Evaluation of families of crack users in relation to support groups

Evaluación de las familias de usuarios de crack en el grupo de apoyo

ABSTRACT

Objective:

to evaluate the perception of the relatives of crack users in relation to the support groups offered to this population in a Psychosocial Care Center for Alcohol and Drugs in the South of Brazil.

Method:

the fourth-generation theoretical framework was used for evaluation, having as methodological device the hermeneutical-dialectic circle. Data collection occurred through 500 hours of observations and interviews with 12 relatives of crack users, and the comparative constant method was used in the analysis, generating the “family group” unit of meaning.

Results:

this group was regarded by the family members as a space for guidance on the management of users in their home environment. They reported the need for a basic structure to conduct the groups, greater duration of the meetings, confidentiality of information and diversity of timetables.

Final considerations:

investment in education and training of nursing professionals focused on group care is suggested to the education institutions.

Descriptors:
Self-Help Groups; Health Services Research; Crack Cocaine; Family; Mental Health

RESUMEN

Objetivo:

evaluar la percepción de los familiares de usuarios de crack sobre grupos de apoyo ofertados a ese núcleo de cuidado en un CAPS (Centro de Atención Psicosocial) Alcohol y Drogas del sur de Brasil.

Método:

se utilizó el referencial teórico de la evaluación de cuarta generación, teniendo como dispositivo metodológico el círculo hermenéutico-dialéctico. La recolección de datos ocurrió a través de 500 horas de observaciones y entrevistas con 12 familiares de usuarios de crack, y en el análisis se utilizó el método comparativo constante, que generó la unidad de significado “grupo de familia”.

Resultados:

ese grupo fue evaluado por los familiares como un espacio que instrumentaliza para el manejo del usuario en domicilio. Evaluaron la necesidad de estructura básica para la realización de los grupos, de mayor duración de los encuentros, de sigilo de las informaciones y de diversidad de horarios.

Consideraciones finales:

se sugiere a las instituciones de enseñanza inversiones en la formación y en la calificación de profesionales de enfermería dirigidos a la atención en grupo.

Descriptores:
Grupos de Autoayuda; Investigación en Servicios de Salud; Cocaína Crack; Familia; Salud Mental

RESUMO

Objetivo:

avaliar a percepção dos familiares de usuários de crack sobre grupos de apoio ofertados a esse núcleo de cuidado em um Caps Álcool e Drogas do sul do Brasil.

Método:

utilizou-se o referencial teórico da avaliação de quarta geração, tendo como dispositivo metodológico o círculo hermenêutico-dialético. A coleta de dados ocorreu através de 500 horas de observações e entrevistas com 12 familiares de usuários de crack, e na análise foi utilizado o método comparativo constante, que gerou a unidade de significado “grupo de família”.

Resultados:

esse grupo foi avaliado pelos familiares como um espaço que instrumentaliza para o manejo do o usuário em domicílio. Avaliaram a necessidade de estrutura básica para a realização dos grupos, de maior duração dos encontros, de sigilo das informações e de diversidade de horários.

Considerações finais:

sugere-se às instituições de ensino investimentos na formação e na qualificação de profissionais da enfermagem voltados para o atendimento em grupo.

Descritores:
Grupos de Apoio; Pesquisa sobre Serviços de Saúde; Cocaína Crack; Família; Saúde Mental

INTRODUCTION

The current mental health legislation advocates the gradual and planned reduction of beds in psychiatric hospitals, and prioritizes the deployment of community-based mental health services and actions that are able to effectively meet the needs of users requiring care⁽¹⁾.

Among the community-based services, Psychosocial Care Centers for Alcohol and Drugs (Caps) stand out, having been created to meet the great demand of users of crack, cocaine, alcohol and other drugs in Brazil, which has become a matter of public health. According to the World Health Organization, at least 10% of the population in urban centers all over the world consumes psychoactive substances in harmful ways⁽¹⁾. These centers are strategic devices of the network and begin to be deployed mainly in large metropolitan areas and regions or border municipalities with relevant epidemiological indicators⁽¹⁾.

A psychoactive substance that has caught the attention of the authorities, the media and society in general is crack, as it reaches all social classes and has been associated with the triggering of aggression and violence by public opinion, in addition to causing damages to personal health⁽²⁾. Crack is the result of a mixture of baking soda, cocaine hydrochloride and adulterants and, when smoked, it produces small particles absorbed by the lungs, rapidly causing the sensation of fleeting pleasure⁽³⁾.

