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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.16 no.47 Murcia jul. 2017  Epub 01-Jul-2017 


Characteristics of work and strategies in mental health care with crack user

Gustavo Costa-de-Oliveira1  , Cintia Nasi2  , Annie Jeanninne Bisso-Lacchini2  , Jacó Fernando Schneider3  , Leandro Barbosa-de-Pinho4 

1Nurse. Master in Nursing. Student of the Postgraduate Program in Nursing of Federal University of Rio Grande do Sul (UFRGS), Doctorate level. Porto Alegre, RS, Brazil.

2Nurse, PhD in Nursing. Adjunct Professor of Federal University of Health Sciences of Porto Alegre (UFCSPA). Porto Alegre, RS, Brazil.

3Nurse, Doctor of Nursing. Full Professor in the School of Nursing, UFRGS. Porto Alegre, RS, Brazil

4Nurse, Doctor of Psychiatric Nursing. Adjunct Professor, School of Nursing, UFRGS. Porto Alegre, RS, Brazil.



To know work characteristics and care strategies in mental health with crack users, from the daily life of a Psychosocial Care Center for Alcohol and Other Drugs (CAPS AD).


Qualitative and evaluative study, case study, developed in a CAPS AD, Rio Grande do Sul, Brazil. It was used as theoretical and methodological framework, the Fourth Generation Evaluation. Data collection occurred from January to March 2013. There were 36 interviews with workers, users, family members and managers.

Results: The service daily provides flexible spaces that stimulate creativity and centrality in the user. Prioritizes bonding and listening to strengthen the relationship with the user and weaken their relationship with the drug.

Final considerations:

It is considered the importance of substitutive services in the consolidation of diversified care strategies that can reframe the centrality of drug and rescue user's protagonism.

Keywords: Mental health; health services; substance-related disorders; nursing


The contemporary trends of care in the field of health have brought the need to develop new conceptual frameworks and approaches that make it possible to think over the way of life of people that, at some point, experience health problems1. It is also in this sense that is displayed the insertion of the practice in mental health, as an open field to new paradigms and unrelated to tight and absolute views of the world.

In this perspective, it is understood that the services of mental health, among those the Psychosocial Care Centers for Alcohol and Other Drugs (CAPS AD), come with the possibility of diversifying the worker’s practice. It is known that, as strategical services of the brazilian psychiatric reform process, they have a gap to the incorporation of new technologies of user-targeted care. This means that is necessary to invest in a care that goes beyond illness, understanding the whole person’s life, because the disease is only a part of it.

In the case of drug use, particularly crack use, the user-targeted care seems more relevant and necessary. The reasons for this points out to a greater epidemiological trend for the use2)(3, in addition to unique issues, related to the own drug’s organic composition, which causes greater physical and chemical dependence4)(5.

In relation to the epidemiological aspects, crack has been considered one of the biggest current problems of public health. In 2012, in a national survey based on the drug, it was estimated that there was an increase in the use rate from 0,5% to 1,1%. In 2015, from results present in the World Drug Use Report, published by the United Nations, there was an increase in the use of cocaine and its derivatives, especially in the South America countries, once the supply of raw material seems higher than it is in the considered developed countries2)(3.

Crack does not bring only repercussions to the field of mental health. It is a drug that causes heavy dependence, bringing significant unfolding in the users’ and their relatives’ everyday lives. Crack users, generally, are more aggressive4 and have or develop fragile familiar relationship6. They are generally young men, with low schooling and in a vulnerable social situation, taking them to approach drug trafficking4. However, also an increase in the use of the drug by women has been pointed out, with equal precarious family relationships and greater trend to prostitution and the development of sexually transmitted diseases7)(8.

It is understood that the formation of bonding with the user is primordial to comprehend the established relation with the drug, for it is known that is a strong relationship, of hard break up and change. Despite of the associated risks to the drug use, of the social context social in which the user is inserted and epidemiological reports which have been mentioning the importance of working on the issue in the ambit of public health, it is understood that all this reality imposes to the health services a new challenge, involving the running and organization of the practices.

