CAPS psychosocial care centres (Brazil)

1. Introduction

Version followed: Brazil's national federal model. That means the Rede de Atenção Psicossocial (RAPS) ordinance, Portaria GM/MS 3.088/2011, the Ministry of Health manual Saúde Mental no SUS: os Centros de Atenção Psicossocial (2004), and the list of CAPS actions in Portaria SAS/MS 854/2012 (as reproduced in the Ministry's 2013 CAPS/UA manual), all read within Law 10.216/2001. Crisis procedures come from one named service, CAPS III Adulto Brasilândia (São Paulo), and are marked as such. Later consolidations and amendments of the RAPS ordinances (e.g. Portaria de Consolidação nº 3/2017 and the 2017 changes that added new service types) are not drawn on [uncertain].

What it is. A CAPS (Centro de Atenção Psicossocial) is not a single therapy. It is a public, open-door, community-based mental health service of Brazil's SUS. Its multiprofessional team provides daily care to people with severe and persistent mental disorders and to people with problematic alcohol or drug use, and it was designed to replace psychiatric hospital admission [source: MS 2004; Portaria 3.088 Art. 7]. CAPS are the strategic hub of the RAPS. They receive people in crisis, coordinate each person's Projeto Terapêutico Singular (PTS, the individualised care plan), support primary care through apoio matricial (matrix support), and organise the local network [source: MS 2004; Portaria 3.088 Arts. 2, 7, 8].

Core idea of change. Change happens in the person's territory, not in an institution. That territory includes the neighbourhood, relationships and daily life. Care builds on a trusting bond (vínculo) with a reference professional, on collective activities, and on restoring the person's ties, rights and social participation (work, housing, culture, citizenship) [source: MS 2004; Portaria 3.088 Art. 2]. Crisis is treated as a rupture in the person's life and relationships that can open space for change. It is managed in freedom, with the person's support network, rather than corrected by confinement [source: CAPS III Brasilândia, Atenção à Crise].

Who this guide is for. It is written for a psychotherapist working in a CAPS team (often as a psychologist, one of the "higher-level" professionals) or working with one (referring, receiving matrix support, sharing a PTS). No personal certification or licence exists for delivering "CAPS": the service as a whole is set up and funded by the health authorities, and staff work under their own professional councils. The national accreditation procedure (habilitação) is not drawn on [uncertain].

Modalities [source: Portaria 3.088 Art. 7 §4; hours and minimum teams from MS 2004]:

"Higher-level" professionals include psychologists, social workers, occupational therapists and pedagogues. Mid-level staff include nursing technicians, administrative staff, educators and craft instructors [source: MS 2004].

2. Framework

CAPS care is not divided into a fixed number of sessions. It is a continuous pathway whose intensity changes with need. The stages below are an organising sequence assembled from the sources. The labels "Stage 1–5" are my own [synthesis]; their contents are sourced.

Stage 1. Access and acolhimento (reception).

• Goal: receive anyone who arrives, understand the situation broadly, begin a bond and decide the next step.
• Format: people come on their own or are referred, preferably to the CAPS covering where they live. There is no waiting list and no requirement of a referral letter. The first contact is a welcoming, listening encounter, in which a diagnosis is useful but not the goal. If the person is isolated at home, a home visit can be made with the Family Health team when a relative or neighbour asks [source: MS 2004]. Initial acolhimento also covers people arriving in crisis [source: Portaria 854/2012 via MS 2013].
• Exit criteria: either the person fits the CAPS profile (severe or persistent distress, or problematic substance use, that stops them living their life) and moves to Stage 2, or they are referred to the right point of the network with the referral followed through [source: MS 2004; MS/CNMP 2014].

Stage 2. PTS construction and reference professional.

• Goal: agree an individualised plan of activities inside and outside the CAPS, and name a terapeuta/técnico de referência (reference therapist or worker, TR).
• Format: the team, the user and the family build it together, and it is reviewed periodically [source: Portaria 3.088 Art. 7 §3; MS 2004]. A PTS typically moves through four moments: assessment or hypothesis, goal-setting, division of responsibilities, and reassessment [source: Caçapava Roteiro, citing MS 2007 Clínica ampliada].

Stage 3. Care at the right intensity [source: MS 2004]:

• Intensive: daily attendance, for people in crisis or with serious difficulty in family or social life.
• Semi-intensive: up to 12 days a month, for people who have improved but still need direct team support to regain autonomy.
• Non-intensive: up to 3 days a month, for people who no longer need continuous support to live in the community.
• All three regimes can be delivered at home. Frequency is flexible and depends on the PTS, access to the service, family support and community or work involvement. These regimes originate in an earlier ordinance (Portaria 336/2002) [uncertain].
• Moving between regimes: follows the criteria above and is decided in PTS review with the user.