Brazil has a high prevalence rate of cocaine users, in its various presentations, estimated at 0.7% in the population between 15-64 years old, representing the highest number of users in South America⁽⁴⁾. In the early 1990s, less than 10% of drug users admitted in hospitals were crack users; however, at the end of this same decade, this number rose to 80%. In the world, it is estimated that 14 million people make improper use of cocaine and crack, which is the main responsible for hospitalizations in the United States⁽⁵⁾.

The compulsive use of crack interferes with the user’s individual dimension, also compromising his/her social relationships, in such a way that stable and normalized social and family ties become fragile and break, progressively marginalizing him/her. The difficulty of coexistence between user and family is characterized as one of the main obstacles to be faced regarding the use of this substance⁽⁶⁾.

In this scenario, the AD care centers must insert the family in the context of care for crack users. When considering mental health care, the family’s insertion in the treatment is an indispensable element for the drug user’s rehabilitation. In this way, the family’s involvement in the mental health service and in the care for the crack user can favor the affective approach between its members, overcoming prejudice in relation to their disability and dangerousness and demystifying the idea of social exclusion⁽⁷⁾.

The AD care centers feature a series of activities aimed at both drug users and their families, due to the importance of the latter’s involvement in the former’s treatment. This participation can occur in different ways, such as through individual care, group care, workshops and home visits⁽¹⁾.

This study focuses on the support groups intended for relatives of crack users, who seek to obtain information, guidance, opinions, encouragement, experience-sharing and psychological support in these places. In addition, these groups offer to participants the opportunity to develop skills to fight the disease and for the treatment of their crack-using relative, from the contact with other people who experience similar situations⁽⁸⁾.

In the group, people can also develop bonds of friendship with the other participants. Over time, through the therapeutic bond, they start adhering more easily to the therapeutic activities proposed. This adhesion allows and promotes intersubjective exchanges, inclusion, self-perception, self-knowledge and expressions of affection, becoming a vehicle for the processing of information^(9-10). In addition, these spaces provide relief for distress and clarification of doubts, thus facilitating conviviality at the home environment and reaffirming the affective bonds between user and family.

This study stems from the experience of the researchers in education and extension activities in an AD care center, where the socialization with relatives of crack users in the family groups enabled exchanges about this reality. In this way, the family groups appear as powerful spaces for care. Thus, the guiding question is: what is the perception of the families of crack users about the support groups offered to this population in an AD care center located on the western border of Rio Grande do Sul?

It is understood that the fourth-generation theoretical framework can bring forward the empowerment of families as protagonists of the changes required for the qualification of the AD care centers in the care for the families of crack users in support groups.

This study is expected to enable advances in the scientific knowledge within the field of mental health and substance abuse, as well as report the importance of support groups as a strategy for care in alternative services, consolidating the network of support to the family of crack users.

OBJECTIVE

Evaluate the perception of the relatives of crack users in relation to the support groups offered to this population in an AD care center.

METHOD

Ethical aspects

Two copies of the Free and Informed Consent Form were used, in accordance with Resolution No. 466 of December 12, 2012, of the National Health Council, which approves the guidelines and regulatory norms for research involving human beings⁽¹¹⁾. This study was approved by the Research Ethics Committee of Universidade Federal do Rio Grande do Sul (UFRGS). It should be noted that this research was conducted in accordance with the ethical standards required.

Theoretical-methodological framework

The theoretical-methodological framework used in the research is that of the fourth-generation evaluation, proposed by Guba and Lincoln⁽¹²⁾. It is characterized by being descriptive and analytical, with a qualitative approach to data. It is also descriptive for having observed, recorded and correlated the facts without manipulating them.

Fourth-generation evaluation is a form of assessment in which the claims, concerns and issues of the group of interest serve as basis for determining the required information, which is implemented through the methodological assumptions of the constructivist paradigm⁽¹²⁾. The hermeneutic-dialectic circle was used as data collection technique which foresees, in a first step, observation and, subsequently, the interviews.

Type of study

It is an evaluation of the qualitative type, constructivist, responsive, with a hermeneutical-dialectic approach.

Methodological procedure

Study scenario

This study was conducted in an AD care center with one year of operation, located on the western border of the state of Rio Grande do Sul, serving a population of 125,435 inhabitants⁽¹³⁾.

