Abstract
This article discusses the internships at the psychosocial health system of Natal, Northeast region of Brazil, as part of training in psychology. The objective of these internships is to offer students work experiences in public health both inside and outside health services. Based on Institutional Analysis and Schizoanalysis, these experiences were examined through two analysers: (1) the power of knowledge and (2) the need for by-passes. We conclude that health provokes tensions between instituted practices in health services and those instituted in psychology training.
Introduction
In Brazil, the structuring of health policies has been subjected to a process of continuous changes due to the action of important social and political groups that fight for advances in the sanitary reform movement, as well as the consolidation of Brazilian Unified Health System (Sistema Único de Saúde, SUS). Consequently, many sectors involved with the SUS have a fundamental role in inducing changes in both care practices and professional training (Ceccim and Feuerwerker, 2004). Historically, these changes are centred in a new conception of health that emphasizes health promotion, the autonomy of staff teams and users of the services, as well as co-responsibility for health care. It is certain that, since its creation, SUS has achieved victories, but also faces impasses, as pointed out by Campos (2007): ‘[…] insufficient funding, growth of primary care with speed and quality smaller than necessary; virtual regionalization and integration between towns and services and efficacy and efficiency of hospitals and specialized services below what is expected’. In daily activities, it can be perceived that there is still the risk of distancing of the SUS propositions and the prevalence of an approach centred in individual practices that place responsibility upon the service user in a paternalistic and guilt-apportioning mentality (Haeser et al., 2012).
In this context, one of the strategies that health services can deploy for avoiding the risk of a continuous centralization, privatization and becoming distant from Brazilian population’s real needs is to focus on professional training of those who will operate the system. The training of health professionals has remained oblivious of the changes in the management of the sector, of the critical debate about the structure of care systems, as well as of the political requirement of social control. That is why a social movement towards an education reform that can answer to the public interests is necessary – a training programme that is academically, scientifically, ethically and humanistically directed to SUS (Ceccim and Feuerwerker, 2004). We believe that this proposal may deflagrate what Guattari (1987) calls transversality movements, in opposition to verticality movements provoked by introjections of norms and instituted demands, present on subjected groups, and horizontality movements that consist in associating different sectors without establishing a relationship between them. Such movements – vertical and horizontal – are not in tune with the proposal of care defended by the SUS.
In contrast, transversality places its bets on the shifting necessary for the group to become a device that can produce new realities, sustaining unprecedented processes and open to invention. The group becomes a subject group that supports its own creation. Therefore, transversality ‘[…] is a dimension that intends to overcome both impasses, the one of pure verticality and that of pure horizontality; it tends to be accomplished when maximal communication occurs between different levels and, particularly, between different senses’ (Guattari, 1987: 96). We bet on transversality in the experiences that will be presented is to try and not to reproduce hierarchies such as manager–worker–user and teacher–student so that powerful encounters may happen, life can move and care is done. Our point of departure is that the SUS was built on the coexistence of vertical and horizontal movements with transversal ones, of instituted and instituting forces that present within us and among us and that cross over into health practices.
From this point of view, new practices for training must come up with proposals for transforming professional practices, according to a critical reflection about the work in health care. They have to be founded in the experimentation of alterity with service users in the different territories in which life demands care. Such practices must allow room for embodying into learning and teaching both the relationships established in the routine of health care and in the management of this sector. Thus, training must go beyond searching for a diagnosis and intervening over an illness; it must make an effort of offering a care adequate […] to the health needs of each person and populations, to the needs of management and of social control in health; it should be able to re-scale the development of people’s autonomy up to the point where they can influence the shaping of care policies. (Ceccim and Feuerwerker, 2004: 43)
Thus, it is a detour in the training process in order to encompass subjectivity production processes, development of skills and reasoning that flow into the SUS, provoking tensions with regard to the dominant form of acting in health care that still places scientific–technical aspects as the central point.
