Implementation of brief psychoanalytic groups for people exposed to violence: Challenges and strategies for access and adherence

ABSTRACT

This study analyzes the implementation of brief psychoanalytic groups aimed at people exposed to violence, examining the challenges and strategies related to access and adherence to this type of intervention. The research was conducted in the context of the Núcleo de Atenção e Pesquisa em Violência (NAPEV), covering seven cycles of care carried out between July 2021 and October 2023. During this period, 230 individuals were referred to the groups, revealing a consistent demand for this type of psychosocial intervention. The results show significant variations in access and adherence rates over the years, with access decreasing from 57.14%, in 202,1 to 29.25%, in 2023, while adherence fluctuated, peaking at 70.83% in 2022. Data analysis highlights the complexity inherent in implementing psychosocial technologies in contexts of vulnerability, underscoring the need for tailored strategies that consider the specificities of populations exposed to violence. This study contributes to understanding the factors that influence participation in psychoanalytic groups and provides input for improving public policies aimed at the mental health of vulnerable populations.

KEYWORDS
Psychoanalysis; Exposure to violence; Psychotherapy, group; Implementation science

RESUMO

O presente estudo analisa a implementação de grupos breves psicanalíticos destinados a pessoas expostas à violência, examinando os desafios e estratégias relacionados ao acesso e à adesão a essa modalidade de intervenção. A pesquisa foi desenvolvida no contexto do Núcleo de Atenção e Pesquisa em Violência (Napev), abrangendo sete ciclos de atendimento realizados entre julho de 2021 e outubro de 2023. Durante esse período, 230 indivíduos foram encaminhados para os grupos, revelando uma demanda consistente por esse tipo de intervenção psicossocial. Os resultados demonstram variações significativas nas taxas de acesso e adesão ao longo dos anos, com o acesso diminuindo de 57,14%, em 2021, para 29,25%, em 2023, enquanto a adesão apresentou oscilações, atingindo um pico de 70,83% em 2022. A análise dos dados aponta para a complexidade inerente à implementação de tecnologias psicossociais em contextos de vulnerabilidade, evidenciando a necessidade de estratégias adaptadas que considerem as especificidades das populações expostas à violência. O estudo contribui para a compreensão dos fatores que influenciam a participação em grupos psicanalíticos e oferece subsídios para o aprimoramento de políticas públicas voltadas à saúde mental de populações vulneráveis.

PALAVRAS-CHAVES
Psicanálise; Exposição à violência; Psicoterapia de grupo; Ciência da implementação

RESUMEN

Este estudio analiza la implementación de grupos psicoanalíticos breves dirigidos a personas expuestas a la violencia, examinando desafíos y estrategias relacionados con el acceso y la adhesión a este tipo de intervención. La investigación se desarrolló en el contexto del Centro de Atención e Investigación sobre la Violencia (NAPEV), abarcando siete ciclos de atención realizados entre julio de 2021 y octubre de 2023. Durante este período, 230 personas fueron derivadas a los grupos, lo que revela una demanda constante de este tipo de intervención psicosocial. Los resultados demuestran variaciones significativas en las tasas de acceso y adhesión a lo largo de los años, con una disminución del acceso del 57,14 %, en 2021, al 29,25 %, en 2023, mientras que la adherencia mostró oscilaciones, alcanzando un máximo del 70,83 % en 2022. El análisis de los datos señala la complejidad inherente de la implementación de tecnologías psicosociales en contextos de vulnerabilidad, destacando la necesidad de estrategias adaptadas que consideren las especificidades de las poblaciones expuestas a la violencia. Este estudio contribuye a la comprensión de los factores que influyen en la participación en grupos psicoanalíticos y ofrece perspectivas para mejorar las políticas públicas dirigidas a la salud mental de las poblaciones vulnerables.

PALABRAS CLAVE
Psicoanálisis; Exposición a la violencia; Psicoterapia de grupo; Ciencia de la implementación

Introduction

The global scenery, clearly under the impact of the COVID-19 pandemic, revealed and stressed pre-existent social vulnerabilities, thus incisively disclosing how fragile were groups such as children, adolescents, teenagers and women. The need for social isolation, though crucial for restraining the virus, did, paradoxically, confine a number of individuals in environments where violence was already either latent or explicit. During that period, emergent studies¹⁴ did shed light on the intensification of gender, race and social class inequalities, besides difficulties as to incorporating children’s voices and desires concerning building up care and prevention proposals.

