Mental health care in the family health strategy: the experience of matrix support


Anne Larissa Lima Guimarães GurgelI ; Maria Salete Bessa JorgeII; Emília Cristina Carvalho Rocha CaminhaIII; José Pereira Maia NetoIV; Mardênia Gomes Ferreira VasconcelosV

I Nurse graduated from the State University of Ceará (UECE). E-mail: annegurgel@hotmail.com
II Nurse. PhD in Nursing. Post-PhD in Public Health. Professor at the State University of Ceará (UECE). Researcher 1B - CNPq. Fortaleza, Ceará, Brazil. E-mail: maria.salete.jorge@gmail.com
III Nurse. Master in Collective Health from the State University of Ceará. Specialist in Mental Health. Professor of the Faculdade de Tecnologia Intensiva (FATECI). Fortaleza, Ceará, Brazil. E-mail: e.caminha@hotmail.com
IV Psychologist. Master in Collective Health. Specialist in Elderly Health and Mental Health. Substitute professor at the State University of Ceará (UECE). Fortaleza, Ceará, Brazil. E-mail: maianeto01@hotmail.com
VN urse. PhD in Public Health. Professor of the Undergraduate Nursing Course of the State University of Ceará (UECE). Fortaleza, Ceará, Brazil. E-mail: mardenia.gomes@uece.br

DOI: http://dx.doi.org/10.12957/reuerj.2017.7101




Objective: to examine the mental health care provided by family health teams in primary health care and the practice of matrix support. Method: in this qualitative, critical analytical study, data were collected from June to August 2011 by semi-structured interviews of 14 health personnel and seven relatives of family health clinic users. The data were analyzed and interpreted using the content analysis technique. Results: access to mental health care in the Family Health Strategy was one aspect observed in this discussion, particularly the dialogue between the strategy and the psychosocial care center. Also stressed was the power of matrix support in producing mental health care. Conclusion: it was concluded that matrix support is an important team capacity building strategy, which reinforces the premises of the psychiatric reform and provides users with more accessible health services.

Keywords: Mental health; primary health care; matrix support; comprehensive health care.




The Brazilian Health System (SUS) has the Family Health Strategy (FHS) as a device to reformulate the healthcare model, emphasizing the care for families in the areas where they live and where their social relations are built. Among its basic objectives, the FHS assumes the humanized assistance and the creation of bonds that enable professionals to intervene in the community through specific actions that produce knowledge about prevention and health promotion1.

Thus, through the territorial work of multidisciplinary family health teams, it becomes possible to broaden the professionals' view of the health-disease process and to create therapeutic projects that are in line with the family and social situation of each user, thus being a powerful device in the follow-up of the patient under psychological distress 2.

This context contributes to strengthen the innovations coming from the psychiatric reform, since the progress achieved by mental health has expanded and made possible more concrete actions of care that evidence the recovery and social reintegration of the user. Therefore, it is not only a movement, but, above all, a long process of change3.

In this sense, the psychiatric reform has raised the importance of expanding new articulations of mental health, among them, with Primary Health Care, specifically within the scope of Family Health Units, as a means of putting an end to traditional care models and generating a new way of intervening before the user with mental disorder or in psychological distress4.

The matrix support (MS) is the perspective of expanding the articulations in mental health in primary care, as it functions as an assistential and pedagogical device, allowing greater resolution in mental health care. In this context, the objective of the present study was to analyze the mental health care promoted by the family health team in primary care and the practice of the matrix support.



In mental health care, the objective of proposing new practices is to provide an understanding of the insanity and of the social role of the individual in psychological distress, which differs from that announced by the hospital-centered psychiatric model.

The matrix support emerges in this scenario as a strategy through which the teams responsible for the work in the scope of Primary Care are enabled to attend and follow up users with mental disorder, since the lack of knowledge of the professionals about this theme results in damages for the comprehensiveness of care.

Given its innovative nature and its potential to bring mental health care closer to the everyday reality of primary health care services, the MS has been receiving a well-deserved attention in the field of collective health practices, being pointed out by different authors as a strategy that enhances accountability of mental health cases by primary care and collaborates with the implementation of a comprehensive health care 5-10.

