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The Royal College of Psychiatrists Improving the lives of people with mental illness

Psychiatry in Minas Gerais, Brazil

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27/01/2014 12:25:05

Psychiatry in Minas Gerais, Brazil


“First there is the word; as soon as the first word is noted down we have already started to create the concrete. The word is the concrete in fact.”


Lais Mendes Guimarães
 


Brazil was the first country I studied in geography at school. I still remember the, then, shocking size of its cities and especially the megalopolis of Belo Horizonte in Minas Gerais, where several small cities had melted into a giant. I’ve since become a habitual visitor to Brazil, and my friends talk about Minas with peculiar warmth – an affection for its people, as if they were the true heart of country.
 

Mariana and Ouro Preto are historic cities in Minas, dating from the 1700s, famous for gold and churches, portrayed in guidebooks with a picture of a vertiginous street rising up into mist from the green valley below. They played an important part in history:  the rush for gold and the exploitation of minerals, slavery, the short-lived reign of the Emperors and the doomed uprising of Tiradentes. They were so different from the Brazil of beaches and big cities that I’d already visited, so when I made contact with a Psychiatrist called Lais from Mariana, and the possibility of observing and learning a bit about Psychiatry in Brazil arose, I seized it with both hands.
 

I flew into Belo Horizonte – a hilly, planned city of wide avenues. Somehow I’d been expecting it to be flat – maybe the name, or my imagination from geography lessons, had something to do with it. Rodrigo picked me up at the bus terminal in the centre and we left the clogged traffic of the megalopolis behind and turned towards the hills. It was raining. Rodrigo explained that the hills, though green, lacked vegetation because the porous soil leaches nutrients. There was red dust, which the rain had turned to mud, everywhere – coating the roads, the cars, the bushes. Minas Gerais means General Mines but I’d learnt had long run out of its precious stones; these mines were very much active however and Rodrigo told me half of Brazil’s iron ore came from these hills. They were beautiful, even in the rain.
Ouro Preto


When the road entered Ouro Preto it became a fairground ride – white colonial buildings lining  impossibly steep streets, and a baroque church appeared to be topping every hill. Mariana, by contrast was calmer, lower, slightly flatter. Here the churches were the real stars, having less competition than in Ouro Preto. Apparently, it was from Mariana that the Vatican maintained its control on Ouro Preto’s gold.

Lais Mendes Guimarães, who had invited me, is a true General Psychiatrist. She divides her time between a CAPS (Centro de Apoio Psychosocial – a community mental health team equivalent) service in Ouro Preto and a Polyclinic where she works in Matriciamento (a kind of Primary Care Psychiatry service) in Mariana, so I was going to get a taste of both.

27/01/2014 12:30:58

Matriciamento in Mariana

“Matriciamento or matrix support is a new way of generating health, in which two or more teams, in a process of shared construction, create a proposal of educational-therapeutic intervention.”

Guia Pratico Matriciamento Saude Mental


My first encounter with Brazil’s health system was in a polyclinic atop a hill in Cabanas in Mariana. Cabanas was once a favela, or at least was a bit of the town which grew in an unplanned way, and the residents of Mariana tend to stigmatise its residents, even though they form the great bulk of the municipality. Inside the long white concrete building, two things grabbed me – the clean efficiency of the place, and the lack of computers.

 

We soon began a discussion with the team, composed of health workers who went out and actively engaged with families in the district and brought them to health appointments, a bit like an assertive-outreach team for all aspects of health. They worked for a basic salary and were school educated to 18. As well as the Psychologist who came with us there was also a highly organised nurse and the “GPs” who were pre-specialisation medical trainees popped their head in when there was a patient of theirs to discuss. A paediatrician called in to discuss why she had concerns about a child.

Our discussions and the case-mix were very wide-ranging, from a woman in a psychotic crisis who had thrown a stone at the building the day before, to people with problems with drugs and alcohol, depression, and the usual Psychiatric disorders. There were a lot of referrals of children - maybe 40% and the child Psychiatry service Crescer struggles to cope, so some were allocated to be seen initially by the Psychologist from our team.

The guidelines to Matriciamento talk about the teams working as a network of horizontal practitioners, all ready to catch the patient as they fall into ill-health and move them on to the most relevant part of the net – all teams being equal, all doing their part educating one another.  To me it seemed an efficient system, if one that takes a high-toll on the workers directly exposed to the fears and feelings of the families that they’re involved with and from whose milieu they come. The Psychiatrist and Psychologist took on a role of sages, dispensing wisdom, physical health advice, signposting to various agencies, as well as a great deal of evaluating the response of people to life-events and family stresses and breakups. The nurse coordinated, kept count, organised.