Stage 3a. Crisis care (entered at any point).

• Goal: manage the crisis in freedom and avoid psychiatric admission.
• Format: intensified daily care, home care, and day or night reception (acolhimento diurno/noturno). Night or weekend reception is limited to 7 consecutive days or 10 non-consecutive days in 30, preferably for users already in a PTS [source: MS 2004]. A CAPS III or CAPS AD III provides 24-hour reception [source: Portaria 3.088].
• Exit criteria: the acute situation is resolved, a crisis plan is agreed and added to the PTS, and care steps down [source: CAPS III Brasilândia]. Hospital admission is used only when extra-hospital resources are insufficient [source: Law 10.216 Art. 4].

Stage 4. Psychosocial rehabilitation in the territory.

• Goal: restore contractual power and participation.
• Format: work and income projects, housing (therapeutic residences, transitional units), education, culture, rights, and protagonism in assemblies and associations [source: Portaria 854 via MS 2013; Portaria 3.088 Arts. 9, 11].

Stage 5. Transition to shared or primary care.

• The CAPS or primary care coordinates longitudinal follow-up, and matrix support keeps the CAPS involved after transfer [source: MS 2013; MS/CNMP 2014].
• The sources give no formal discharge criteria [uncertain]. A practical rule: step down to primary care with matrix support once the person has spent a sustained period in the non-intensive regime, has a crisis plan, has an active support network outside the CAPS, and agrees to the move [synthesis].

Daily service structure [source: Portaria 3.088 Art. 7 §2; MS 2004]:

• Activities happen mainly in collective spaces: groups, workshops and user assemblies.
• The team meets daily.
• Meals are provided: one per 4-hour shift, two per 8-hour day, four for 24-hour stays.
• A weekly assembly of users, staff, families and guests discusses how the service runs.

3. Guiding principles

Principles from the RAPS ordinance (Art. 2) and Law 10.216, each with my one-line practical reading [source: Portaria 3.088 Art. 2; Law 10.216 Art. 2; practical readings are synthesis]:

• Respect for human rights, autonomy and freedom. Ask, negotiate and record the person's preferences before acting. Coercion is an exception that you must justify.
• Equity and social determinants of health. Treat lack of income, housing, documents or schooling as clinical targets in the PTS, not as background.
• Combating stigma and prejudice. Use the person's name and their own words, not diagnostic labels, in meetings and records. Work against exclusion in schools, workplaces and families.
• Comprehensive, multiprofessional care. No single profession owns the case. Your psychotherapy is one strand of a PTS.
• Humanised care centred on the person's needs. Begin with what the person and family say they need, not with what the service has on offer.
• Diversified care strategies. Offer several routes, such as individual, group, workshop, home, territory and family work, and change the mix as needs change.
• Territory-based activity for inclusion and citizenship. Hold a share of your contacts outside the building: at home, in the neighbourhood, in community spaces.
• Harm reduction. Set substance-use goals with the person. Abstinence is not a precondition for care [also MS 2004 on CAPS AD].
• Community base with user and family participation and social control. Bring service decisions to the assembly. Invite families in as partners.
• Regionalised, intersectoral network. Every PTS should name the other services involved (primary care, social assistance, education, justice) and who links with each.
• Continuing education. Use team meetings and clinical-institutional supervision for case learning.
• The PTS is the central axis of care. Every intervention should trace back to an agreed, reviewed plan.
• Least invasive setting; community care preferred; admission only when extra-hospital resources are insufficient [Law 10.216 Arts. 2, 4]. Before any admission, record which community options were tried and why they were not enough.
• Right to information and to a doctor at any time [Law 10.216 Art. 2]. Explain diagnosis, treatment and rights plainly, and tell the person and family that they hold these rights.

Principles from the Ministry manuals and CAPS practice:

• Bond over diagnosis [MS 2004]. In the first contacts, prioritise trust and understanding. Diagnosis can wait.
• The bond decides the reference professional [MS 2004]. The TR can change if another worker holds a stronger bond.
• Open door, literal and symbolic [MS 2013]. Avoid locked doors and admission barriers, and let people come and go.
• Collective spaces first [Portaria 3.088 Art. 7 §2]. Use groups, workshops and assemblies by default, and individual sessions where the PTS calls for them.
• Families are partners [MS 2004]. Plan family contact from the start, while respecting what the user consents to.
• Universal reception, no "não tem perfil" ("not our profile") refusals [MS/CNMP 2014, for children and adolescents]. Assess and give an initial response to everyone, even when the case will be followed elsewhere.
• Committed referral (encaminhamento implicado) [MS/CNMP 2014]. Follow a referral through until the other service has actually received the person.
• Each case is singular (cada caso é um caso) [MS/CNMP 2014]. Build each PTS from scratch rather than from a diagnostic template.
• Shared definition of demand [MS/CNMP 2014]. Not every form of suffering needs ongoing health care. Some needs are better met by education, social assistance or culture.
• Decisions in crisis are shared [CAPS III Brasilândia]. Decide with the user and their support network, not by technical authority alone.
• Timely access prevents admission [CAPS III Brasilândia]. Same-day response to a crisis matters more than any single technique.
• Critical, negotiated use of medication [CAPS III Brasilândia; GAM]. Medication is a tool to discuss, not a cure, and the user takes part in decisions about it.

