of thinking about these relations and of assigning
Despite this indicative of network care, studies values, being constituted by a set of updates of the
indicate that the FHS teams report difficulties in relations that the subjects establish with the professional
providing care to people suffering from mental illness, institution, that is, its professional implications(21).
referring to the fragility of this specific care and the need The institution, in turn, would be the rules and rules
for training for it .
(7-11)
established and socially constructed, such as family,
In addition, it is relevant that Mental Health care education, health, work, among others(22). In this sense,
is also understood in the context of general health, in the individual and / or collective subject can problematize
which the worker acknowledges that the mental health his daily work, recognizing himself involved with the
demand can be present in several complaints reported aspects and institutions that he questions.
by the users that reach the FHS. Thus, thinking about It is believed, therefore, that the Institutional
PEH as a strategy capable of generating reflective Socio-clinic can act in the perspective of generating PEH
processes and covering mental health care can result in processes. It does not consist in a technical modality
comprehensive care of the person and the family. or protocol of practice and analysis, but in a way to
Given this context, there is a new demand for question the object and intentions of analysis, seeking
the training of workers at work, for work and for the to understand the social dynamics(21).
work (12)
. In order to expand understanding and look Its principles consist of characteristics to be
at mental health as a care integrated with practice and observed in the beaconing of institutional interventions.
that takes into account the integrality of the subject, it is They are: participation of the subjects in the device;

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 Rézio LA, Fortuna CM, Borges FA. 3

analysis of order and demands; analyzer work; various senses crystallized in institutions, broadening
application of refund arrangements; analysis of the the theoretical bases and methodologies, in addition to
transformations that occur as the work progresses; enabling the production of knowledge and new practices

intention of knowledge production; attention to contexts at the same time. In this way, the researcher is the

and institutional interference, and the analysis of the subject and object of knowledge(27).

implications(21). The data presented comprised part of a doctoral

thesis whose field of intervention was composed by two
The devices are elements such as writing, speech,
FHS of a large municipality of the State of Mato Grosso.
videos, among others, created for / in situations of
All the workers from the participating FHS, interested
intervention, that can destabilize the instituted ways of
in the PEH / Mental Health process, were invited to
functioning of the institutions, and can also become an
participate in the intervention research, totaling 20
analyzer if they can put some situation under analysis,
subjects: eleven workers from team I and nine workers
revealing the structure of the institution, provoking it
from team II, eleven community health agents (CHA);
and forcing it to speak(21,23-24).
two doctors; two nurses; two nursing techniques;
The order refers to an official request for imaginary two receptionists and a typist. This number fluctuated
solutions or actions to restore order and allows the during the training meetings so that each group had, on
intervention to begin. It involves not only who asks average, five to seven people participating.
for the intervention, but also what is asked for(23). The As an instrument, the semi-structured interview
demands are conscious, manifest, deliberate aspects with all workers was used as an instrument, seeking
and also unconscious and unsaid aspects, and may be information about daily work, Mental Health practices in
in tune with the order or not. Thus, the order also has the FHS and experiences in PEH. Based on the answers,
individual demands .
(23,25) the analysis and the group reimbursement, themes were

During the analytical process, transformations occur included to guide the training sessions in Mental Health.

that, for Socio-clinic, deserve attention and attention. The topics studied were: organizational proposals based on

In the same way, there are institutional interferences, NPEP; psychiatric reform and Mental Health network care;
reception and approaches to the user in mental suffering
processes of intersection and noise produced when
and in use of psychoactive substance; team work; singular
institutional logics enter into contradiction.
therapeutic design; use of tools / scales / tools for Mental
In order for this process to take place, it is
Health care and Mental Health care strategies in the FHS.
necessary to analyze the implications of the researcher
These training meetings were also configured as data
and the other participants in the development of socio-
production space.
clinical research. Analyzing the implications is to analyze
The PEH was guided by the principles of Institutional
the relationships that the subjects establish with the
Socio-clinic with the workers who accepted to participate,
institutions that pass through them(26). totaling 12 meetings, with an average of two hours. The
Using the principles of Institutional Socio-clinic meetings were recorded and transcribed for analysis,
to mark PEH in Mental Health in the FHS can be a protecting the identity of participants.
potentiator of learning processes and cause workers to One also used the researcher’s field diary on the
think and reflect on their respective work processes. intervention research. In this diary, there were reports
Therefore, aiming to answer the research question of group movements, resistances, advances; content
of how Socio-clinic can enhance the development of PEH discussed, that is, the narrative of the historical-social
in Mental Health in the FHS this study aims to analyze a context reflected in the research activity(28).