Even before the creation of the SUS, changes of the work organization in health care made interdisciplinary teams valued and opened a new field of work to psychologists that presented difficulties from the beginning. Psychology was regulated as a profession in 1962 to work basically in four areas: clinical work, schools, teaching and occupational psychology (Paulin and Luzio, 2009).
It was in the 1970s that psychologists formally joined public health services in Brazil, in a process that gained force during the 1980s due to (1) a need for an effective qualification for human resources in public health in which occupational psychology practices, up to then developed inside companies, could help; (2) Brazilian economic and social crisis during the 1980s and the resulting retraction in the market for private clinical work led psychologists to move their clinical skills to different environments, particularly health services; (3) a significant movement of this professional category towards redefining the function psychologists have in society, widening traditional fields of work and creating new ones more geared to answer Brazilian society’s needs, namely, in the field of social policies; and (4) the strong diffusion of psychoanalysis in Brazil and, consequently, a greater familiarity of society with psychology (Dimenstein, 2001; Oliveira et al., 2004; Vasconcelos, 1999). Besides these factors, sanitary and psychiatric reforms, in which psychologists had an important role, created a focus for absorbing these professionals into public services for the implementation of the new health policies.
However, once inside the services, psychologists adopted the traditional individual-centred clinical model with analytical, psychotherapeutic or psychodiagnostic objectives. This conception of clinic is out of tune with the principles of the SUS since it is the expression of a universal know-how applied to a universal, non-historical subject unconnected to his or her social and cultural context (Dimenstein, 2001); it is a practice that lacks understanding about the SUS. As a consequence, there is a limited use of techniques related to the traditional approach to clinic adopted at the universities (Paulin and Luzio, 2009).
Psychology, as a science and as a profession, adopts a traditional model of clinic which results, when it comes to public health, in a persistent separation between psychology and politics, a lack of political consideration of professional performance. However, both training and professional practice show that this separation is not viable given that psychology deals with subjects that are socially and historically situated and that no performance is apolitical, as it always has effects in the different social groups involved. Work in the SUS demands that practices become political as a professional stance that is neutral and uncompromised with its ethical and political effects goes against the principles of the SUS. Discussing traditional clinic, Moreira et al. (2007) highlight the need for a social clinic that blossoms as a political, ethical practice developed by the interventions, that is engaged in health promotion and with Brazilian social reality. This clinic emerges as a collective space for the support of alterity; it is based on critical analysis of the power of its interventions and not on the division between knowledge and social commitment, associating the psychological subject with the political one. This clinic is always attentive to the contexts in which it is inserted, to the multi-determination of reality and to the need of supporting difference and singularity.
The context in which SUS was created requires transdisciplinary work, even if what happens is only interdisciplinary actions as mere integration of related fields of knowledge but, nevertheless, moves away from traditional clinic, creating a field in process of institutionalization in which instituted forces that tend to reproduce are confronted with instituting forces searching for new practices. Sousa and Romagnoli (2012) associate transdisciplinarity with a rhizomatic practice that allows the connection of different disciplines in an association that happens not only among academic knowledge but also with art, technology and popular culture: ‘a critical force for destabilizing and disturbing the divisions between fields of knowledge, specialties and relations of power. Transdisciplinarity summons a know-how that builds creative, innovative forms of intervention’ (Sousa and Romagnoli, 2012: 78). It is a practice that happens occasionally and briefly but that can be pursued. Thus, we observe that training in psychology for a future integration to SUS happens according to the way in which professionals and students struggle between hardenings and subjugations, among movements of expansion, composition of forms, forces and power produced at the encounter between teachers, trainees, staff teams and users. The conflicts between these dimensions are usually experimented as great tensions that we hope to reveal next.
Psychology internships in the city of Natal and their fields of forces
In Rio Grande do Norte, psychology courses in two universities – one private and another state-sponsored – offer, on their curriculum, basic disciplines concerning theoretical–practical contents for insertion of students in the SUS. In both universities, on the fourth year of training the students can opt for one of two different emphases. The one we discuss here is the emphasis on health psychology: the students spend their fourth year practising in public health centres and in clinical psychology. The discussion presented in this article is based on the experience of supervising students who choose this emphasis.