The work of the MS is based on a theoretical and pedagogical support to the teams composing the Family Health Strategy (FHS), which is the reference team. From this, a process of accountability begins, in which the reference team becomes responsible for conducting and solving milder cases over time, that is, a longitudinal care, deeply rooted in reception and bonding 5.

The construction of a care network in which the FHS and substitutive mental health services are articulated and agreed upon with therapeutic plans and care tools is fundamental to overcome definitively the old institutionalizing practices and to found mental health care through comprehensive care that emanates from psychosocial practices. Thus, it is built a logic of co-responsibility that replaces the practice of indiscriminate referrals to the Centers for Psychosocial Care (CAPS in Portuguese)11.

The performance of the MS also generates support so that the primary care professionals become able to intervene and deal with simpler cases of mental health in their assigned area, enabling access to health services and an individualized and resolute therapeutic plan.



This is a critical and analytical study focusing on the qualitative approach, which allows the understanding and analysis of the social phenomenon and its relations in the field of mental health and primary care. This type of study facilitates the understanding of the subjective issues inherent to attitudes, relationships and social structures 12.

The research was carried out from June to August of 2011 in two units of Family Health Strategy (FHS), one of them located in the Regional Executive Secretariat V (SER V) of the city of Fortaleza and the other in the Health Surveillance Area V (AVISA V) in Maracanaú, both located in the State of Ceará.

The research participants were 14 health professionals from the FHS teams and seven family members of users of the service. The sampling process was ended due to empirical theoretical saturation. This process is frequently used in qualitative health research, being used to close the sample size and thus terminate the capture of new data. It happens when the information collected begins to repeat and the search for new subjects is not able to deepen the theoretical reflection provoked by the objectives of the study 13.

This article is part of a research called Production of health care and its articulations with the care lines of the SUS and the mental health care network, financed by the Brazilian Ministry of Health, which was submitted to the analysis of the Ethics Committee for Research with Human Beings, of the State University of Ceará, and received a favorable opinion with no. 08573214-1. The ethical principles, such as autonomy, beneficence, non-maleficence and justice, were observed in Resolution 196/96 of the National Health Council, in force at the time of approval of the project. Thus, the interviewees had access to the Informed Consent Form (ICF), received explanation about the risks and benefits of the research, the voluntary participation, as well as the guarantee of secrecy and anonymity. These were guaranteed by identifying the participants with composite code of the professional category and the interview number.

For the data collection, a semi-structured interview was used, with the aid of a previously elaborated script, composed of open questions about the following theme: access and solubility of mental health care in Primary Care.

In order to organize the information, three steps were followed, namely: ordering, classification and final analysis of the data, which includes classification of the respondents' speeches, components of the empirical categories, horizontal and vertical synthesis, and comparison of information, by grouping convergent, divergent and complementary ideas 14,15. Next, empirical material and theoretical referential are contextualized; convergent and divergent ideas of meaning are confronted, as well as those complementing each other, and the analysis is made from the emerging categories.

The analysis of the empirical material was based on reference in which the object of analysis is the social praxis, and the meaning that is sought is the political ethical affirmation of the thought, being isolated parts of the text to extract sections capable of being used, allowing the comparison with other texts related to the subject of study14. The findings were classified from the categories that emerged from the exhaustive reading of the texts and the guiding questions and goals proposed above.



It is important to characterize the participants of the research, since it brings the reader closer to the context studied. Thus, two groups participated in the interview, the professionals of the family health team and the family members.

The professionals who participated in the research are: nurses, physicians and dentists. The physicians presented the longest time of training and performance in the FHS. They reported having previous experience with mental health, with two to three years of work in the area. On the other hand, nurses and dentists have between two and three years of experience in the team, and professionals had a lower age range than that presented by the physicians, in addition to reporting not having had previous experience with mental health. The group represented by the relatives of the users was mostly composed of women (mothers, sisters and daughters) aged between 36 and 45 years.