4. Intervention inventory

The official list of CAPS actions is the one in Portaria SAS/MS 854/2012, reproduced in MS 2013. The 2004 manual adds the activity types it groups under them. Each action below is named as in the sources. Step-by-step procedures are only partly specified in the national documents, so steps not found in a source are marked [synthesis]. All example language is illustrative.

4.1 Acolhimento inicial (initial reception)

• Purpose / when: the first contact for anyone who arrives, whether walking in, referred, or brought in crisis. It aims to understand the situation broadly and start a bond [source: MS 2004; Portaria 854 via MS 2013].
• Steps:
  1. Receive the person the same day, without requiring a referral letter or appointment [source: MS 2004, open door].
  2. Listen to the person's own account of what is happening and what they want. Ask about the family as well [source: MS 2004].
  3. Explore the life context: housing, income, work or school, relationships, substance use, past care and admissions, and current risk [synthesis].
  4. Decide jointly whether the CAPS is the right service [source: MS 2004].
     • If it is: agree first activities and a provisional reference worker, and set the date for the PTS discussion [synthesis on timing].
     • If not: make a committed referral and confirm the other service actually receives the person [source: MS/CNMP 2014].
  5. Record the encounter and bring it to the daily team meeting [synthesis].
• Example language (illustrative): "You don't need to have a diagnosis or a referral to be here. Tell me what has been happening, in your own words." / "Who else in your life knows about this, and who would you want involved?"
• Watch for: turning acolhimento into triage that screens people out. The CAPSi guidance explicitly rejects "não tem perfil" refusals [MS/CNMP 2014]. Also watch for risk that needs same-day crisis care (see 4.9).
• Working when: the person comes back, names a contact person in the team, and has a next step agreed.

4.2 Construction of the PTS (Projeto Terapêutico Singular)

• Purpose / when: after acolhimento for everyone followed by the CAPS; revisited periodically and after any crisis. The PTS is "the central axis" of care [source: Portaria 3.088 Art. 2 XII]. It is a set of activities inside and outside the CAPS tailored to the person [source: MS 2004].
• Steps (four moments, as in the Ministry's Clínica ampliada framework, via the Caçapava Roteiro):
  1. Assessment / hypotheses. Cover the organic, psychological and social picture. Identify risks and vulnerabilities, and how the person relates to illness, desires, work, culture, family and network. Useful tools:
     • a genogram;
     • an ecomap of the person's links with family, community and services;
     • the person's or family's explicit request;
     • the "unsaid" (the implicit context of the request);
     • a review of what earlier care did and its effects.
  2. Goals. Set short-, medium- and long-term goals. The team member with the strongest bond negotiates them with the person.
  3. Division of responsibilities. Write a table of date, goal, who does it, deadline and date achieved. Give one committed person per action, without loading every action onto a single worker.
  4. Reassessment. Review on a date set by the team according to need, and correct course.
• Participants: the team, the user and the family build it together [Portaria 3.088 Art. 7 §3]. Other services involved should be named and invited (primary care, CRAS/CREAS social assistance, school, Conselho Tutelar, justice) [Caçapava Roteiro; MS/CNMP 2014].
• Example language (illustrative): "If things were going better six months from now, what would be different in an ordinary day?" / "So: you'll go with Ana to the CRAS on Tuesday about your ID card; I'll call your sister; the doctor will review the medication on the 20th. We'll check together in a month."
• Watch for: a PTS written by the team about the person rather than with them, goals that are only symptom-based, and no named owner or date.
• Working when: goals are in the person's own words, actions get done by the named people, and reviews actually happen.

4.3 Reference therapist / worker (terapeuta or técnico de referência)

• Purpose: one professional, often the person who did the acolhimento, monitors the PTS with the user, adjusts activities and frequency, keeps in contact with the family, and leads periodic goal review with the user and the team [source: MS 2004].
• Steps:
  1. Name the TR at the PTS meeting.
  2. Have regular one-to-one contacts on a frequency set by the care regime [synthesis].
  3. Be the family's point of contact.
  4. Bring the case to team meetings for review.
  5. Coordinate the other professionals and services involved [synthesis].
  6. Hand over to another worker if the bond is stronger elsewhere. The role is not necessarily permanent [MS 2004].
• Example language (illustrative): "I'm your reference here. If something changes, or a group isn't working for you, come to me first and we'll rethink the plan."
• Watch for: the TR becoming the only carer, which creates burnout and dependency. Some CAPS share a TR with an outreach worker, as in the Ministry's case example [MS/CNMP 2014].