During 2014, we followed around 25 students in their placement at the public psychosocial health system of Natal’s metropolitan region which includes many different teams and services that receive people in severe psychic distress – for instance, psychosocial community centres (Centro de Atenção Psicossocial, CAPS), primary healthcare centres, basic health centres (Unidade Básica de Saúde, UBS) and street clinics (consulting offices in the street). The internship also involved actions in the boundaries between psychology and social services, at the interface between sanitary services and shelters for homeless people.
The theoretical basis for this work was the Institutional Analysis of René Lourau and Schizoanalysis of Gilles Deleuze and Felix Guattari. Taking as a starting point the practical experiences during internship, we examined training in psychology and its relation to the SUS, trying to map provisionally the tour de forces between instituted and instituting, between what is established and reproduced and what is pointing towards new practices in daily care (Lourau, 1975). We also looked for hard lines and flexible lines during professional training and their potency for differing through the rhizomatic movements that we tried to produce (Deleuze and Guattari, 1995). This power play and the lines of tension are present in every process of institutionalization and relate to the movement through which institutions and subjectivation processes (re)produce themselves permanently.
For Lourau (1980), institutions have a theoretical genesis that always refers to a philosophical, conceptual framework; however, they also possess a practical genesis associated with the movements and concrete social facts that coexist in its procedures. Lourau, at this point of his writings, gives special attention to the dialectical nature of the universal, particular and unique so that each moment is based on the denial, breakthrough and conservation of what came earlier. In order to know an institution, it is necessary to consider the interactions between these moments and the forces that go with them, which are not directly visible and are in constant mutation and contradiction, a process that is inherent to all institutions.
In its practical genesis, the institution is understood as a field of opposite forces – those of the instituted and of the instituting. The field of what is instituted indicates a propensity for inaction, pending towards stabilization – a tendency for preserving what is universal. The field of the instituting, on the other hand, designates the potential for mutation – a force oriented towards transformation and materialized in what is singular. However, it is during the process of institutionalization – a singular moment – that we find both activities at the same time. These forces are present in a dialectical, processual manner and compose this sphere of contradictory forces that produce effects (Lourau, 2004). The elements of social reality that manifest the contradictions and incoherencies existing in the institutions and social systems are called analysers – situations or elements that denounce the relations of power in a group, in a practice or in an institution.
Deleuze and Guattari (1995) invoke immanency, the exteriority of forces that act upon reality to support relationships and their effects in the search for connections, with openness towards what affects. In this manner, they abandon the domain of representation in favour of the domain of experimentation, agencying, flows and a world that is composed and decomposed by relationships. From this point of view, reality works as a rhizome, a dimension without beginnings, ends or centres that testifies the capability of multiplication and expansion through connections and production of lines more or less hard and molar, more or less flexible and molecular. This mechanism of reality is that of immanency, in which multiple lines and levels of forces coexist and act at the same time: hard lines that classify and act in a binary form and flexible ones that affect subjectivity and create zones of indetermination that allow agency. This effect on subjectivity comes from the outside and from the exterior and is supported by the effected relationships. When this occurs, lines of flight are built, converging towards processes that bring the new processes that are always collective, connecting to intensity, to life.
From the experiences during training, we defend the search for both instituting practices and the production of agency that sprouts in the middle of things, in the encounters between people and in the forces at play between people and institutions. Thus, we encourage the interns to produce a ‘logbook’, not for registering chronologically a description of facts but to produce the anti-genealogy, the mapping of what was being produced as event, as rupture and as novelty in the ways stakeholders see and say that support the existence of collective spaces of life and in which the instituting potential of life can manifest itself.
With this perspective, we used two principles of the rhizome – multiplicity and anti-genealogy – to think about the internship experiences, with emphasis on two analysers produced in the encounter with reality. The proposal is to work with the rhizome concepts and principles in order to produce thoughts on the immanency of these experiences in their instituting movements. The analysers that were used were the power of knowledge and the need for detours.