process of PEH in Mental Health with FHS teams, guided As this is an intervention research, the results were

by the principles of Institutional Socio-clinic, pointing out discussed with the participants as they were produced.
For the organization of the empirical material, the
tips to the development and construction of a critical,
work of transcription was carried out, followed by the
reflexive, contextualized and problematizing knowledge.
transposition, by means of a more attentive and reflexive

Method reading, considering the speeches and the acts / gestures

in the different encounters and returning them to the
Research-intervention based on the theoretical teams. Finally, the work of reconstitution was carried out,
reference of Institutional Analysis – Socio-clinic and in which the construction of a narrative argued around
carried out from March 2016 to February 2017. The the analysis of the categories(29).
intervention research has the political character of At the reconstitution stage, we sought to identify
search for transformations from the interrogation of the tips for the experience of a Mental Health training

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4 Rev. Latino-Am. Enfermagem 2019;27:e3204.

through PEH, that is: when analyzing the transcribed an administrative reorganization in the distribution of
material, guided by the principles of Socio-clinic, we services to universities, it is necessary to change and
sought to separate statements, attitudes, behaviors, start the practice in another unit, sometimes performing
actions and postures that could be tips or points of an irresponsible practice regarding the continuity of care
attention to any experience of PEH and, therefore, be for the other and co-responsibility in this process.
analyzed and discussed with the health professionals
The second clue to PEH is to lose the illusion that
who composed this intervention research.
there is control and that this is part of the movement
The research was approved by the Research
to learn concepts, practices and to think collectively.
Ethics Committee with the opinion of CAAE No.
Allowing not to control the learning process is also an
53029016.2.0000.5393. The aim was to guarantee
important clue to self-management-based training for
the anonymity of the participants and preserve the
the collective. What if it does not work out? What if the team
confidentiality of the information. The speeches were
does not want to? And if they do not accept it? What if they do
identified by the letter T, referring to worker, followed by
not identify with the proposal? Will I account for this process?
the randomly chosen Arabic numeration, and the diary
(Researcher’s Journal February /2016)
of the researcher were indicated with this nomenclature,
followed by the month and year. In this sense, sharing the findings with the
participants in a formative perspective centered on the
Results PEH, using the restitution based on the principles of the
Socio-clinic, is the third clue presented. The restitution
The experience in the process of PEH for the
can be an opportunity to pause to look at the process.
formation in Mental Health points to some beaconing
The purpose of the restitution was not to pass on
tips guided by the Institutional Socio-clinic.
information, but to share perceptions with the team,
The first clue is the reflection and attention to
putting them in the analysis. The exercise was to
the process of making, planning and thinking the PEH,
approximate processes of self-management and self-
about the instituted way of organizing and planning the
analysis. But how is this [restitution]? Are you going
trainings and activities in the service, be they graduation,
postgraduate or residency activities, since the first to tell us what you’ve written down and what you’re

device created was the inclusion of the management, thinking? (T16); When students come here, they record,