In this context, we present the information obtained from professionals and family members of users, categorized in aspects observed in the discussion of access to mental health care in the FHS. These aspects are described in the categories: Access and resolution in mental health: a dialogue between the Family Health Strategy and the Psychosocial Care Center; Access and the mode of production of mental health care.

Access and resolution in mental health: a dialogue between the FHS and CAPS

The issue of access and resolution in mental health emerges from the main aspects of psychiatric reform in Brazil that have challenged the institutionalization of psychiatric patients and reoriented the knowledge and practices related to care for the person with mental disorder or psychic suffering9,16. With the objective of forming a care network that provides care to the user in their community, having access to interdisciplinarity and intersectoriality, new possibilities for the production of care have been developed, seeking to stimulate users' autonomy, with the appreciation of their singularities and civil rights 17. In this sense, it is understood that the advances provided by the psychiatric reform were crucial for the reorientation of mental health care, as described by a professional:

In the past, any case that came in here, if I saw it was a problem, I did not feel empowered. [...] but why cannot I tell her to come 20 minutes, 10 minutes to talk to me once a week? Listening, evaluating; she is already medicated, the medication helps along with this listening. (Nurse 05 – FHS)

In this discourse, we can see a broadening of the care given to the subject, insofar as the professional shows that the care limited to a biological practice is not enough to meet the demands of the individual, being necessary the attitude of care and attention to the other 16.

Care under a broader perspective makes FHS professionals indispensable in structuring the mental health care network, insofar as they are closer to the user and, therefore, know their social, economic and family situation, helping in the elaboration of therapeutic projects consistent with the living conditions of each subject11,18.

Despite the continuous effort to provide comprehensive and resolute care to users with psychic suffering, there is still a therapeutic trend in health services that favors the medicalization of the patient and the disease, seeking to alleviate the symptoms.

[...] what often happens is that the person comes monthly or every two months to get their medication. It should not be only coming and taking the medication, there should be emphasis on appointment also. But this has not been done, because our time is limited to only this receipt of prescription and medication. (Physician 01 – FHS)

[...] the patient usually comes to the health facility to receive the medication. At this moment, their blood pressure is verified, some aspects are evaluated, as well as diabetes [...] there are a lot of people for us to deal with, so we have to work with these measures, only. (Nurse 02 – FHS)

It is thus understood that services and professionals still find it difficult to offer this care based on welcoming, bonding and co-responsibility19. Other offers of care are necessary, including alternative care and prior to pharmacological interventions, allowing the construction of a more systematic and integrated care 20.

One of the possible facilitators for this process is the performance of the multidisciplinary team. Through the care provided by the team, the solution of mental health cases becomes easier to achieve once everyone starts to share the same goal, that is, to contribute to the therapeutic project of the user. When it comes to this understanding, the logic that only mental health professionals should be responsible to an individual with mental disorder or psychic suffering is questioned, and everyone becomes a participant in the psychosocial rehabilitation process, as can be observed in the next speech:

The health-illness-intervention process is not a monopoly, nor an exclusive tool of any specialty, belonging to the entire health field. This makes the matrix support an interdisciplinary work process, with practices involving knowledge exchange and building. (Nurse 03 – FHS)

In this context, the matrix support in mental health has proved to be as an important device in the solution of mental health care, insofar as it provides an effective dialogue between the different services that make up the network. Due to its pedagogical-therapeutic nature, it enables FHS professionals to have greater safety in the construction of therapeutic projects that are in line with the mental health demands presented to them.

It was evident in the speeches that the matrix support was able to cause a restructuring of knowledge. Such a situation favors access, once users have a new possibility of carrying out their treatment, inserted in their community and having a multidisciplinary team to rely on, according to their health demands.

When questioned about the improvement in access to health, relatives of users with psychic disorders reported feeling satisfied to have a health service close to their homes, in this case, the Family Health Units. Living with the mental illness of a family member is a painful process that almost always overwhelms families, and this was referred by all the interviewees. Faced with the suffering existing in the family, simply knowing that there is a health service available already relieves many tensions.