The increasing number of injuries, both intentional and not intentional, suicides, nourishing insecurity, besides domestic violence perpetrated by intimate partners¹,⁵ did stress the urgency as to improving prevention services and response for the violence, thus making clear the complexity of this phenomenon, as well as its multifaceted nature. In such context, the implementation of specific psycho-social interventions, such as the short-lasting psychoanalytic groups, emerge as a promising strategy as to caring people exposed to violence.

Violence against children and adolescents became clear in mistreatment concerning their physical, emotional and sexual needs, besides disregard, and registered a worrying increase since the pandemic advent⁶. Reports indicate an increase as to emotional abuse and as to the indirect exposure to domestic violence, such as serious parental conflicts observed⁶. Such correlation is usually associated to increasing parental stress, to deterioration of the parents’ mental health, and to anger feelings⁷–¹⁹.

The situation was further exacerbated by conditions such as the risk of unemployment, the economic pressure¹¹,¹² and the memory of personal experiences parents carried from their own childhood, related to negative parenthood (physical hostility and negligent control)⁶,⁹,¹³. Despite the notorious exposure to increased domestic violence, the identification of specific changes related to either physical, sexual or emotional violence remained a challenge, as well as did negligence situations¹⁴.

Exposure to violence, whatever its forms, carries out deleterious effects for children’s mental and physical health throughout their lives, thus requiring rigorous actions involving investigation, prevention and protection¹⁵–¹⁷. The relevance of mistreatment against children as a matter of public health, and the priority to be granted to those groups for actions aimed at the promotion of public health¹⁹ stress he mandatory urgency for analyzing implementation, evaluation and dissemination of prevention programs and family protection, aimed at mitigating psycho-social sequels of violence in the pandemic context.

Violence carried out by intimate partners in the pandemic context

The number of aggressions carried out by intimate partners did also register significant increase during the COVID-19 pandemic. Interestingly, an increase was observed in both physical and psychological violence associated to the increase in alcohol consumption, (IRR=1.68, p<.0.001, CI [1.37, 2.07])¹⁹, and those occurrences were three times more likely when involving couples who did contract the virus²⁹.

Those data led the World Health Organization (WHO) to issue guidance for the governors to adopt measures for the control of alcohol consumption, due to its capacity to exacerbate aggressive reactions and reduce the cognitive capacity in conflictual moments. In Spain, denouncements of violence against women during the pandemic came down to 19%, but an increase of severity was reported among those who lived with the partner [Odds Ratio (OR) = 1.33], women who cared for social support (1.22).

The difficulties for looking for help due to the confinement did shed light on the need for protection measures for women in cohabitation with aggressive partners, and who cared for social support²¹. Social support, both formal and not formal, is a crucial factor for the interruption of the violence cycle²², and restrictions imposed by the pandemic did limit both such support and the access to essential resources meant to denounce and break that cycle²¹,²².

Brazilian scenario of violence against women

In Brazil, researches carried out by the Instituto Datafolha (The DataFolha Institute), ordered by the Fórum Brasileiro de Segurança Pública (FBSP) (Brazilian Forum on Public Safety), point out to an increasing trend of violence against women in the household since 2017, which was intensified in 2021 under the pandemic scenario and social isolation measures.²³ When compared to 2019, the number of domestic aggressions went from 42.65% to 48.8%, with increased participation of partners, boy-friends and ex-partners²⁴.

The increase of the infra-family violence included as well aggressions associated to parents, brothers, stepfathers, stepmothers, sons and daughters. As collateral effect, in Brazil the violence against women during the pandemic revealed a contradiction: reduction of records on deceitful physical harm, rape of vulnerable and threat, but a 22.2% increase of female murders and 6% of murders of women.

This suggests that girls and women faced greater difficulties to denounce due to the social isolation, thus resulting in less police records. Social isolation led to more intimacy with the aggressor, more physical and psychological manipulation, and more restricted protection structure, both formal and informal²⁵. When compared to 2019, March and April in 2020 showed a 22.2% increase of murders of women in Brazil, 56.9% of which in São Paulo. Despite the reduction registered in May, the months of March, April, and May in 2019 and 2020 still sum a 2.2 augmentation, which suggests a possible decrease in lethal violence, or incorrect records²⁶.