by means of the Municipal Health Department, in the talk, ask, and then walk away; We do not even know
process of choosing the units participating in the study, anything (T20); It was good that you talked to us about
without inserting or consulting these units on their it. We already knew, but did not speak (T19).
interests in participating, restricting the choice to the The fourth clue would be to look beyond what
Municipal Health Department. the person says in the face of situations of tension
Sometimes this organization and planning become and tensions in the encounters, paying attention to
contradictory with the proposal presented by the fact what their speech carries, what “ghosts”, previous
that there is collective participation in decision-making experiences, that is, the institutions that cross them.
processes from the beginning of intervention planning.
When we began the evaluation of the meeting, I began to return
Including only management in this process and
to them about my perception of the group’s lack of interest in
creating a territory of doubts, fears and longings can
the delays, demarcations, use of cell phones, among others;
lead to participation in the study by obligation, seeking
naturally, statements were made that resumed restitution.
to satisfy management, even as a means to continue
Then, they began to verbalize the obligation to participate in the
being the exemplary service, which meets what is
group (Researcher’s Diary August /2016); No one has explained
proposed or imposed. The students come here, they start
anything to us until you arrive. They called here, they warned
an activity here and then they leave and we have the population
you that you would come and that it was something of mental
to answer (T16); They came from far away to take a photo of

the patient and the family is in expectation [...]; comes another health (T9).

student, comes another, at some point, it annoys and does not The participation of the management in the

solve (T20). indication of the participating units brought a resistance

These reports provided a reflective look to the effect to the non-explanation, consultation and discussion
health team, shifting from the place already known: in team before the entrance in the field. The team has
the place of teacher. Often, as a teacher, he enters always experienced the process of heterogeneity, that
the field of practice, enters the space and territory of is, from the control and action of others, in a relationship
the user / family and health team, and then through of vertically hierarchical power. Therefore, attention

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 Rézio LA, Fortuna CM, Borges FA. 5

should be paid to what the speech pronounced in the Discussion

meetings carries.
The implication analysis of the researcher is the It is a challenge to construct and think about

fifth clue in which, through this movement, it was effective ways of training workers from their health

sometimes possible to redirect acts and behaviors as work context so that decision-making processes are

the implications were identified. based on the collective so that workers and users

The entry into the field was initiated on the basis of actively participate(31). Not recognizing that the
organization of the health work process is a result of
a misguided and over-implied reasoning that the desire,
the inclusion and interaction of workers and users can
the ideologies and implications of the researcher were in
produce bureaucratic forms of work, with the subjective
accordance with the desire, ideologies and implications
impoverishment of the worker and, consequently, of
of the workers and managers. A misunderstanding that
the care(32). Thus, the worker may lose his desire for
may occur in other training experiences centered on the
work as he fails to recognize himself in the final product
perspective of PEH, which can be redirected from the
of his work process.
analysis of implication.
Heterogeneous management can increase the
The structural-professional implication with the
exploitation of labor, alienation, reproduction of the
formation process and with the specialty in Mental
instituted and the naturalization of daily life, and in
Health and the existence of a psycho-affective level
response to this context, self-managed proposals may
with the militancy in Mental Health resulted in fear
arise as an institutional movement(33).
and insecurity related to the fact of being a teacher
The training process (undergraduate, graduate,
of a Higher Education Institution with work in Health
residences and in-service training) is not owned by
Mental. I think I have demanded a lot from this intervention.
PEH. If the PEH facilitator does not take care of the
Required to respond correctly in response to an expectation of
construction of knowledge in the collective, taking
the willingness to implement the Psychosocial Care Network,
responsibility for the process itself, it can reproduce
to walk with Psychosocial Care, to involve and bring network
the instituted way of functioning of the institutions,
workers closer to mental health care (Researcher’s Journal
preventing the unprecedented occurrence(2), as well as
May/2016).
the creative and creative power of the collective.
As a means of problematizing Mental Health care
The course of the PEH happens from the movement of
in the service during the PEH process, the group was
the collective, the joint construction, the problematization
offered a discussion about the work process, while a
directed to the needs. Therefore, there is no timetable
reflection of the daily practices, rethinking the object,
or lesson plan to follow; there are agreements and
instrument and purpose of work in Mental Health from
directives, based on the principles of NPEP.
the contributions of Mendes-Gonçalves(30), guiding the
The restitution, as an opportunity to deepen or
formation in Mental Health in the context of work,
question the analyzes(21), was another Socio-clinic
provoking reflections and provocations on the daily principle used to experience PEH in the training in service
life of these practices, being this the sixth clue for the in Mental Health, which also could favor the movement
development of PEH actions. We did our work and did not of the collective and the notion of lack of control.
think about the object, instrument and purpose; I had never In doing the restitution and sharing of the PEH
stopped to think about it, to reflect, for a year doing my job and process in Mental Health, the workers also occupied a
I did not even know what I was doing (T13); I go for the visit place of actors of the learning movement, being able to
and often have not even stopped to think about the purpose. speak of institutional attitudes and interferences as: to
[...] now, I keep thinking about the way to the patient’s home rethink and to talk about the obligation to participate
(T8); My object of work was the disease itself, the madness, and its relation with behaviors of resistance, stiffness
because I saw the symptom more [...], now, I cannot think and tension in the encounters.
about it [...] in the subject (T3). Looking beyond the behaviors and speeches
And the seventh track is the indication of learning presented, comprising, therefore, the institutions that
how to facilitate and experience processes of PEH in the cross the professionals, could favor the understanding
act of doing, taking into account PEH’s own perspective and resolution of conflicts in the process of formation.
that is, putting into action trying to do, in practice, in the In this case, resistance as a barrier to the development
daily work. We were going, doing, when he realized, he was of PEH should not be taken as a negative sense, but
already doing Permanent Education. (T19) an opportunity or a way to preserve a certain way of