4.4 Individual care (atendimento individual)

• Purpose / when: to build or carry out the PTS, including clinical follow-up [source: Portaria 854 via MS 2013]. The 2004 manual lists medication, psychotherapy and guidance (orientação) [source: MS 2004]. The national documents do not prescribe a psychotherapy model [uncertain]. Use your own evidence-based method within the PTS.
• Steps [synthesis]:
  1. Agree with the person the focus of your sessions and how they link to the PTS goals.
  2. Agree a session frequency consistent with the care regime.
  3. Report progress at PTS review, with the person's knowledge.
• Watch for: individual therapy displacing collective and territorial activities. The ordinance gives collective spaces priority [Portaria 3.088 Art. 7 §2].

4.5 Group care (atendimento em grupo)

• Purpose: collective activities that build sociability, belonging, autonomy and citizenship [source: Portaria 854 via MS 2013]. Examples the 2004 manual lists:
  • therapeutic groups;
  • sports groups;
  • reading and discussion groups;
  • producing a newspaper [source: MS 2004].
• Steps [synthesis]:
  1. Define the group's aim, whether open or closed, frequency, and who coordinates.
  2. Agree a group contract at the start. GAM groups, for example, open with a contrato de convivência (living-together agreement) covering confidentiality, timing, phones and photos, revisable by the group [source: GAM-UFU].
  3. Link each member's participation to their PTS.
  4. Review attendance and fit at the team meeting.
• Example language (illustrative): "Before we start, let's agree together how we want this group to work: what stays in the room, and what we do if someone needs to leave."

4.6 Therapeutic workshops (oficinas terapêuticas) and expressive and communicative practices

• Purpose: to widen the person's expressive repertoire and access to culture, and to build skills and social ties [source: MS 2004; Portaria 854 via MS 2013]. Run by a professional or monitor. Three types [MS 2004]:
  • Expressive: visual arts, body expression, dance, verbal expression, music, photography, theatre.
  • Income-generating: cooking, carpentry, sewing, crafts, ceramics. These may or may not match the person's former trade.
  • Literacy: for people who never had schooling or could not continue it.
• Steps [synthesis]:
  1. Offer workshops according to the person's interests recorded in the PTS.
  2. Set a regular weekly slot.
  3. Where possible, connect products and performances to community venues and markets, so that the workshop leads outward to culture, school or income projects (see 4.12).
• Watch for: workshops becoming time-filling with no link to the person's goals or to the territory.

4.7 Body practices (práticas corporais)

• Purpose: activities that support body awareness, self-image and psychomotor coordination [source: Portaria 854 via MS 2013]. Concrete formats (e.g. walking groups, dance, sport) are not specified beyond the 2004 manual's mention of sport and body expression [uncertain].
• Steps [synthesis]: offer them in groups, preferably in public community spaces such as parks or sports courts, and adapt them to the person's physical health.

4.8 Family care (atendimento para a família)

• Purpose: individual or group support to families that shares responsibility for care [source: Portaria 854 via MS 2013]. Families are "partners in treatment" and are invited to:
  • family groups;
  • individual family support;
  • home visits;
  • assemblies;
  • family associations;
  • work and community projects [source: MS 2004].
• Steps [synthesis]:
  1. Map the family with a genogram during PTS assessment.
  2. Agree with the user what may be shared.
  3. Invite the family to the PTS meeting and to a family group.
  4. Name the TR as the family's contact.
  5. Respond to family crises the same day, by phone or home visit.
• Example language (illustrative): "You know him best outside these walls. What have you noticed helps when things start to go wrong?"
• Watch for: the family being used only as an informant or controller of medication, carer exhaustion, and violence within the family (activate the protection network; see section 5).