The importance of short-term psycho-analytic groups in the mental health area

The psycho-analytic approach offers significant gains as to the care for people exposed to violence, providing safe hearing and speaking spaces that legitimate the experience and make it easier for them to elaborate the traumatic event. The lack of such spaces may perpetuate the violence suffered and transmitted from generation to generation²⁷,³².

As a special gain, the mutual hearing in psychoanalytic groups contributes for the elaboration of shame and blame feelings, promoting identification among the individuals and increasing tolerance³¹. When it occurs, the transmission of psychic elements among generations may be either worked out, and supported by symbols (inter-generationality), or without re-assigning meanings to the suffering experience (trans-generationality), perpetuating violence cycles.

Thus, the elaboration of traumatic events is a preventive action to prevent future generations from falling ill – a relevant contribution by the psycho-analysis for public policies³¹, especially in contexts of social unprotection and rights violation³³.

Scientific evidences and public health

Submitting the psycho-analysis to the process of re-building solid evidences is rather a matter of public health than of scientific legitimation³⁴. Evidences are crucial for governments to define investment parameters for financial resources and decide on health policies³⁴. Harsh critics are directed to the use of therapeutic approaches without evidences, which result in unjustified public expenditures and damages for the patients³⁵.

Under the psychoanalytic perspective, the State operates as a third party that grants an ambience that is sufficiently good for developing mother-son relationship. Nevertheless, what one may observe is the discontinuity of care, support and protection, and a punitive and moralizing attitude. Mothers are often required to adapt themselves to medium class services and values defended by professionals in health, education and social assistance areas.

Contemporaneous psycho-analysis and social applications

Considering this panorama, Onocko Campos emphasizes that the long-suffering Brazilian population does not need silent and indifferent analysts. On the contrary, contemporaneous psycho-analysis defends the continuity and the qualification of public spaces by means of investments on capacitation and clinic supervision for workers, which would allow them to act in a reparatory and not punitive way, thus assuming an ethic commitment and the centrality of the psycho-social work with families²⁸,³²,³⁹.

Contemporaneous psycho-analysis has been exploring multiple application possibilities³⁴,³⁵, widening the access and turning to be a means for the comprehension of social phenomena, such as youngsters’ anti-social behavior when facing privation²⁹,³³, the clinical management in attendance to homeless people under psychic suffer³⁶,³⁷ and contributions for infant-juvenile assistance in mental health³⁸,³⁹.

The approach is also on the social-assistance to the elderly and impaired people, to those exposed to homophobia and racism, and victims of rights violations who are cared for at the Reference Centers of Social Assistance (CRAS) and the Reference Center Specialized in Social Assistance (CREAS)⁴⁰. Other authors explore psycho-analytic considerations on racial prejudice⁴¹, homophobia⁴², gender violence⁴³,⁴⁵, drug traffic⁴⁶ and individual rights⁴⁷.

Phenomenal and methods

The present study is characterized as an implementation research, based on observation, with retrospective and descriptive nature, based on institutional data produced from July, 2021, to October, 2023. This period gazed upon seven cycles for attendance to short-term psychoanalysis groups carried out by the Nucleus for Psychoanalytic Assistance for Persons Exposed to Violence (NAPEV – Núcleo de Assistência Psicanalítica para Pessoas Expostas à Violência). At the origin, NAPEV was located at the Clinics Hospital (Hospital das Clínicas, HC), and today is permanently operating at the Integrated Center for Onco-hematologic Researches in Childhood (Centro Integrado de Pesquisas Oncohematológicas na Infância – CIPOI), both at Campinas State University (Universidade Estadual de Campinas – UNICAMP).

Data collection was approved by the Ethics Committee on Research of Campinas State University (Comitê em Pesquisa da Universidade Estadual de Campinas), under Certificate of Submission of Ethics Evaluation (Certificado de Apresentação de Apreciação Ética – CAAE) Nr. 07227019.3.0000.5404 and expert’s report Nr. 4.496.491, in compliance with Resolution Nr. 266/2012 by the National Council on Health, which decides on researches involving human beings⁴⁸.