Thereby, the requirement of spaces that propitiate creativity, freedom and autonomy of the staff for the organization of the targeted in crack users mental health work, as well as the constitution of practices that allow this user to be protagonist of their therapy, in themselves justify the importance of discussing the object of this study. If the focus of caring is to transform the user's relationship with the drug, it is necessary to know the characteristics of the work and the strategies of care with this user, in order to reverse the centrality of the user in the substance.

In this sense, we have as an objective to know the characteristics of the work and strategies of care with the user of crack, from the daily life of a CAPS AD.


This is about is a clipping of the research "Qualitative evaluation of the network of mental health services for users of crack - ViaREDE", funded by the National Council for Scientific and Technological Development (CNPq) and the Ministry of Health (MS). It was developed by the Federal University of Rio Grande do Sul (UFRGS), in partnership with the Federal University of Pelotas. It is a research of an evaluative nature, of the case study type, developed in a city of Rio Grande do Sul, Brazil. The Fourth Generation Assessment was used as the theoretical-methodological reference of the study9.

The Fourth Generation Assessment proposes a constructivist and responsive assessment. The term responsive is used to designate a different way of focusing the evaluation, delimited by an interactive process and negotiation that involves interest groups. This means that the evaluation process takes into account what these interest groups construct about the evaluated object, that is, the evaluation apprehends the quotidian, the interest of these groups in this process and the meanings that give to their practice9

In the ViaREDE survey, the data were collected through observation and semi-structured interviews with the interest groups - staff, users, family and mental health managers of the municipality, from January to March, 2013.

Field observations totaled 189 hours, being recorded in a field diary. Regarding the interviews, 36 were performed in all, eight of them with professionals from the CAPS AD team, ten with users of this health service, eleven with relatives of CAPS AD users and seven with mental health managers.

In this study, the results found on the characteristics of the work and the mental health care strategies with the crack user were treated. The interviewees' information was coded as "E", when the interviewee was a member of the team, "G" when referring to the manager and "U" when the interviewee was the user. This codification also followed the order of the interviewee in the evaluation process. For example, when we refer to U3, it means that it was the third user interviewed.

The criterion of inclusion of the professionals and the managers was to work in the CAPS AD and in the mental health management of the municipality for at least six months. As for the users, the criteria were to attend CAPS AD or to have attended another service of the mental health network due to the use of crack; who volunteered participate in the research and who were not under clinical conditions that would hinder their interview.

Thus, the initial respondent R1 participates in an open interview to determine an initial construct in relation to the focus of the research. He is asked and invited to construct, describe and comment. At the end of the interview, the respondent is asked to indicate another respondent, called R2.

The central themes, conceptions, ideas, values, concerns and questions proposed by R1 are analyzed by the researcher, formulating a construction called C1. The second respondent (R2) is interviewed and, if any construction addressed by R1 is not contemplated by R2, R2 is invited to comment on it. The R2 interview produces information from R2 and a critique of the construction of R1. The researcher concludes the second analysis resulting in C2, a more sophisticated and informed construction, and so on until finalizing the data collection.

After the data collection and the organization of the constructions of each group, the negotiation stage was carried out. The interviewees were assembled and the interim results of the analysis of the data were presented, so that they could have access to all the information and had the opportunity to modify them or to assert their credibility9. From the negotiation, the researchers proceeded to the final stage of analysis of the data, in which issues arose were regrouped, allowing the construction of thematic categories.

The results of this article were organized from the thematic category "characteristics of mental health work with the crack user". In this category, interest groups evaluated the innovative and creative potential of mental health work, which focus is on the use of strategies related to bonding, welcoming and respecting the subjects' demands.

The project was submitted to the evaluation by the Research Ethics Committee of the Nursing School of UFRGS. It was also, at the request of the said Committee, evaluated by the National Commission for Ethics in Research of the Ministry of Health, receiving an opinion favorable to its execution under No. 337/2012.

It was also guaranteed the anonymity of the study participants and respected all the ethical and legal precepts that govern human research, as recommended by the Ministry of Health (Resolution 466/2012 of the National Health Council), as well was respected the decision of withdrawal by the respondents, according to the Free and Informed Consent Form.