The guide to how to set up Matriciamento talks about moving the discussions away from the illness to the patient in a more holistic way and so from ill-health to health.  What I saw was a team that appeared embedded in the life of its patient or users, prepared to get involved with their family dynamics, to help them get financial and practical support and to achieve health in its fullest definition. It is demanding, asking a bit more of everyone than they are trained to do: for example the basic health workers need to be confidantes, friends, a substitute for the Psychiatrist when they are not present, the nurse has to coordinate, to be a bit of an administrator, the Psychiatrist needs to be a font of wisdom about almost anything, and to be an unofficial leader in an ultra-democratic system. The roles of Psychiatrist and Psychologist appear to have a degree of interchangeability about them, possibly more than in the UK. The rewards are a system that appears, superficially from the outside, to work and to offer patients a level of healthcare that approximates that in the UK, with far less paperwork or bureaucracy.

 

An Away Day

Lais was a bit nervous about the away day. A lot of different teams had been asked along, all with some connection to primary care services. A lecture about suicide risk, turned as they frequently do, into gruesome stories of overheard suicides or personal offloading of experiences. It felt like any mental health service I’d ever worked in. Two presentations on Matriciamento led to a discussion about the services of the polyclinic and the CAPS and suddenly a room which had seemed largely homogenous turns into two teams with their own dynamics and persecutory ideas.

 

The subject of flow between the teams is the thorniest; one of the polyclinic doctors said he’d referred to CAPS, only for his patient to be turned away. The CAPS team in turn became protective. I felt as if I was back in my own work, confronted by a GP surgery or a complaining relative. Lais intervened gently, bridging the two services, talking about a net which must try and catch the fish wherever it falls, a net which tries to adapt to the inevitable holes in it. The discussion turned to the ambulance service, the SAMU, which was reluctant to transport Psychiatric patients without a police escort. And again there was an echo of my own service, but more importantly the people in the room had found a common enemy and the tensions of earlier began to dissolve.

 

27/01/2014 14:56:32

CAPS-AD

It took us some time to find CAPS-AD in Ouro Preto. The drug and alcohol service was having an open day, which had been well-published with leaflets; there were going to be lectures and a sale of products made by the service users. Lais and I wandered the steep streets of Ouro Preto, first in her car that managed the cobbled hills without a single slip of a tyre, until we eventually hit upon a lorry offloading, and we had to continue on foot. The district was poor, originally the home of liberated slaves. We encountered one of Lais’ patients who greeted us warmly and offered to take us to the CAPS-AD. Lais was again comforted by the feeling of her patients watching over her, protecting her, maybe reinforcing her place in the wider network of her town’s society where she plays such an important part.

The Garden at CAPS-ADThe drug and alcohol service was located in a large villa with a garden. Users worked tending plots of vegetables and there was a small stall of colourful objects made by them for sale under the downstairs veranda. Inside, university students gave presentations on the fat and sugar content of food, on oral hygiene, on cleaning your home water tank, on caring for your baby. The oral hygiene exhibition was giving away free toothpaste and brushes and was especially popular. We joined the service users in a lecture about sexually transmitted diseases that had them engaged and joining in. A nurse gave a condom demonstration and I was transported to being back at school. Afterwards I went with Lais to explore the town of Ouro Preto and the place where the dentist Tiradentes was hung, drawn and quartered for his “bourgeois uprising” against the taxes of Portugal. We ran into a man offering his services as tourist guide. Lais quickly made her excuses; he was an ex-patient, one that the team had desperately tried to engage. He had quite marked psychotic ideas about the substantial student population in the town and had a history of threatening behaviour towards them. The team had made immense efforts to keep him engaged but he would have nothing to do with them anymore, and his family were oblivious of his ideas. For now Lais and her team could do nothing.


 

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Dr Dewi Pritchard

Dr Dewi Pritchard


Dr Dewi Pritchard is currently a Consultant Psychiatrist in East London, with an involvement in medical education, and the SUD-World project which promotes educational exchange with mental health organisations in Latin America.

He has an interest in languages and writing, and has recently been learning Brazilian Portuguese.