4.9 Crisis care (atenção às situações de crise)

• Purpose / when: to manage crises in the service, at home or in other meaningful places, with attentive listening [source: Portaria 854 via MS 2013]. Managing crises well is central to avoiding psychiatric admission [MS 2004]. CAPS receive people in the acute phase and coordinate any need for hospital or transitional residence [Portaria 3.088 Art. 8].
• Steps (as practised at CAPS III Brasilândia, São Paulo; one service's protocol, not a national standard):
  1. Identify crisis. Their working criteria, adapted from Dell'Acqua and Mezzina (Trieste), treat a situation as a crisis when three or more of six features are present:
     • severe acute psychiatric symptoms;
     • serious rupture of family or social relationships;
     • refusal of treatment while still accepting contact;
     • obstinate refusal of contact;
     • an alarm situation at home or in the community that the person cannot cope with alone;
     • risk in the territory (a local addition, reflecting urban violence).
  2. Respond quickly. Fast access is treated as the key to avoiding admission. A crisis team attached to the daily duty roster (psychologists, nurses, physical educators, psychiatrists) coordinates intensified care.
  3. Hold network meetings from the first contact. These are dialogic meetings with the person and their support network, inspired by Finnish Open Dialogue. The decision about the acute situation is made jointly by the user, the network and the service.
  4. Choose the care setting using an agreed crisis flowchart. The team agrees in advance where a person in crisis goes, to avoid gaps in care. The decision considers the support network, access to the proposed care and severity. Options:
     • full-time reception at the CAPS (acolhimento integral);
     • day reception;
     • intensified care in the territory.
  5. Use medication critically, weighing its psychoactive effects rather than expecting a cure, and in line with GAM (see 4.18).
  6. Track everyone in full-time reception on a shared kanban board, which organises team discussion and feeds the PTS.
  7. After the acute phase, agree a written Plano de Crise (crisis plan) among workers, the person and the network, and add it to the PTS. [source: CAPS III Brasilândia, Atenção à Crise]
• Example language (illustrative): "We'd like to meet with you and the people who matter to you, today if possible, and decide together what happens next." / "When things got this bad before, what helped and what made it worse? Let's write that into your crisis plan."
• Watch for:
  • suicide or violence risk, assessed with standard practice and documented. If there is a suicide risk, do lethal-means counselling with the family, covering safe storage or removal [synthesis];
  • medical causes of the crisis, such as intoxication, withdrawal or physical illness. These may need SAMU 192, an UPA 24h or a hospital emergency department [Portaria 3.088 Arts. 5, 10];
  • escalation to coercion. The sources do not cover restraint or involuntary measures in the CAPS [uncertain]. If any coercive step is contemplated, document why less restrictive options failed (Law 10.216 Art. 4) [synthesis].

4.10 Day and night reception (acolhimento diurno e/ou noturno)

• Purpose / when: hospitality in the CAPS to give respite from conflictual situations, restore interpersonal, family and community ties, or meet intensive clinical needs [source: Portaria 854 via MS 2013; MS/CNMP 2014].
• Steps:
  1. Reserve night or weekend stays for serious distress or to prevent a crisis from escalating, preferably for users already in a PTS [MS 2004].
  2. Limit stays to 7 consecutive days or 10 non-consecutive days in 30 [MS 2004]. 24-hour reception is in CAPS III and CAPS AD III [Portaria 3.088].
  3. Provide meals as set out in Section 2 [MS 2004].
  4. For children and adolescents, encourage family presence, but guarantee access even without it [MS/CNMP 2014].
• Watch for: reception turning into de facto admission. Plan the exit from day one [synthesis].

4.11 Home care (atendimento domiciliar)

• Purpose: care in the person's or family's home to understand their context and relationships [source: Portaria 854 via MS 2013]. Also used to reach isolated people when a relative or neighbour asks, coordinated with the Family Health team [MS 2004]. Any care regime can be delivered at home [MS 2004].
• Steps [synthesis]:
  1. Agree the visit with the person if possible.
  2. Go in pairs, ideally with the community health agent who knows the household.
  3. Observe the living conditions and the relationships in the home.
  4. Agree one concrete next step.
  5. Record what you saw in the PTS.
• Example language (illustrative): "Your mother asked us to come by. We're not here to take you anywhere. We wanted to hear from you how things are."

4.12 Psychosocial rehabilitation actions (ações de reabilitação psicossocial)

• Purpose: to strengthen users and families through work, income, housing, education, culture and rights [source: Portaria 854 via MS 2013]. The 2004 manual adds social support: job placement, documents and rights [MS 2004]. The RAPS rehabilitation component includes work and income initiatives, solidarity enterprises and social cooperatives [Portaria 3.088 Art. 5].
• Steps [synthesis]:
  1. Include at least one goal on work, housing, education or culture in each PTS.
  2. Help the person get documents and benefits.
  3. Link them to local cooperatives or solidarity-economy projects.
  4. For people discharged after long hospital stays, arrange the De Volta para Casa allowance [source: Portaria 3.088 Art. 11 §3; Law 10.708/2003] and a therapeutic residence (see 4.19).

4.13 Promoting contractual capacity (promoção de contratualidade)

• Purpose: to accompany users in the settings of daily life (bank, market, school, public services, work) so they can widen their capacity to negotiate, their networks and their autonomy [source: Portaria 854 via MS 2013].
• Steps [synthesis]:
  1. Choose with the person one real-world task they find hard.
  2. Accompany them once, modelling and coaching.
  3. Next time, wait nearby while they do it.
  4. Then debrief only.
• Example language (illustrative): "This time I'll come with you to the bank and you do the talking. I'm there if you get stuck."