Thus, instead of placing interns into the services based on the instituted ways of being a health psychologist, the experiences of internship were oriented by the search for connections that would allow for the ‘invention’ of other ways of being a psychologist, the emergence of the new precisely where the instituted revealed its failures and captures by halting the agencying necessary to produce health.
Analyser 1 – the power of knowledge: encounters between listener interns, sick users and supervising trainer psychologists
The intern thought she’d turned into a statue, but she didn’t. She spoke with anger, daring and ironic, building images without the foreseeable rebelliousness of academic speeches. She not the statue, it was what she was learning. Without history, techniques and humanisms become cement. (Baptista, 2000: 42)
At the different services where the internships happened, this first analyser emerged from the relationship of the interns with the service psychologists. Many times the interns questioned the control exerted by supervisors over their practices. This situation revealed the relations of power based upon specialists’ knowledge that disqualify different types of knowledge and refuse to take into consideration service users’ knowledge that, according to the SUS principles, should be considered, particularly for conquering autonomy. These are relations of power that insist on established representations, in the places instituted by the academy and by the field of health, tending to imprison the force of life in crystallized representations that are reproduced without change, in a relationship that is standardized and crystallized and prevents different forms of agency.
On the last supervision meeting we conducted a ‘Tale Tent’ 1 so that the interns could speak about their experiences. On this occasion, the interns, usually open and reflexive, were full of regrets, complaining about the great number of exams in their curricular disciplines. The first group to report on their experience had always been engaged in the activities but refused to speak about their performance. They had worked with a group of teenagers at Psychosocial Care Centre for children and teenagers 2 on which there was a girl of about 17 years old who frequently heard voices and talked about sadness and incomprehension. She suffered discrimination at school; at home, her grandmother–caretaker attributed hearing voices to demons suggesting that she should go to an evangelical church.
On the beginning of second semester, the service psychologist started to interrupt any interventions made by the group, and when the teenager asked about the voices, she answered that it was a psychotic crisis due to schizophrenia and that she should not give importance to it. Outside this collective space, the interns established a dialogue with the girl and she started to write a book about her life and the voices she heard. On the group meeting, she tried to show her book, but the psychologist said that it was not the moment to do so. The teenager then started to take her book to other spaces, speaking to people but keeping silent when in the ‘therapeutic group’. One of the interns tried, within the space of the group meeting, to keep an outraged silence in face of the institutional violence but began to feel that life and psychology should generate resistance to this type of violence.
At the end of the Tale Tent, this intern heard the reports of other colleagues that developed interventions out of the traditional ‘psy’ patterns that provoked tensioning on what was instituted about the professional performance. Hearing that, she said, ‘we were kept as listeners because the psychologist did not accept and gave no voice to me or to the service users’. She also questioned, ‘if I am to be accepted as a psychologist, is my job to establish diagnostics?’ The intervention and psychological knowledge inside that alleged therapeutic space hushed everybody, ‘apprentice’ interns and ‘delirious’ users, that resisted producing rhizomes on what was established.
On this particular experience one can identify the instituted marks of supervision as a training device through the exercise of control by the supervisor upon the supervised without their participation on the active construction of knowledge and practices – reflexes of the history of training in psychology (Coimbra, 1989; Severo, 2014). Another instituted trait in the professional practice of psychologists is the demand for making the diagnostic of disorders, with the objective of looking for normality and classifying ‘deviants’, thus ‘smoothing’ what is unique by fitting it into models (Lavrador, 2012).