Characterizing short-term psycho-analytic groups

The short-term psycho-analytic groups were structured as a psycho-social technology, grounded on basic principles of psycho-analysis applied to public health contexts. Each attendance cycle included ten 90 minute-long weekly meetings, and was structured as follows: start-out meeting dedicated to welcoming participants, presenting the structure and establishing the therapeutic contract; eight intervention meetings; and final closure session on mourning, separation anxieties and identification of both internal and exterior resources.

Each group included up to ten participants, guided by couples of therapists – one NAPEV’s professional and one resident at UNICAMP’s Multi-professional Residence Program on Mental Health and Collective Health. In order to assure both the fidelity and the quality of the intervention over all cycles, a weekly meeting specialized in the clinic supervision approach in psycho-analytic group was carried out.

The methodology of the groups was based on the creation of a safe listening and speaking space, where participants would elaborate traumatic experiences related to being exposed to violence. The theoretical referential was based on contributions of authors such as Winnicott⁴⁹, Bion⁵⁰, Pichón-Rivière⁴⁰ and Kaës⁵¹, who broach the importance of groups when elaborating traumas and building up repairing connections.

Meeting schedules were kept consistent over each cycle: groups of 14 to 17 year old teens took place on Mondays, from 2h30pm to 4pm; and 18+ female groups took place on Fridays, from 2h30pm to 4pm. Both groups met at the same location, but in different rooms.

Inclusion and exclusion criteria

The study involved two groups stratified by age: teenagers from 14 to 17 year old (both genders) and adult women aged 18 or above, who did accept to be attended in groups and presented some distress involving either direct or indirect violence in whatever the modality (physical, psychologic, sexual, neglect or violence witnessing). Indirect exposure to personal experiences or to witnessing violence situations in either family or community contexts were also considered⁵²,⁵⁵.

NAPEV is included in the North region of Campinas, and attended the sorted out population referred by basic attention units, the Núcleo de Apoio à Saúde da Família – NASF (Supporting Nucleous for Family Health), CRAS, CREAS and Serviço de Convivência e Fortalecimento de Vínculos – SCFV (Social Interaction and Bond-Strengthening Service), integrated to the Comitê Gestor da Pesquisa (Management Committee of the Research) during the process implementation. Participants were forwarded by means of standard on-line applications, and were contacted by the NAPEV team in order to confirm participation and to receive logistic guidance. Free tickets for public transportation were delivered – one of the strategies considered to make easier the access to the service. Monthly meetings bringing together the implementation team and reference professionals of partner services did enable cases to be jointly discussed and followed, thus assuring care continuity over all cycles.

The study did not include persons with psychotic disturbances in acute conditions, abuse of psychoactive drugs that could affect participation in group activities, and situations under eminent risk that would require immediate protection interventions.

Data collection and analysis

Data were collected by means of systematic leading, participation and permanence in the groups, and were organized based on assistance year and cycle, thus allowing for comparative analysis of access and adherence rates. Variables were dealt with as categories, and analyzed according to attendance and simple crossing. For analysis purpose, two main variables were considered: a) Access rate: percentage of individuals referred to the program who did participate of at least one session of the group; b) Adherence rate: percentage of participants who remained in the group after the first contact, considering participation in at least 50% of the sessions programed.

Data analysis was carried out in descriptive way, with attendance and percentage calculation, thus enabling trends to be identified over the different implementation cycles. In order to check out any variations that could be statistically significant as to access rates and adherence among the years under analysis, the chi-square of independence was applied, as it is appropriate for categoric variations, not requiring assumed normality in data distribution. Statistic analyses and charts elaboration were carried out in Python ambiance (version 3.13.5), using Jupyter Notebook.

The implementation process was analyzed using a sample composed by 145 records stored in cloud computing, including medical records of the group, reports, meeting registers and other documents provided by NAPEV. Information collected were submitted to detailed analysis, classified in categories based on data, kind and content. Furthermore, open interviews were carried out with 12 professionals directly involved with NAPEV implementation: 02 occupational therapists, 01 nurse; 02 resident psychologists in the Program for Multi-professional Residence in Mental and Collective Health at the UNICAMP; 01 female psychologist, clinical supervisor for the NAPEV; 02 occupational therapists, who did coordinate actions with partner services; and 03 researchers in Master programs in the Work Group on Psychoanalysis and Violence – Interfaces. The interviews, which lasted about thirty minutes, were carried out in September and October 2023, using message applicative WhatsApp. Both the documental analysis and the interviews did make it possible to put into context and go deeper in quantitative data interpretation, and validate qualitative analyses on factor that might have interfered on the access and adherence to the groups.