One of the first concerns raised by interest groups regarding the characteristics of work in mental health is about the innovative and creative potential of work, since they perceive that actions do not meet the needs and expectations of users. For them, they are parts built in flexible spaces that propose and stimulate this creativity, a freedom and autonomy:

[...] here and also in CAPS itself has a line that we follow, which is a non-rigid line, something flexible, like working within the possible, within the necessity. (E2)

The management seeks to aggregate workers who wish to act with situations involving substance use, considering their ideas, freedom, creativity and autonomy to act in the service, as well as to think and interfere in the organization of the work and in the potentializing and creation of new knowledge. (G1)

The statements show a concern with freedom assigned to the worker in relation to his work, allowing him to create, think, rethink, correct or err, without reprisals. This seems to be essential for this professional to interact with the crack user, understanding their demands, their desires and expectations.

This also seems to be the manager's commitment when selecting staff. According to G1, the mental health worker, especially in the field of alcohol and other drugs, needs to be aware of the complexity of working with users of psychoactive substances and, in the workplace, of being creative in their health interventions.

Thus, innovation points to the production of mental health care that envisages the empowerment of action and the fight against the segregation of health care, still very present in the context of mental health. There is, therefore, an urgent need to produce new answers, a new attitude towards crack users, which requires, above all, a greater capacity for compromise and acceptance. It is necessary to produce in the devices of mental health new forms of meetings, interested, above all, in the production of life10).

Faced with this, health actions that segment should be replaced by care that understands that the users' needs for crack are complex. This means that the crack user needs health care in a broad way that provides diversified psychosocial and drug treatment:

It does not work just to let it go, if you take care of one part and not take care of the other [...] (E3)

[...] talking about the drug issue, of course I do not like this concept that psychiatrist only gives medicine ... but I think that the question of medication you have to have at least one of each class to make the options.(E8)

From the speeches, it is observed that the innovative ability of taking care pass through by to realize and to know how to sophisticate the clinic. In the case of E8, for example, it seems important to let the worker choose the drugs to treat the symptoms presented by the user, because this can also to broaden not only the supply, but also the look one has for the need of the other.

For a long time, mental health was a field of exclusion. However, discussions about patients' chronification, the asylum system, the biomedical model, the non-social reinsertion, the violation of human rights and of citizenship have given rise to political, scientific and social initiatives that could change this situation. These initiatives have brought to light new ways of working on user recovery, and, in doing so, are rethinking how to organize services, away from the bonds of disease and exclusion11.

It is in this sense that we believe in the power of work in mental health in scenarios and space that allow the worker the diversified use of his tools, that is, he can negotiate, debate or discuss with the user and the staff the best way to intervene about the crack user's reality. This is how it becomes possible the construction of a new clinic, which is not the clinic of the disease, focused on only a portion of it, but the user's clinic, which is broader, more comprehensive and complex.

If the work seems to be innovative and creative in mental health, it is because it seems to be able to systematize knowledge that is not always systematizable, that is, knowledge that is in the realm of human relations, which are changeable, can be transformed. In mental health, there is no right or wrong, because it is not possible to look at the subject from a dichotomy: today the practice can be solving in a way, but tomorrow there may be a need for a different technological arsenal for care. This is because everything, in this context, is constantly changing; the paralysis does not transform. It is the possibility of reviewing the practices that give the worker new challenge, in the sense of rediscovering his skills and exactions12.

Once more, it is referred to the use of light technologies such as listening and bonding13 that potentialized this new relationship between the worker and the user, and can be visualized from the following reports:

[...] there are things to be done other than crack. There is someone there, who has anguishes that have led him to crack and that has anguishes that result from the use of crack, and this is a work with the worker himself, to also be able to open a space in himself, to be able to open a listening channel, a possibility to be able to help this user. (E8)

[...] frequently, people already are in abstinence, but because of the bond issue ... they end up staying here [...] then we establish a bond with that user, and that user consequently ends up coming more to the service. (E2)

We work from the listening to this person ... we trust what people are telling us and often they do not tell us the truth. (E1)

[...] a clear conscience that something is being done because if you make a bet in the process, in the bond, in the time of the user, not to be with him at wherever he goes, that's what we've been building. (E7)

The appropriation to new strategies is essential for the development of actions in mental health that transform social reality, insofar as they facilitate the construction of care with the user. Thus, in mental health services, listening and bonding become fundamental elements in the process of health coproduction, but also promote the creation of mechanisms to support and reflect on new arrangements that encourage the dynamization of the service and effective care14.