Therefore, in the lived experiments with the interns and the tension with ‘psy’ supervisors, Deleuze and Guattari’s rhizome served as a guide when attempting to undo the dichotomies/identities of subject and object of study/intervention, as well as those of a ‘structure’ upon which the experiences should be produced. It was then possible to identify the lines of production of desires that were at stake and the lines they produce within the multiplicity of possibilities in the context in which the psychologist acts, without looking for a unity, for a fixed ‘psychologist identity’ that organizes practices. On the contrary, according to the principle of multiplicity, we seek experimentation with other ways of doing psychology in different contexts, on the possible ‘lines of flight’ for acting; we see to destabilize institutional prescriptions so that the ‘nature’ of ‘being a health psychologist’ is always changing under the scrutiny of the many combinations and arrangements (agencying!) that are built in the practice between people and institutions. ‘Agencying is precisely this growth in the dimensions of multiplicity that necessarily changes nature as it increases its connections’ (Deleuze and Guattari, 1995: 16–17).
University-based supervision during psychology internship in health services should be revised and shift towards strengthening a permanent in-service education. Both supervisions, academic and service-based, have to start from the concrete reality of health workers, taking it as an object of attention and reflection, with their active participation, sharing their conceptions and their work relations. This analytical process necessarily has to be collective so that each participant can master what is going on and is triggered by a situation (analyser) which is enabling and puts the group in analysis. Besides, the implications of the many subjects involved have to be made explicit (Merhy et al., 2006).
For this purpose, work processes may include reflexive and study groups in joint sessions (Costa and Silva, 2013): investment in regular courses and seminars, study groups and the conduction of advanced studies and research (Lobosque, 2010). In the specific case of internships, dialogue between academic knowledge and the experience of health workers must be established (Ramminger and Brito, 2011). Consequently, we stress the importance of supervision to promoting agencying, in which academic and service knowledge may be able to dialogue and suffer tensioning and analysis, creating other knowledge and ways of doing from the experience of interns, service users and health workers.
Thus, changes are necessary in the instituted ways of supervising the training in psychology and in the practice within health services – to identify symptoms and classify ‘cases’ – betting on the auto-analysis of collectives and on producing knowledge based on the singularity and the construction of group-as-subjects that exercise their ability to analyse the field of forces in which they are inserted and to resist to instituted know-how.
Analyser 2 – the need of detours: interns’ encounters with the street and the production of other ways of health practice
Experimenting with health care and clinical work during internship with homeless people was at the same time challenging and able to reveal multiple failures in the different public policies involved. It was possible to come close to the lives of the homeless due to a progressive immersion which started with work in two places: in front of a shelter where 57 people slept every day and at a town square where workshops for homeless people for the development of citizenship and for strengthening the social bonds between them are held.
The internship reports convey the difficulties of establishing a conversation circle with people on the street since they usually were under the effects of alcohol and other drugs. The distress of not knowing how ‘to do something’ and of ‘listening’ with so much noise in the street and in a circle, ‘open and in a public space’, with people ‘in an altered state’ was present all the time during supervision. The initial experience had a big impact and often had a paralysing effect on the interns who tried ‘to promote health’ in a context completely distant of psychologists’ traditional settings. Insecurity and destabilization were constant and so was the need for hearing the ‘noises’ that came from those who were under the effect of alcohol and drugs. The disorganized, tumultuous speeches in the circles were manifestations of problems upon which one could act/propose actions, precisely the noises and excesses that public services usually cannot tolerate or receive. In this setting, learning was related to perceiving other forms that thinking could assume in ‘crisis’ situations – which could be heard in its disturbing difference of the certainties each one brought from the theoretical and methodological references given at the university.
Thus, we started to discuss how to build ways of action beyond traditional clinic, trying to convene the transversality proposed by Guattari (1987), in order to support questioning and collective expression zones and the complexity present in our professional routine. To do so, the challenge was to put into operation the anti-genealogical principle (Deleuze and Guattari, 1995), according to which, instead of searching for instituted origins, one should chart the events, the uniqueness in which there is rupture and the production of difference in the ways people see and say things in a determined historical time and institutional context. In anti-genealogy, we try to identify the fields of forces at stake and the lines of the micropolitical production of the subjectivation processes, going beyond chronological milestone markers and searching for ruptures with the instituted ways of seeing and saying.