Outcomes and discussion

The outcomes presented in this study, which derive from the implementation process of short-term psychoanalytic groups, reveal important nuances concerning the access and adhesion of persons exposed to violence. Over seven attendance cycles, 230 individuals were referred, revealing a consistent demand for this kind of intervention. One may observe that, although the absolute number of referrals did increase in 2023, such augmentation might be related to the larger number of cycles carried out during that year, as the average number of referrals per cycle was quite stable over the period analyzed, as shown in graph 1.

Graph 1.
Participants referred to the program per year and average per cycle

However, data analysis of access and adherence over the years (table 1) points out persistent challenges that deserve deeper discussion, according to Silva’s⁵² perspective in his PhD thesis, as he emphasizes how complex is the implementation of psycho-social technologies in contexts of vulnerability.

Table 1.
Implementation attendance – NAPEV

Year	Cycles	Referred	Accessed	Joined
2021	2	70	40 (57.14%)	9 (22.50%)
2022	2	55	24 (45.5%)	17 (70.83%)
2023	3	105	31 (29.25%)	13 (41.96%)

Analysis of access rates

One may observe an increase trend of the number of annual referrals, which culminate at 105 referrals in 2023. Nevertheless, the proportion of individuals who actually did participate in at least one group session (column ‘Did access’ in table 1) showed a progressive fall – from 57.14%, in 2021, to 29.25%, in 2023. This reduction is visually represented in graph 2, which shows yearly referral composition, highlighting individuals who did access the group against those who, although referred, did not show up at not even one session.

Graph 2.
Composition of referred participants by program access status, by year (2021 – 2023)

Such fall might be a multifactor one, reflecting from logistic and socioeconomic barriers to the complexity inherent to the adherence of vulnerable populations to mental health services. In his thesis, as he approaches the implementation of psycho-analytic groups for people exposed to violence, Silva⁵² remarks the importance of considering the social context and specificities of those populations, who often face obstacles such as stigma, lack of resources, transportation difficulties and the very nature of the trauma, which can pose difficulties for the initial engagement.

The progressive reduction of access taxes might be related to different contextual factors. First, the implementation period came along with the COVID-19 pandemic and its socio-economic consequences, when access barriers to mental health services might have been intensified. As pointed out by Jubilut et al.², social isolation measures did disproportionally impact vulnerable populations, posing additional obstacles on the access to specialized services.

Furthermore, those outcomes may have also been influenced by changes as to the location where groups should to meet: in 2021, meetings used to occur in services on their same territory; however, since 2022 and 2023, they were transferred to a more centralized and specialized space inside the University. Despite offering better infrastructure and specialization, the centralization in such environment may also pose new access barriers to a population that already faces mobility and familiarity challenges involving institutional environments.

Analysis of adherence taxes

On the other hand, adherence tax (column ‘Did adhere’ on table 1), which measures the groups’ permanence after the first contact, did present an interesting variation. In 2021, adherence was 22.5%, jumping to 70.83% in 2022, then settling on 41.96% in 2023. This dynamic is illustrated on graph 3, which represents the annual composition of participants, according to the minimum adherence to the groups (attendance to at least 50% of the sessions)

Graph 3.
Composition of referred participants by program adherence status, by year (2021 – 2023)

Maximum adherence occurred in 2022, contrasting with the access reduction and suggesting that, once initial barriers have been surpassed, and attachment has been established, permanence in the groups becomes more likely. These findings corroborate psychanalytic literature on the importance of establishing secure therapeutic attachment for traumatized populations⁴⁹,⁵⁰.

The high adherence rate in 2022 might be related to more favorable reception and attachment strategies developed by the team over the first year of implementation. As remarked by Kaës⁵¹, the quality of group holding and the capacity to support afflictions are determinant factors for the participants’ permanence in psychoanalytic groups.