[...] taking care of her is not easy, because of all her children I am the only one who takes care; the others do not even care. It's too tiring because I also have my children to take care of. At least I know that if I have some difficulty I can bring her here [Family Health Unit]. (Family member 07)

I feel responsible [for her father's treatment] . I am the caretaker of everything. Not only to take him to the doctor, I have to help too, tell him why it is not working, tell the problems that he is going through, the day-to-day. (Family member 03)

Therefore, the guarantee of access to the service generated by the MS emerges as a support not only to the users but also to the family caregivers, insofar as it gives them the confidence of not being alone, and the assurance of co-responsibility for the care of the subject with mental disorder or in psychological distress.

Access and the mode of production of mental health care

The need to provide care closely, accompanying the subject and establishing a relationship of co-responsibility, making use of qualified listening, welcoming and establishing solid bonds based on respect and sharing are strategies that enhance the quality of care and consequently access to the care demanded, thus contributing to the empowerment of the subjects.

In this sense, the MS appears as a tool of combat to a long social construction in which the subjects in psychic illness were considered as dangerous and unproductive beings, thus perpetuating institutionalizing practices and chronifying these subjects16,21. Issues such as these fortify the construction of a co-responsibility logic that replaces the practice of indiscriminate referrals to CAPS22.

This co-responsibility, based on the logic of interdisciplinarity, although it has its value recognized, is still fragile and needs to be enhanced and expanded in order to offer comprehensive care.

I particularly think that the difficulty I have is that I do not know how to master, [...] I accompany the mentally ill person, but we usually go to the doctor; it is more the issue of the medication, itself. (Nurse 12 – FHS)

I came to take care of my daughter's health. [...] I seek the doctor to give her the right medication so that she gets well. [...] I came [to CAPS] because of the medication treatment, because she sought the doctor to receive diazepam. [...] Just because she takes these sleeping pills, to the nerves. (Family member 1)

[...] pressure problem, every two months I'm going to get the pressure medicine. But in the CAPS, [...] we only receive the medicine; the appointment is only with the psychiatrist. (Family member 5)

He [the user of the service] only seeks the doctor to renew the prescription of the controlled drug, right ?! He does not seek the others. (Family member 2).

As expressed in the speeches, the attention paid to mental health users in the context of primary care is limited to medical appointments to renew prescription drugs. This kind of care, in turn, is focused only on the illness and not the intersubjective experience of the subjects23 .

These behaviors are challenges for the construction of a resolute mental health care, since the care to the subject is linked to a certain professional class, depriving them of acomprehensive and transversal care through interdisciplinarity. In addition, the use of medications in care practices still plays a central role, especially when the focus is attention to crisis19.

The proposal of matrix support contributes to the overcoming of this fragmented logic of work and, in this sense, by having available a multidisciplinary team that works in the perspective of interdisciplinarity, the user counts on an articulation of knowledge, which will constitute a collective knowledge potentially capable of approach and give resolution to the various demands that the subject brings to the service service24.

Thus, several types of knowledge are articulated in the perspective of providing access to such comprehensive care25. This logic of work overlaps with the fragmentation of care, favoring the overcoming of the limits imposed by the reality of precariousness of the mental health network or primary care26, thus improving not only the services in the territory of the FHS, but also the communication with other devices of care, such as the CAPS.



The matrix support is, undoubtedly, an innovative strategy to expand knowledge about mental health care and contributes to the resolution capacity in Primary Care, highlighting the importance of accounting primary care professionals towards mental health care through training that enables them understanding and putting into practice actions that go beyond prescriptions.

The access of the users through the matrix support, according to the eyes of their relatives, has been seen as something positive, due to the facilitation that is generated through the existence of a health unit close to their residences. However, the relatives have felt the lack of resolution of problems, as well as the physical and emotional overload resulting from the provision of care.

Thus, this strategy is a major advance in the field of mental health, given its potential to produce care based on co-responsibility, in which the therapeutic focus is diverted from the disease to the subject and their issues.

Based on the analysis made, it is concluded that the matrix support is an important strategy to train CAPS teams, strengthening the assumptions of the psychiatric reform and providing users with greater accessibility to health services. However, it is understood that there is still a long way to go in order for professionals to take responsibility for care by modifying the gaze on mental health and the desire to become a participant in the implementation of an effective care network.



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