Health practices have evidenced listening as an action that minimizes problems. By benefiting from listening, the user finds comfort and diminishing of the suffering. For this reason, it is important that the professional is attentive to the demands of the subject and to take care of him without previous judgment15.

In this sense, the bond is considered decisive in the relationship of care between mental health worker, user and family, once agency the exchanges of knowledge, converging them for the accomplishment of therapeutic acts together16.The bond can be recognized by the establishment of a relationship of solidarity and trust, so that the health professional understands the reception as an important strategy for the development of care15.

In order to do so, it is necessary for the worker to incorporate aspects of the human-human relationship into his everyday life, such as: conversation, listening, touching, sharing ideas, showing concern and expressing affection, among others17. However, it also seems to be necessary, in the case of crack users, to establish rules and limits within the mental health services, as highlighted mainly by the users:

[...] comes this drunk person or with the drink inside the bag, he will end up messing up and giving the image to the drug addict to do the very same thing. [...] They do not have a limit, they have no rules and they are not firm. We are the uncontrolled watch, we are all cluttered because we are drugged, and we are out of time. They are not having the pulse to deal with certain people. (U2)

I often see people coming in with alcohol, I think it's wrong. This is a treatment center here. [...] I do not know, the staff has to hang up, call the family to talk to them and this person. You need to set limits.(U5)

I think it takes a certain pulse to talk about what can and cannot, because in reality you must have a limit, especially for us. [...] Those who must have a firm hand are the coordinators because if one drug addict comes to the other and says that he is wrong he will not accept it.(U6)

More firm pulse, there are some fellows [...] who touch other people's things, you cannot let anything in the wardrobe, when you come back, it's all gone. [...] That's just wrong, because whoever wants to get in shape should not be in the middle of it.(U8)

During interviews and the observation phase, it was noticed that users were dissatisfied with the lack of rules in functioning and permanence in CAPS AD. This condition seems to be an important component of the care, since crack allows the user to "break" social norms. In order to regain self-control, it is necessary to invest, within the service, in a learning and adjustment that would allow him to understand that the world imposes commitments and regulations on his coexistence.

However, it is necessary to consider that most of the treatments offered in these situations are based mainly on the establishment of an ego strong enough to make the user give up the desires and instincts that lead him to consume the drug. One should not build relations based on the authoritarian model, excessive regulation, so that the experience of using the services be not harmful or painful. If this happens, there is a risk of creating a deep discomfort and returning it to the consumption of the substance18.

In this sense, it is necessary to find a common path that can be agreed upon by the worker and the crack user. What is revealed is an act of mutual interpretation between what the service can offer and what the user wants in his daily life16.It is in this sense that the importance of the creative and innovative potential of mental health work is signaled. This means that there is a dialectic that allows the worker to position himself and reflect on the world around him, showing that the act of caring presupposes the composition of limits, but also the necessary flexibility so that there is no rupture of bonds and abandonment of treatment.


Regarding the characteristics work in mental health with the crack user, the importance of substitutive services in the consolidation of user-targeted care strategies was highlighted. Thus, the results evidenced the need for investment in listening, in the bond with the user and in the treatment based on a contract, in which there is negotiation, but at times, the construction of more precise limits in this coexistence. Thus it is possible to increase the knowledge about the user's relationship with crack, so that the worker can resize this relationship.

The limit, as discussed, at first may seem restrictive to the user, preventing him from participating in decisions. However, for the users' own interest group, it is necessary. In this challenge, at first ambivalent, the worker must assess the ability to use social rules to show the user that he can "push just a little bit" in a pedagogical way. If the drug allows it to overturn these rules, he will have to take consequences. But the limit must also be worked so that it does not deviate from this pedagogical character, since it can reinforce a tendency of punishment and marginalization.

Regarding the evaluation method, the main characteristic to highlight is the possibility of giving voice to the interest groups in the evaluation process. This means that the evaluated object was constructed and negotiated with them, in a participatory and formative process. However, there is a need to establish concrete goals and objectives for evaluation indicators, so that there is a change in service practices. Research has been devoting itself to the topic at the moment.


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Received: December 14, 2015; Accepted: January 26, 2016

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