Data source

Data collection took place in the period from June to September 2013 and featured 15 professionals designated as group of interest, from the total of 30 workers available at the service at that time. Four psychologists, three caretakers, two nursing technicians, three workshop instructors, an occupational therapist, a nurse and a doctor participated in data collection.

Data collection and organization

Five-hundred hours of observation were carried out, recorded in a field log. Initially, observation happened more freely, with the goal of understanding the service’s operation, the so-called previous ethnography stage⁽¹²⁾, totaling 160 hours. Then, the observations started focusing on the object of study, following a set of guidelines divided into three main categories (service, service to families of crack users and workers), for a total of 340 hours. This study included the participation of four observers which were not part of the service, who had knowledge about participatory observation and took turns in all shifts to collect more data about the research object.

Through the use of the hermeneutic-dialectic circle, the first interviews were less structured, allowing the respondent to talk freely about the service. However, as the interviews were carried out, the analysis allowed identifying issues to be expressed in the following ones, so that, increasingly, they became more structured, while continuing to allow all respondents to bring up new issues, if they so wished.

Twelve relatives of crack users who authorized the recording of the interviews and were in accordance with the criteria for inclusion were interviewed. The criteria for selection of the participants included those who belonged to at least one of the five family groups offered by the AD care center at the time of data collection, over 18 years old and with good conditions for communication. As criterion for exclusion, relatives who were not inserted in any groups offered by the service were disregarded. The subjects who made up the study were referred to as F (family) and numbered 1 to 12, in the order of interviews.

The interviews were scheduled previously according to the day, time and place chosen by the interviewees themselves. All of them were recorded and then heard, to introduce questions/issues for the next interview in the hermeneutic circle. In this way, the first interview lasted 20 minutes, and the last, one hour, seeing as the first respondent answered only two questions, and the last, twelve.

With the completion of the whole hermeneutic-dialectic circle, the interviews were transcribed in full. In this way, the stage of organization and analysis of the results to be presented at the negotiation meeting was initiated, which served to reach a consensus about the group. This meeting was held by the researcher herself and occurred through prior scheduling of date and time, having featured the attendance of 12 respondents.

Data analysis

For data analysis, the constant comparative method was used, which allows the analysis to be performed concomitantly with data collection⁽¹²⁾. Thus, these units made it possible to build the themes which subsequently directed the analytical categories of this study. In this way, the unit of meaning “family group” was discussed in the analytical category “care for the crack user’s family members”.

RESULTS

Family group

Most of the relatives of crack users interviewed were female (66.6%), consisting of mothers (58.3%), sisters (25%) and wives (8.3%), aged between 40 and 59 years old (60%). In relation to education level, most of the relatives reported incomplete elementary school (41.6%). Most respondents attended the AD care center once a week (58.3%) to participate in the family groups. Most of these families’ monthly income consisted of a single minimum wage (50%).

Prior to the opening of the AD care center, the support group for the relatives of crack users was organized in another care center of the same municipality. However, the rooms available for these groups were small, hindering the accommodation of the participants and the possibility for each family member to speak. In addition, the meetings occurred in just one day of the week, which often ended up demotivating the participants due to the lack of choice of times for attendance.

The difference is that it’s bigger here, the meeting rooms are larger. There wasn’t the same space there, because it was small and there were a lot of people in the group, it was a tight fit. (F5)

The room at that other center was small, but there were a lot of people, once there were 40 of them in a single room. (F7)

A family member said to another that was getting to know the service, in the hallway, that the rooms here at the AD care center are great, they’re big, and meetings are held at five different times. (Observer A)

The relatives evaluated negatively the overcrowding in the family groups at the other care center, as well as the size of the rooms. In the observations carried out during data collection, some family members reported positive points in relation to the wide physical structure of the AD care center and to the provision of five different times for holding the meetings. Thus, the importance of a proper room is understood, where everyone can be seen, in an environment that is conducive to exchanges, without interruptions.

The service provided by the AD care center through the support groups for the relatives of crack users was evaluated as an activity of paramount importance because, in addition to inserting the family member in the service’s daily routine, it provides relief and learning.