4.14 Strengthening protagonism and the assembly (fortalecimento do protagonismo; assembleia)

• Purpose: user and family participation in managing the service and the network, rights advocacy and associations [source: Portaria 854 via MS 2013]. The assembly, ideally weekly, brings together staff, users, families and guests to discuss and improve how the service runs [MS 2004]. MS 2013 calls it an important strategy for making the CAPS a place of convivência (living together).
• Steps:
  1. Hold the assembly at a fixed weekly time [MS 2004].
  2. Rotate chairing and minute-taking among users [synthesis].
  3. Bring decisions back and report on them at the next assembly [synthesis].
  4. Support users to form or join associations and health councils (social control) [Portaria 3.088 Art. 2; mechanics synthesis].
• Watch for: staff dominating the agenda, or complaints raised in the assembly going unanswered.

4.15 Intra- and intersectoral network articulation, and committed referral

• Purpose: linking the person's care with health, education, justice, social assistance, human rights and community resources [source: Portaria 854 via MS 2013]. Referral must be followed until the person is actually received, and is never just a form [MS/CNMP 2014].
• Steps:
  1. List every service in the PTS with a named contact person [Caçapava Roteiro].
  2. Phone or accompany the person to the first appointment [synthesis].
  3. Hold joint case meetings, for example with the Family Health team and CREAS [MS/CNMP 2014 case example].
  4. For children and adolescents, work with the school, the Conselho Tutelar and the justice system. Keep measures that remove a child from home or restrict their liberty exceptional and brief [MS/CNMP 2014].

4.16 Matrix support (matriciamento / apoio matricial)

• Purpose: systematic on-site support to primary care, emergency and hospital teams, including case discussion [source: Portaria 854 via MS 2013]. It means shared responsibility for cases, joint home visits and consultation on complex cases, and it is explicitly not a referral chain [MS 2004]. The manual suggests one mental health matrix team per 6–9 Family Health teams where coverage is large [MS 2004].
• Steps:
  1. Hold regular matrix meetings with each Family Health team, on a fixed date [MS/CNMP 2014].
  2. In the meetings, discuss cases and build or adjust shared PTSs [source: Caçapava Roteiro].
  3. Offer joint consultations and joint home visits [MS 2004].
  4. Agree who keeps longitudinal care [synthesis]. The Guia Prático de Matriciamento em Saúde Mental (Chiaverini et al., 2011) gives detailed procedures for joint consultation, interconsultation, genograms and ecomaps, but it is not drawn on here [uncertain]. Those procedures are not reproduced here.
• Example language (illustrative, to a Family Health doctor): "Let's see Mr. Silva together this week. You keep following him, and we'll work out the plan between us."

4.17 Harm reduction and CAPS AD care

• Purpose: actions to minimise the harms of psychoactive substance use, including for people not in contact with the health system [source: Portaria 854 via MS 2013]. CAPS AD offers individual, group and home care, plus 2–4 beds for rest and detoxification, and works on prevention and harm reduction with goals "not limited to total abstinence" [MS 2004]. Hospital beds are for severe withdrawal and intoxication [Portaria 3.088 Art. 10]. Unidades de Acolhimento offer residential stays of up to 6 months for people with drug-related needs who are socially vulnerable. The reference CAPS alone decides admission and writes the PTS [Portaria 3.088 Art. 9].
• Steps [synthesis, consistent with sources]:
  1. Ask about the person's own goals for their use.
  2. Agree concrete safety steps.
  3. Link the person to street outreach (Consultório na Rua) and primary care for physical health [Portaria 3.088 Art. 6].
  4. Use day or night reception in CAPS AD III for periods of high risk.
  5. Use outpatient detoxification in CAPS AD when medically appropriate [MS 2004]. Medical protocols are outside this guide.
• Example language (illustrative): "You don't have to stop to come here. What would you like to change first about how you use?"