Factors that influence both the access and the adherence

Factors that did influence both the access and the permanence in short-term psychoanalytic groups were identified based on a retrospective documental sample, that included records produced the implementation of NAPEV took place, and included group records, technical reports, meeting reports and institutional documents. Furthermore, individual interviews were carried out with members of the team who were directly involved with the implementation, aiming at a deeper comprehension of determinants observed in quantitative data. Both the documental analysis and the interviews made it possible to identify and validate the factors that did influence the access and the adherence of short-term to psychoanalytic groups.

Data analysis reveals the complexity of factors that influence both the access and the adherence. Silva⁵² broaches the relevance of accessible channels and confidence construction as pillars for the efficacy of psycho-social interventions, which is in line with the need of adapted strategies meant to grant not just the access, but the continuity of care.

The use of the independence⁵⁴ chi-squared test shed light on statistically significant differences as to the distribution of access data (x2 = 13.38, p=0.0012, gl=2) and adherence (x² = 10,00, p= 0.0067, gl=2) between the years analyzed. Those outcomes suggest that taxes variations observed in rates are not observed there by hazard: they indicate the influence of structural and contextual factors on users’ behavior concerning the therapeutic proposal. The identification of those factors was based of the division of quantitative data, institutional records and reports by the implementation team into triangles, thus allowing for a more comprehensive interpretation of the results. Apparently, changes in the attendance location, composition of the technical team and possible context variables which are not yet systematically studied might have exerted direct impact on the participation pattern.

Among the main factors identified as influent on the access stand out: a) Geographic and transportation barriers: the location of the groups and the availability of adequate public transport system: the place where the groups are located and the availability of proper public transportation exert direct impact on the users’ participation capacity; b) The stigma associated to mental health care: populations exposed to violence often face multiple stigmas, which might make it difficult for them to look for specialize assistance; c) Complexity of social demands: issues such as house instability, food insecurity and unemployment may compete with prioritizing mental health; d) Trauma characteristics: the nature and severity of traumatic experiences might influence the star-out capacity to engage in group activities.

As to the factors that promote adherence, once the first contact is established, we may observe: a) The quality of the therapeutic attachment: the capacity of the team to establish a safe and welcoming environment is critical for the permanence; b) Identification among partners: the acknowledgement of similar experiences among participants makes it easier for the process elaboration and reduce isolation; c) Flexibility at the approach: interventions: the adaptation of interventions to specific need of each group contributes for maintaining both the interest and the participation; d) Social support: building a support network within the group will strengthen motivation for continuity.

Implications for the clinical practice

Findings provided by this study have important implications for the clinical practice and for the formulation of public policies meant to caring people exposed to violence. The discrepancy among access and adherence rates suggests the need for strategies that must be specific for each moment along the caring process.

In order to improve the start-out process, suggestions are: a) Services decentralization: the provision of groups in different territories may reduce geographic barriers and add to the users’ familiarity as to care spaces; b) Active search strategies: the development of pro-active identification actions may widen the interference range; c) Inter-sectorial articulation: integrating health services, social assistance and education might make it easier for addressing and following-up the cases; d) Flexible time-schedule: offering groups in different periods and hours over the week might conciliate the users’ routines and responsibilities.

In order to strengthen adherence, it is suggested: a) Investment on team preparation: continuous improvement of the professionals’ technical and relational abilities is critical for the quality of the care they provide; b) Regular clinic supervision: technical and emotional support provided to the team adds for them to maintain the quality of interventions; c) Cultural adaptation: Taking into account participants’ cultural, ethnic and socio-economic specificities provides richer therapeutic approaches; d) Post-group follow-up: offering support once cycles are over might consolidate therapeutic gains and prevent setbacks.

Limitations of the study

It is worth acknowledging the limits of the present study, which include the relatively short observation period, the absence of a control group to compare outcomes and the limited size of the sample. Besides, the analysis was based on quantitative outcomes data, and did not contemplate qualitative evaluations of therapeutic results observed. Therefore, statistic findings, though relevant, must be interprated with caution as to generalization to other contexts and populations.

Future studies might benefit from the inclusion of standard evaluation tools of symptoms and life quality, as well as from qualitative interviews with participants and professionals so as to grant a deeper comprehension of factors that influence both the access and the adherence.