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6 Rev. Latino-Am. Enfermagem 2019;27:e3204.

working / life in the face of a change of course, as well The overlap also experienced is the result of strong
as possibilities of facing some imposed determinations ideological engagements(21) – in this context, the militancy
by management(34). and specialization in Mental Health. The objective is not
The principles of Institutional Socio-clinic favored to make the overlap disappear, but to perceive it, to
that the facilitator of PEH (and researcher) could make it visible and analyzable, consequently, no longer
interpret this stiffening in the group as a possibility acting in the field of overlapping, but of implication,
of growth and involvement with in-service training, producing a new knowledge(38).
stimulating instituting processes of self-management. Making PEH for Mental Health training and being
Being aware of these institutional interferences, concomitantly guided by the principles of Socio-clinic
such as the fact that municipal management includes favor spaces and opportunities to re-discuss and revise
services in a taxing way, has opened the possibility the needs of the group, revisit the initial proposal and
for a more powerful meeting. Otherwise, disputes, understand that the PEH is a field of dialogue that should
disagreements and conflicts could be established .
(35-36) also consider the institutional interferences , the diverse
During the restitution, there was no recrimination implications and desires of all involved.
or accusations charged with impotent denunciations, but Another point consisted in using the concepts of
it was used as a space for the enunciation of things, object, instrument and purpose, to review the work
being constructive and respectful(22). process. The work process is a means of constructing
Through the restitution, it was possible to review subjectivities where the subject establishes
the demand of the group, understanding that it is relationships and (re)produces their existence, having
changing and does not necessarily happen explicitly. as elements the object, in which the work will be
The process of re-discussion of demands was relevant applied, through the use of instruments, which are
to the analysis of the implication of the researcher material or non-material forms (such as knowledge,
and facilitator of PEH, since, from the planning of the individual consultation, medicine, among others) in
research as a member of the Psychiatric Reform and a order to achieve a specific purpose(30).
specialist in Mental Health, she sought to meet a goal of Perceiving these aspects of the work process is also
transforming practices service through PEH. a clue so that one can progress in the transformation
Analyzing these implications with the object of of professional practices from the reflective look to the
study, based on Socio-clinic, favored new directions daily life of these.
and attention for the PEH process, presenting a great In this way of learning from the collective, many
contribution to the PEH facilitator in order to reflect on workers pointed to paths that widened their gaze to the
how the researcher relates to his object of study and person in mental distress and / or use of psychoactive
work and in what form this interaction takes place - substance (PAS), while reflecting on the object,
analysis of implication(25). The implication can be divided, instrument and purpose of their job. Thus, PEH, guided
didactically, into three dimensions: affective-libidinal, by the principles of Socio-clinic, can lead to unlearning,
related to the affections, of liking or not, of the empathy de-territorializations and reflections.
present or absent between the researcher and the object The movement of de-territorialization mobilized by
of study; historical-existential are the world views that the PEH also traverses this perception about the work,
carry themselves and structural-professional are the of the institutional implications, that is to say, if one
issues related to work . Therefore, it was possible to
(37)
intends to advance in the discussions about what has
go through auto-analytical processes of analysis of the been produced of effectiveness and power in the care,
implication of the researcher with his research, going and the reflection on the clinic, on the work process
through the dimensions of this implication. is relevant and can point to change paths not by the
This understanding of the implications allowed imposition of knowledge or determinations of practices,
the researcher to understand that the need for control but by the joint construction of these.
or destabilization against non-control, as presented Thus, as the encounters occurred, the team also
previously, was related to the implication with her began to be clear about the proposal, since it also started
work as a teacher, that is, the teaching institution went an active participation in the discussions, planning and
through the research. Just as motivated by its ideology evaluations of the meetings, understanding that the
and affection with Mental Health care, it remained over- facilitator was not in a position to pass on information,
motivated, acting from an objective of implementing but to construct meanings that would transform the
Mental Health actions in basic care in articulation with practice of health work collectively, resulting in PEH
the other services of the health network. actions.