4.18 Medication management and GAM (Gestão Autônoma da Medicação)

• Purpose:
  • Medication needs are reviewed regularly with the team. The CAPS may organise dispensing and advise families [MS 2004].
  • GAM is a Brazilian adaptation of a guide from Quebec (origin not confirmed in the sources [uncertain]). It is used in CAPS groups to support users' informed participation in decisions about their medication [source: GAM-UFU, citing Onocko Campos, Passos, Palombini et al., 2014]. CAPS III Brasilândia uses it in crisis care.
• Steps:
  1. Run a group with a moderator, who holds a space for listening, questioning and collective construction [GAM-UFU].
  2. Open with a group agreement (contrato de convivência).
  3. Work through the guide's steps in the version followed:
     • getting to know yourself, in the spirit of its slogan that you are a person and not an illness;
     • observing your own daily life and quality of life;
     • widening autonomy: support network, SUS rights, medical reports;
     • talking about psychiatric medicines: names, prescription types, effects and adverse effects;
     • ways of talking with professionals and other options;
     • planning actions, including how others may react, and linking them to the PTS.
  4. Encourage participants to raise doses and side effects with the prescriber and team, rather than stopping alone. [GAM-UFU; group size, number and frequency of sessions are not specified there [uncertain]]
• Watch for: GAM being read as anti-medication. Its stated aim is not to decide for or against medication [GAM-UFU].

4.19 Support for therapeutic residences and transitional housing

• Purpose: support to Serviços Residenciais Terapêuticos, which are community homes for people discharged after two or more years in hospital. Also co-responsibility for residents' social reinsertion and support to transitional residential services [source: Portaria 3.088 Art. 11; Portaria 854 via MS 2013].
• Steps:
  1. Make regular visits to the residence and run house meetings [synthesis].
  2. Keep each resident's PTS [Portaria 3.088 Art. 9 §1 for UA].
  3. Plan exit from a transitional unit from the start; MS 2013 calls this a "saída programada" (planned exit).

4.20 Coordinating hospital admission when it is unavoidable

• Purpose / when: only when extra-hospital resources are insufficient [Law 10.216 Art. 4]. Psychiatric beds in general hospitals are the RAPS hospital component, and the hospital must build the PTS jointly with the CAPS [Portaria 3.088 Art. 10].
• Steps:
  1. Document which community options were tried [synthesis].
  2. Know the legal forms of admission [Law 10.216 Arts. 6–9]:
     • voluntary, with a signed declaration;
     • involuntary, at a third party's request, with the Public Prosecutor notified within 72 hours;
     • compulsory, by court order. All require a detailed medical report by a doctor registered with the state medical council (CRM).
  3. Keep the TR in contact during the admission and plan discharge back to the CAPS [synthesis; Law 10.216 Art. 5 for long-stay patients].

4.21 Community activities

• Purpose: joint activities with neighbourhood associations and local institutions, such as festivals and walks [MS 2004], plus links to Centros de Convivência e Cultura (community centres for social and cultural life) [Portaria 3.088 Art. 6 §4]. They support inclusion and fight stigma.
• Steps [synthesis]: co-organise at least one public event a term with users, held in a community venue rather than in the CAPS.

4.22 Daily team meeting and clinical-institutional supervision

• Purpose: daily team meetings are one of the CAPS's collective spaces [Portaria 3.088 Art. 7 §2]. Meeting rooms are meant for team, intersectoral and supervision meetings and continuing education [MS 2013].
• Steps [synthesis]:
  1. Review new acolhimentos, people in crisis or in reception (for example from the kanban board) and PTS reviews due.
  2. Allocate visits and accompaniments.
  3. Use supervision for stuck cases and team conflict.

5. Handling problems

The national documents name principles more than problem-handling procedures. Unless a source is given, the guidance below is my own [synthesis], built to be consistent with the sources cited.