As I have a problem, I need to try and help others who have similar problems. The psychologist in the group teaches us, explains things, and we also get the chance to vent. She clarifies many things we don’t know. (F2)

The meetings are helping me. I see that I’m not the only one to have this problem, I’m not the only who deals with this, there are people who go through worse things [...]. I say what I think, I speak the news, clarify my doubts, I think that’s enough. I think that’s good. (F4)

The family group provides guidance and clarification of doubts about the treatment and the disorders caused by the use or abuse of alcohol and other drugs. In this way, the relatives’ group experience allows them to learn new behaviors, through the sharing of their problems and through acceptance, being an excellent therapeutic resource for strengthening the family at such moment.

During data collection, the AD care center offered five times for holding the meetings of the groups of support to relatives of crack users, which facilitates the participation of these families, contributing to the maintenance of the user’s treatment.

It has improved, because now there’s a meeting for each of the three shifts. Mine starts at 10:15. There’s even one at night. It’s gotten better for those who work. Those who can’t come in the morning or afternoon, may come at night. That’s a lot better. (F3)

It works for me. I asked to be part of that one because sometimes I do housecleaning and that’s the only time I can come. We can choose a time when we can participate. (F10)

The family members of crack users evaluated as positive the offer of meetings in the three shifts (morning, afternoon and evening), in addition to the different times, as it facilitated their participation in the treatment, without disrupting their work and leisure routines.

However, the respondents reported that the meetings did not last long enough for them to express themselves equally.

Depending on the amount of people who are in the group, sometimes some can speak and others can’t. (F7)

It’s just 1 hour. So I think 1 hour is not enough, I think it needs to last a little longer, 2 hours tops. That’s because many mothers want to speak and sometimes we’re eager to talk and vent, but we’re short on time so we can’t. (F9)

The time intended for the group sessions should be organized so that all members can speak, providing greater participation and involvement of all, within the previously established time.

Some participants had difficulty to interact in the group, especially due to being around strangers. Despite this initial barrier, they thought it was important to listen to the life experiences of other families and learn from these reports.

There are a few who are sometimes embarrassed to speak in front of others, especially those who come for the first time, they usually ask to speak in private, they’re scared of exposing themselves in front of everybody. (F12)

The family members usually don’t speak, that’s why I talk a lot during the meeting, because the families look withdrawn and weary of exposing their drug user-related issues. (F1)

The respondents reported that there are many families who come to the meetings for the first time and feel too embarrassed to talk or even expose themselves in front of other people. They arrive there frightened and withdrawn and assume a position of listening in that first moment. It is up to the moderator of the group to notice this initial difficulty and assist in their integration, emphasizing the importance of verbalization of each participant’s case, both for themselves and for the other members of the group.

The family members evaluated as important the confidentiality of the information that is revealed by the members of the group. Trust in this secrecy facilitates the exposure of the stories told by the relatives of crack users.

That’s how it should be, it stays there, you can cry, scream, swear, say everything you think, but it stays there. (F11)

Thus, it is important that the coordinator of the group emphasizes at each meeting the importance of the confidentiality of the information shared, an agreement by which all participants must abide.

The respondents also reported changes in their conduct caused by their participation in the group at the AD health center, in relation to the crack user.

The group here at the center helps mostly in relation to his behavior. It helps us being firmer, telling him the things he needs to hear, learning how to say no. (F11)

I used to believe drug users were nothing but rascals. Because it’s one thing to look at it from the outside! But it’s a lot different when it happens to us. I began to understand what was a user was. Because I didn’t know how to deal with it before, but now I do. They have taught me a lot here at the group, but it’s hard. (F12)

The relatives evaluated positively their change in attitudes with respect to the drug user’s chemical dependency. They reported that the meetings helped them understand the addiction, the user’s behavioral issues, in addition to helping maintain a more energetic conduct at the home environment.

The respondents evaluated their participation in the group as important because they felt welcomed there, which allowed them to speak, cry, talk, ask for help, that is, express their feelings, without fear of being judged.

DISCUSSION

The basic structure for organizing a group is based on the physical condition of the environment for realization of the activities, such as: a large, well ventilated and bright room, with accommodation for all participants, allowing all of them to be seen⁽¹⁴⁾.

This conception of ambience converges to the construction of welcoming and harmonious places that propitiate the meeting between health professionals and users of the service, ensuring their well-being and going against the stereotype that these spaces are cold and hostile. Thus, they need to be not only more functionally appropriate, but also provide pleasurable environments to all who use them⁽¹⁵⁾.