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 Rézio LA, Fortuna CM, Borges FA. 7

These processes have made the facilitator / by instituted models and by specialized looks for
worker and the workers face difficult scenes such as: Mental Health as specificity, leading to a more
not knowing; do not control; the preconceptions; the objective, positivist formation with few flexibilities and
exercise of a look at oneself and at one’s own practice; possibilities of speech or creation in the group and
to question the reason for certain attitudes routinely by the group. Thus, it is considered that Institutional
committed mechanized, given as natural, generating a Socio-clinic, as a beacon of a process of Mental
certain burden of suffering. In this movement, building the Health training through PEH, can favor or facilitate
formation from the context, fragilities and potentialities movements of looking and perceiving these captures
was something powerful and transformative. of the instituting forces in daily life.
Care in Mental Health involves legal-political The Institutional Socio-clinic can potentiate the PEH
aspects, training, ethical and political values in which process, pointing out tips to the formation process that
care is centered on the user / family. In considering these can also be strategies for the production of knowledge
aspects, it is no longer possible to think about Mental in the work and for strengthening the inclusion of the
Health care restricted to medicine, centered on medical subjects in the collective construction of learning.
knowledge and power and standardized solutions, but It is emphasized that the seven tips presented
based on wholeness, in the context of the subject, in are not configured as protocols, but are designed to
their psychosocial singularity. assist facilitators and workers involved in the PEH
That is, the transformation of the look into the process. Regardless of the purpose of the training - in
work object leads to the creation of new instruments this study, the focus is on Mental Health -, the tips are
based on inter-sectoral actions that seek the social
indications to consider the crossings and institutional
reinsertion and the autonomy of the users(39). Facing
interferences in health care and, consequently, for
this, it is noticed that the meetings of PEH favored
training and for the work.
moments of learning to learn, deconstructing and
reconstructing new knowledge. Acknowledgements
This critical capacity to look at everyday practice
and activities with a willing eye to identify fragilities, but To the professionals of the Center for Psychosocial
also inventions / creations, permeates the process of Care for Alcohol and other drugs, who were part of
perceiving reality as being dynamic and fruit of a social the process of Permanent Education in Health through
and historical construction, which can be transformed .
(40)
occasional discussions, and the professionals of the
In this sense, PEH participants began to unveil Family Health Strategies participants.
reality in a movement to look at themselves and
practice. Therefore, it consisted in thinking of the References
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Received: Feb 4th 2019

Accepted: Jul 2nd 2019

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