Apresentação - CAPS (WHO QualityRights workshop on good practices for community-based mental health services)

Estive na Coréia do Sul para discutir e pensar políticas de saúde mental para a região do sudeste asiático. Nas apresentações sobre serviços que valem a pena conhecer, tive a alegria de apresentar o CAPS

Texto apresentado:

To introduce this service, it is relevant to mention two aspects of the development context of the CAPS:

First, Brazil has Universal Health System. Public administration provides and organizes services into networks and there are no restrictions on access. CAPS are part of public health policy.

Second, the Brazilian mental health care network is comprised by services and strategies developed in an open and community-based mental health care approach. This network includes independent living facilities, mental health beds in general hospitals, mental health teams in Primary Care, among others. The CAPS are responsible for coordinating the whole mental health care network.

So, keeping that in mind, what are the CAPS?

They are community-based mental health services that works with a rights-centered and people-centered approach, developing practices based on the rights and needs of people with psychosocial disabilities. Some of the key goals of the CAPS are to provide comprehensive and quality mental health care and support, including during challenging and crisis situations., and to promote social inclusion and empowerment by increasing the social participation of people with psychosocial disabilities. In addition, CAPS goals involves combating stigma and prejudice.

CAPS is a service committed to the practice of freedom. There is no involuntary or compulsory admission to this service. People are admitted to the service by spontaneous demand or they can be referred from other social and health services.

There are different types of CAPS, which vary depending on specific needs, the catchment area and hours of operation. I will not detail them because the focus of this presentation are the principles and actions that they all share.

So, only for your information, there are two specialized types of CAPS based on specific needs: one for children and adolescents, and one for adults who abuse alcohol and other drugs

And there are three levels of CAPS depending on the catchment area population and hours of operation

CAPS I are implemented in small municipalities and CAPS II in larger municipalities and regions. Both are day services.

The difference from them to CAPS III is that this last one, the CAPS III, is open 24 hours / 7 days per week. Is the only type of CAPS that offers day and night service.

Since we know how challenging it is to offer night services that work without force and protect users' rights, I'll talk more about CAPS III when explaining night service actions.

With that being said, let's now talk about the structure of all types of CAPS

I have listed here what is the physical structure of it.

The service structure aims to provide a welcoming and comfortable environment, that leads to active participation and interaction. In addition, because CAPS have a community-based approach, the service goes beyond its walls. CAPS activities are also developed in public spaces of the community, such as public parks, community leisure centers and cultural spaces.

I would like draw your attention to the third picture that shows the bedroom structure of a CAPS III. It is a comfortable room, with clean blankets and lockers.

In the other box you can see a list of practioners that are part of the multi-disciplinary team of a CAPS, which includes psychiatrists, nurses, psychologists, social workers, among others.

Talking about the actions of the CAPS, when someone is admitted to the service the firs step is to draw up a Singular Therapeutic Project alongside with the service user.

In a recovery perspective, projects and goals are set considering multiple life scenarios. Hence a therapeutic plan is defined. This tool helps to promote balance of power, considering user participation as the starting point of a recovery process. A therapeutic project is updated from time to time because needs, wishes, and projects change.

Actions and practices developed in the CAPS are related.

For example, a service user can go for an individual appointment (which is a regular action developed by the CAPS). This individual appointment can be counseling, provision of medication, therapy, information on social benefits, and so on. Or, in a group appointment, the service user can engage in group therapy, in body and expressive practices, such as walking and painting, and in income and work generation projects.

I could continue to relate actions to practices, but what is important is that they are developed considering service user’s needs. Therefore, it is not the case for the service to have a ready-made list of activities and to fit people into it. Activities should be meaningful and connect with personal history and goals. So, practices and actions in each CAPS are developed considering this.

About day service and night service, we consider them as actions with those four main goals that are listed here.

I would like to emphasize that all types of CAPS provide care and support during challenging, complex and crisis situations trough day service.

But speaking specifically about night service, it is important to highlight three aspects of the CAPS III:

First, each CAPS III don’t have more than 10 beds, people are only voluntarily admitted to the night service and can stay a maximum of 15 nights in a row.

Secondly, the night service is not exclusively for crisis situations. People can stay overnight for a day or more if they are facing a challenging family situation, or if they need to take a break at home, among other reasons.

Third, the connection to the community is maintained and the rights are protected. For example, in night service users wear their own clothes, keep their belongings, are free to choose when to get up and when to go to bed, and during the day they remain engaged in the activities of the community. A night service cannot be an interruption of a therapeutic plan.

To attend crisis situations a reduced staff remains in the service to provide support, talk, and stay close to the service user, with an embracement attitude, if one cannot sleep. But above all, what happens in a night service is that people sleep.

About core principles of CAPS.

CAPS are open door services, which means that people can access the service without necessarily being referred by another health or social service and that during the hours of opening, users can go whenever they feel necessary.

Regarding the principle of "Taking charge of“, CAPS works with an idea of ​​therapeutic continuity. CAPS respond to all specific mental health needs of people of its catchment area.

CAPS, for the reasons already listed, substitutes psychiatric hospitals and outpatient services.

Legal capacity is promoted through daily empowerment strategies and actions, such as affirming rights of citizenship and giving support to people regain control of their lives.

Developing non-coercive practices is the core of CAPS. Attitudes of respect are crucial to this. It is important to mention that CAPS were created in response to abuses in psychiatric hospitals.

CAPS practices seek to involve users in the service development. For example, CAPS have weekly assemblies that are an opportunity to bring together people to discuss service-related topics such as food quality and activities developed. This makes people be co-responsible for the service and balance power in service.

The CAPS develop practices in the community and with the community. Its is important to create situations of exchange, opening the doors of CAPS to the community. This can be done by inviting people for cultural celebrations in the CAPS or to participate in income and work generation projects.

CAPS promote the approach of recovery focusing on empowerment, connection and on risk taking. The Singular Therapeutic Project is a key element to this.

A lot of research has already been done on CAPS. I have selected here some about service evaluation with a focus on the user's perspective on the service.

The first is a systematic review that analyzed 35 articles. The results show that the level of satisfaction of users and families with the service is high and interdisciplinary actions is a distinctive quality factor.

Here are some examples of findings for your appreciation. Of course, there are challenges in CAPS practices. Challenges involve further improvement in the connection to communities, expanding service offerings, and increasing CAPS III coverage.

Two more recent research also shows the benefits of CAPS.

The first one indicates the factors that from the point of view of the users were related with perception of improvement.

The second shows that in a scale of 1 to 5 the medium level of satisfaction with the service is 4.6.

Last evaluation information: recent epidemiological data showed that having a CAPS in the region is an important protection factor to prevent death by suicide, with a level reduction of 14% compared with regions without CAPS.

So, to conclude, my final message to you is that having more community-based mental health services means better quality of care and rights, and having a growing coverage is our goal.