Currently, the health centers need to open their doors for the families’ insertion, integrating them and encouraging their participation in the activities carried out by the institution, also supporting them so they can jointly contribute to the health of the service’s user^(16-17).

The group services with participants who experience the same situation facilitate the identification and exchange of secrets, particularities and intimacy between members, also allowing the health team to meet the real needs and concerns of these relatives, facilitating the planning of care with greater emphasis on the family^(18-19).

In this way, it is verified that the family group appears as a form of insertion of the family and a strategy used by the support service to assist in the therapeutic process. In addition to including it in the service, it provides guidance on the care for the drug user^(16,20).

Also, it is important that certain specifications, such as time limit, are explained to the participants at the beginning of the session. It is the responsibility of the coordinator of the group to stipulate for how long each participant is allowed to speak, thus favoring the involvement of all family members, ensuring equal opportunities to all of them. The satisfaction of the participants is considered an essential indicator for the evaluation of the effectiveness of the support groups⁽²¹⁾.

In this sense, it is necessary that the professionals who coordinate the groups know how to manage the time conceded to each participant, so everyone is able to express their feelings and doubts. Thus, it is important that the professional has knowledge about the groups, their characteristics and operation dynamics⁽²⁰⁾. He/she must provide a warm and secure environment, enabling and encouraging the families to expose personal matters, so that the care and respect for others, their feelings and their points of view are prioritized^(19,21).

The coordinator also needs to understand that, in the field of Health, professional secrecy requires protection and has great practical and social utility, as it associates legal obligations and moral postulates to be met⁽²¹⁾. Confidentiality must be respected by both parties (participants and professional), seeing as confidence is essential when working with mental health. Secrecy is necessary for the group to feel protected^(7,21).

Thus, participation in the group represents a continuous source of information, which strengthens the family, assisting it in making decisions regarding care for the drug user, based on the knowledge acquired^(7,21).

Study limitations

It is necessary to point out the limitations of this study, considering that the hermeneutical-dialectic process is dynamic, thus there may be data that could have been included in the discussions. However, the time factor interfered with the research process.

Contributions to the field of Nursing

The resulting data of this study may stimulate further research in other scenarios, encompassing different realities in which Nursing is inserted, and thus contribute to improve the service provided to families within the context of crack and other drugs.

FINAL CONSIDERATIONS

This research had as objective to evaluate the perception of the relatives of crack users in relation to the support groups offered to this population in an AD care center in the South of Brazil.

Some issues were brought up by the families during the interviews, including: overcrowded meetings at the other center, family group service, the diversity of timetables for meetings in the AD care center, the duration of the meetings, the discomfort to talk during the meetings felt by some families, the confidentiality of the information disclosed during the meetings and the family’s change in attitude in relation to the crack user.

The groups offered by the AD health center were evaluated as an additional instrument in the care for the relatives of crack users, as they provide knowledge, comfort and relieve anxiety, benefitting also the users. This is how the research’s results reinforce the importance of family groups within an alternative service such as the AD health center, offering solace, information, confrontation against prejudice, support and treatment.

The transformation process the field of mental health went through advocates the presence and strengthening of the participation of the drug user’s family in the alternative daily services in this area, directly affecting the rehabilitation process.

Fourth-generation evaluation is an important methodological possibility in the field of mental health, as it makes it possible to access dimensions which cannot be seized by measurements and indicators. In this way, it is considered that this methodology provided a participatory evaluation process, giving voice to the families of the crack users in the AD health center and allowing the sharing of the results of the analyses by the evaluator and by the group of interest.

This study has as limitation the fact it is based on data pertaining to a specific service and, therefore, does not allow generalizations. Also, considering that the hermeneutical-dialectic process is dynamic, there may be data that could have been included in the discussions. However, the time factor interfered with the research process.

Therefore, it is important that professionals who act as group coordinators in AD health centers seek knowledge about this device of care for family members, with the aim of changing practices focused on the users only. Also, it is important to carry out researches that explore the key challenges in the care for and integration of the family, and in the promotion of groups by the services specialized in mental health.

The training of professionals for this purpose, with an emphasis on creativity and dynamics, would consolidate the participation of relatives who are not very present in the context of these territorial services. The need for education institutions to invest on this discussion and on the training of nursing professionals focused on family group service is emphasized, demonstrating the potential of these workers within the health center.

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Publication Dates

• Publication in this collection
  2018

History

• Received
  20 Mar 2018
• Accepted
  10 Apr 2018