In this micropolitical production, it became possible to recognize the legitimacy of ‘disturbed ways’ of saying and thinking present when crisis was experienced on a street context and the interns were able to move and be conducted to the ‘border’ of the circles, where the people who ‘disturbed’ the workshop stayed, entering and leaving constantly the town square where the workshops were held, and that was concomitantly a space for the workshop and for the collective consumption of drugs. To be on the ‘border’ of the circle invited agencying and connections with health teams and social services, as well as with the homeless who cared for each other and were important references for charting the life potency that existed there – a place where only misery, violence and precariousness of living appeared. In this sense, we tried to dilute the hard lines that segregate and create diseases in ourselves and in the people with whom we were working, in order to connect with different states, with other ways of living. We tried to go into rhizome, as Deleuze and Guattari (1995) say, becoming open to what could be, experimenting and taking the risk of agencying this difference.
An approximation was then made with two of the teams of street clinic 3 that arrived at the town square to do their work. The ‘border cases’ were charted and the interns started to follow the homeless roaming in the network of health services, a path built together with the health teams. The majority of these people had already been seen at the local CAPS Ad, 4 but they had fragile bonds with the teams. Thus, two fronts of intervention were opened: (1) to follow the demands of people with drug addiction at other health services – demands related to different health problems, difficulty in gaining access to the services due to prejudices against the people being ‘homeless’ or ‘belonging to the streets’; (2) to follow cases within the mental health services network, particularly when, given the frailty of bonds already mentioned, a ‘lack of territory and family’ justified the teams’ failure in bonding and, hence, in structuring a psychosocial care protocol for these individuals.
These follow-up practices did not exactly fit the ideal of a ‘therapeutic follow-up’ since the ‘therapeutic’ intention, in a strict sense, was not present and interventions were aimed at being close to the homeless while encouraging them to be protagonists of the tensioning necessary to gain access to health care. At the same time, some detours from the instituted ways of health services were necessary in order to make access to care possible and to question the existing barriers, creating more flexible lines at the immanency of life in its potency. There were many barriers, such as the requirement for an address and identity card for people who did not have a house and had lost their papers while living on the streets or the institutional rules of health agents that refused to assist some people because they were ‘dirty’, ‘wearing shorts and thongs which are not allowed in the hospital’ or with ‘tuberculosis’ when equipment for personal protection were not available – forms of exclusion and prejudices that this population suffers daily. Hard lines many times prevented these subjectivities to connect in a productive way with the surrounding world and with life.
Learning, here, was related to the possibility of perceiving that in order to ‘produce health’ for highly vulnerable people as the homeless, it is necessary a lot more than the use of health technology; that care requires a ‘widening’ of the focus far beyond symptoms, complaints and illnesses and their answer in terms of technical efficacy. To produce health and care in this context requires openness to look at the many existing practices of exclusion and oppression and understanding how the health services may reproduce them, constantly placing them under scrutiny and analysis. The main challenge for the students and for the street-clinic teams was, perhaps, to make homeless population visible to local health services.
Another challenging aspect in the care of the homeless population was to create bonds as it required meeting strategies to enable follow-up. Some of the strategies developed were frequent active searches for people on their known circuits – sending messages through their ‘acquaintances’ and, less frequently, through cell phone messages – some of them did have them. In special, the intern had to become a ‘reference’ for people outside institutional walls, in a movement that many times involved frustration and failure when people they were supposed to follow ‘disappeared’ – which often happened. The interns’ performance there demanded constant negotiation with hard lines that organize and signify health services and practices – that ask for ‘fixity’ and stability to be produced – and with the interns’ own expectations acquired through training – which demanded certain prescribed ways of doing health work or psychological clinic. De-territorialization came up as a way out, as lines of flight for the production of possibilities in health and training, for the dilution of the hard lines that prevented agencying from happening, for the production of the new form.
