Experiences in the health services network and in the street: Captures and detours in psychology training for public health services

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.