Contributions to public policies

The outcomes of this study offer important elements for the improvement of public policies focused on people exposed to violence. By making clear that short-term psychoanalytic groups are not only viable, but also demanded, the initiative reinforces the need for investment on this modality of specialized care for this population.

The variability observed regarding access indices over time sheds light on the relevance of continuously monitoring and adaptation of implementation strategies. As highlighted by Silva⁵², the implementation of psycho-social technologies requires a dynamic process of adjustments and improvements based on hands-on experience and on users’ feedback.

Furthermore, outcomes reinforce the need for integrated approaches that might influence both the access and the permanence of mental health service. Bringing together different sectors and attention levels is critical for the success of interventions.

Conclusions

As demonstrated in this study, the implementation of short-term psycho-analytic groups for people exposed to violence represents a promising strategy for mental health care among vulnerable populations. The outcomes obtained over seven attendance cycles, involving 230 referrals, shed make clear both the potential and the challenges inherent to this modality of psycho-social intervention.

The analysis of data on both access and permanence reveals a complex panorama, characterized by an increasing demand for this type o care, but also by significant obstacles that restrain the users’ effective participation. The progressive reduction of access rates – from 57.14% in 2021 to 29.25% in 2022, contrasting with variable adherence rates, which did register 70.83%, a peak in 2022 – points to the need for different strategies for each phase over the care period.

The findings provided by this study, consonant with theoretical and methodological considerations in Silva’s thesis⁵², reinforce the importance of approaches that are sensible to the context and consider the multiple layers of vulnerability and the barriers that restrain full engagement of people exposed to violence. Counting on its capacity to offer a space to elaborate traumatic experiences and build up new meanings, the psychoanalysis emerges as a powerful tool in this scenario.

However, the efficacy of this approach intrinsically depends on the capacity of health and social assistance services to adapt their structure to the users’ reality, by promoting easier access and a favorable environment for care continuity. The experience reported in this study demonstrates that, once initial barriers are overcome, and the therapeutic attachment is established, the permanence in the groups becomes more likely, thus suggesting that the investment in welcoming and attachment strategies is crucial for the success of the intervention.

Implications of these findings for the clinical practice are significant, pointing to the need of: (a) de-centralization of services, in order to reduce geographic barriers; (b) development of active search strategies, so as to widen interventions reach; (c) investment on the teams preparation and supervision; d) flexible timetable and assistance modalities; and strengthening of inter-sectorial articulation.

From the public policies view, outcomes reinforce the nee of sustained investments on specialized care modalities for people exposed to violence, thus acknowledging the complexity of this phenomenon and the importance of integrated approaches that into account both the clinical aspects and social determinants of health.

Overcoming the challenges identified in the present study will not only improve the clinical practice: it will also strengthen public policies in the mental health area for populations under violence conditions, thus contributing for building up a society that is both more air and equitable. The continuity of researches in this area, including longitudinal studies and qualitative evaluations of therapeutic, will be critical for the continuous refinement of such intervention and for the consolidation of the psychoanalysis as an effective tool in the assistance to vulnerable populations.

Finally, this study contributes for the collective health field, as it demonstrates the feasibility and the relevance of short-term psycho-analytic groups as psycho-social technology, offering empiric subsides for decision-making in public policies and for the development of new research in the area. The experience reported herein turns it evident that, despite the challenges, it is possible to implement psycho-analysis interventions in public health contexts, provided specificities of the populations assisted are considered, and adequate strategies are developed so as to grant access and adherence to the caring services offered.

Data availability:

The research data are contained in the manuscript itself

• Financial support:
  MCTIC/CNPq Call for Proposals No. 28/2018 – Process No. 426778/2018-9

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Edited by

• Editor in charge:
  Gicelle Galvan Machineski, Universidade Estadual do Oeste do Paraná (Unioeste), Cascavel (Paraná/PR), Brasil. Lattes: http://lattes.cnpq.br/7267047092491530 – Orcid: https://orcid.org/0000-0002-8084-921X – e-mail: [e-mail]

Publication Dates

• Publication in this collection
  03 Aug 2026
• Date of issue
  Jul-Sep 2026

History

• Received
  04 Sept 2025
• Accepted
  21 Apr 2026