From that perspective, it was not simply a case of ‘confronting’ what was instituted within the health services network, increasing the dichotomous fracture and the distance between homeless people and the public health services. It was necessary to build a new form of agencying capable of showing other possible practices for this population through the creation of bonds that ‘reveal’ the invisible. Thus, when a homeless person arrived at a health service in the company of an intern, barriers started to break down due to his insistent action and access to care became possible, as did the bonding with health teams of the different services they had to attend.
Regarding the relationship between the university and health services, it was possible too, on the occasion when students joined teams, to build spaces for dialogue between us, internship supervisors and interns, and local managers of primary care services. Joint definition of practices was necessary since we did not have local supervisors in the teams, only partners who received the interns when they moved around with their patients. This dialogue promoted closeness with the social assistance network, as we invited shelter managers to join in the circle. This scenario of dialogue with management and health establishments was marked not only by tensions but also by the collective creation of possibilities that micropolitical experimentation on the streets produced for the care of each service user.
On the whole, the experimentations with internships enabled ‘inventions’ of performance that were anchored on the ethics in favour of life that the adopted theoretical references defend. The need for producing roaming performance, de-territorialization and tensioning of institutions such as ‘professional training’, ‘supervision’, ‘psychology practice’, ‘health service network’ and ‘biomedical health’ permitted detours and a widening of what ‘health’, ‘clinic’ and ‘psychologist’s practice’ meant.
Thus, supervision was redefined from the demands that came up during practice, assuming the form of an inter-institutional supervision that refused to work for ‘[…] intensifying the common isolation of workers on mental health’ (Ferigato and Dias, 2013: 98) and emerged ‘[…] as a potent device of liaison, translation and potentiation’ of the diversity present in the services (Ferigato and Dias, 2013: 98). Within the scope of training, in the specific case of inserting psychology in the SUS, it was fundamental to produce, in the lived experience, detours from a supervision model that establishes hierarchy and fragmentation of knowledge in order to recognize the learning that comes from each encounter with service users, with health teams and with managers.
These two analysers, the power of knowledge and the need for detours, brought to the surface the conflicts and tensions in the field of professional training for working within the SUS, a rhizomatic health system that enfolds clashes between what is instituted and what is instituting, between hard lines and lines of flight – forces and lines present in the formative processes, in the ways psychologists act and in the ways they connect with services, users and community. It is possible, on the daily procedures of work in the SUS, to move away from what is crystallized and hardened, betting on invention.
Final considerations
As seen in the experiences reported here, public health in Brazil is composed of different forces that associate relations of power, knowledge and non-knowledge, values of each profession and the socio-political scenario. We believe that it is on the intercession of these forces that the need for invention springs up and that it is on the destabilization of our certainties that instituting becomes potentiated. Thus, it is fundamental that one analyses critically psychology training and internships and the effects of professionals’ interventions for strengthening or weakening the SUS goals as a public service of quality. In this direction, internship experiences on health services are a privileged scenario for questioning the limits and fragilities of professional training and practice in psychology with regard to the Brazilian reality.
The experiences briefly discussed in this article present different modes of insertion of psychology interns on the public health services (and also social assistance ones) and in the city, developing user-centred interventions and producing tensions that are necessary for the transformation of both, what is instituted in the services and the ways of inhabiting the city that undermine care in contexts of high vulnerability and reproduce social exclusion. Collective spaces for reflection about the experiences in health services and on the streets, with health teams, managers and users, are the basis for producing instituting movements that bet on health and life.
On the other hand, the experiences also put on trial the training in psychology for working in public health services, indicating its current limits and the need for ethical-political principles that are able to expand perspectives and promote the practices’ inventions/detours that are necessary in different contexts. We conclude that psychology training must be focused increasingly in performing an expanded clinic that requires a critical and active stance in order to sustain the encounter between academic knowledge and ethical, libertarian practices. If reality is not given, but is something to be built, one should be attentive to one’s insertion in work spaces, to one’s practices and their effects since they can imprison, reinforcing what exists and keeping lives in their precariousness, or produce a new reality, freeing and increasing the potency of lives.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.