• Person stops attending (non-adherence, "disappears").
  • The sources do not describe a specific active-outreach procedure (busca ativa, i.e. actively seeking out users who stop coming) [uncertain]. The home-care and territorial actions support one [MS 2004; Portaria 854 via MS 2013].
  • [synthesis] After a missed agreed contact, the TR phones the person.
  • [synthesis] If there is no response, the TR contacts the named family or network person, then makes a home visit with the community health agent.
  • [synthesis] At the next contact, ask what made coming hard (transport, timetable, work, stigma, a group that didn't fit). Then change the PTS, not the person. Options include home-based care, a different time, or shared care in primary care.
• Refuses treatment but accepts contact. This is one of the crisis indicators used at Brasilândia [source: CAPS III Brasilândia]. Keep the contact going: home visits, network meetings, informal presence. Negotiate the smallest acceptable step, and remember that the right to refuse medication is part of GAM's rights education [GAM-UFU]. [synthesis]
• Refuses all contact and risk is rising.
  • Hold a network meeting with family and primary care [Brasilândia].
  • Assess medical and suicide risk; use SAMU if there is an emergency.
  • Consider involuntary admission only as a last resort and within Law 10.216, then plan return to the CAPS. [synthesis]
• Stuck PTS (no progress).
  • Return to the first moment, assessment, and ask what the person actually wants. The "manifest request" and the "unsaid" are often different [Caçapava Roteiro].
  • Check whether goals are owned by one named person each and have deadlines [Caçapava Roteiro].
  • Bring the case to supervision.
  • Consider changing the TR if the bond is weak, which the 2004 manual explicitly allows [MS 2004].
• Overwhelm in groups or workshops. Offer partial participation (observing, shorter time), a quieter workshop, or individual contact while easing back in. Review in the team meeting. [synthesis]
• Rupture with the team or the TR.
  • Name it directly and offer a meeting with another team member present.
  • Accept a change of TR if the person asks.
  • Raise service-level grievances at the assembly, where staff must answer them [assembly function: MS 2004; handling: synthesis].
• Disagreement over medication. Use GAM-style dialogue: name the side effects, the person's goals and the options, and bring the prescriber in. Discourage abrupt self-discontinuation without making the person's adherence a condition of care [GAM-UFU; synthesis].
• Family pressing for admission or for control.
  • Meet the family. Explore what they fear and how worn out they are.
  • Offer the family group and crisis plan contacts.
  • Explain the legal criteria for admission (Law 10.216) and the community alternatives.
  • Involve the user in the conversation. [synthesis]
• Intra-family violence, or child protection concerns. Activate the protection network: the Conselho Tutelar for children and adolescents and the care pathway for children and families experiencing violence [MS/CNMP 2014]. Do not let the child's removal from the family be justified by poverty alone (ECA Art. 23, cited in MS/CNMP 2014).
• "Not our profile" disputes between services. Do not refuse. Give an initial assessment and response, then make a committed referral and follow it until the person is received [MS/CNMP 2014].
• Substance use during attendance or reception. Respond with harm reduction rather than exclusion. Review safety and the reception plan with the person. Escalate to an urgency service if there is intoxication or withdrawal risk [MS 2004; Portaria 3.088 Art. 10; specifics synthesis].
• Night reception exceeding limits or becoming residence. Review the PTS. The 2004 manual's limits are 7 consecutive or 10 non-consecutive nights in 30 [MS 2004]. Activate housing routes (Unidade de Acolhimento, therapeutic residence, social assistance) [Portaria 3.088 Arts. 9, 11; synthesis].
• Team overload and fragmentation. Use the daily meeting to share TR loads, and use matrix support so that stable cases are followed in primary care [MS 2004; synthesis]. CAPS III Brasilândia's kanban board is one tool to make the crisis caseload visible [source: CAPS III Brasilândia].
• Policy-specific difficulties. Brazilian mental health policy changed after 2017, including how comunidades terapêuticas (therapeutic communities) are treated and the addition of new service types. Local configurations vary, and those later ordinances are not drawn on [uncertain]. Check the current state and municipal RAPS plan before relying on any service type named here.

Sources

Sources:

• Portaria GM/MS nº 3.088, de 23 de dezembro de 2011 (RAPS), Campinas municipal copy
• Ministério da Saúde (2004). Saúde Mental no SUS: os Centros de Atenção Psicossocial, via LAPS/ENSP-Fiocruz
• Ministério da Saúde (2013). Manual de Estrutura Física dos CAPS e Unidades de Acolhimento: CAPS e UA como lugares da atenção psicossocial nos territórios (reproduces the Portaria SAS/MS 854/2012 action list)
• CAPS III Adulto Brasilândia (São Paulo). Atenção à Crise: uma perspectiva de cuidado em liberdade (Fiocruz Brasília "Nós na Rede")
• NASF-AB Caçapava / SES-SP. Roteiro facilitador de Projeto Terapêutico Singular: um dispositivo em construção
• UFU / SMS Araguari (PET-Saúde Equidade). O guia GAM na prática: compartilhando saberes e experiência
• Lei nº 10.216, de 6 de abril de 2001 (Planalto)
• Ministério da Saúde & Conselho Nacional do Ministério Público (2014). Atenção psicossocial a crianças e adolescentes no SUS: tecendo redes para garantir direitos (TJPE copy)

Further reading (not drawn on):

• Ministério da Saúde (2007). Clínica ampliada, equipe de referência e projeto terapêutico singular, 2nd ed. (via the Caçapava Roteiro).
• Portaria SAS/MS nº 854/2012 (via MS 2013).
• Onocko Campos, R., Passos, E., Palombini, A. et al. (2014). Gestão Autônoma da Medicação: Guia de Apoio a Moderadores (via GAM-UFU).
• Dell'Acqua, G. & Mezzina, R. crisis criteria, as adapted by CAPS III Brasilândia.

Further reading (not drawn on) [uncertain]:

• Chiaverini, D. H. (org.) (2011). Guia Prático de Matriciamento em Saúde Mental (host offline during the electoral blackout period).
• São Paulo municipal Protocolo de Saúde Mental: CAPS (redirect refused).
• WHO (2021). Mental health crisis services: promoting person-centred and rights-based approaches.
• Portaria 336/2002; Portaria de Consolidação nº 3/2017; Law 10.708/2003.