Abstract

Introduction

Using behavior, consciousness and mood altering substances dates back millennia. Throughout human history drugs have been used in rituals and for therapeutic and medicinal ands. However, viewing drug use as a social problem is recent (Labate et al., 2008LABATE, B. C.; FIORE, M; GOULART, S. L. Tráfico, guerra, proibição. In: CARNETIRO, H. (Org.). Drogas e cultura: novas perspectivas. Salvador: Edufba, 2008. p. 23 -38.).

Pulcherio et al. (2010)PULCHERIO; G. et al. Crack: da pedra ao tratamento. Revista de AMRIGS, Porto Alegre, v. 54, n. 3, p. 337-343, 2010., on the topic of crack use, commented that use of the drug in Brazil and worldwide was increasing. Although prevalence in Brazil is low, approximately 1% according to population studies, it is responsible for up to 70% of cocaine related hospitalizations.

Concerning the harmful effects associated with crack, users often suffer from organic and psychological problems. Moreover, they are also exposed to the social risks related use of this drug. The psychological effects of the drug are: feeling persecuted, restlessness and, afterwards, depression; it can also lead to respiratory problems, loss of appetite, sleeplessness, cracked lips and cuts and burns on the fingers and nose. Difficulty eating may lead to malnutrition, dehydration and gastritis (Brasil, 2009BRASIL. Ministério da Saúde. Coordenação Nacional de Saúde Mental, Álcool e Outras Drogas. O crack: como lidar com este grave problema. Brasília, DF, 2009. Disponível em: <http://www.ccs.saude.gov.br/saudemental/pdfs/crackcomolidarcomestegraveproblema.pdf>. Acesso em: 22 ago. 2011.
http://www.ccs.saude.gov.br/saudemental/... ).

Therefore, problems associated with using crack cocaine can be considered to be public health problems, as use of the drug has complicated effects and affects the health and quality of life of users, their families and society as a whole (Azevedo and Miranda, 2010AZEVEDO, D. M.; MIRANDA, F. A. N. Práticas profissionais e tratamento ofertado nos CAPSad no município de Natal-RN: com a palavra a família. Escola Anna Nery Revista de Enfermagem, Rio de Janeiro, v. 14, n. 1, p. 56-63, 2010.).

However, although using this drug is often associated with social, health and public safety problems, it is important to point out that drug use is not the only behavior related to risk, as activities like driving, doing sport, travelling and eating can also cause problems for individuals and, therefore, drug use should not be viewed as something of an essentially negative nature, as it can also occur within stable social relationships, without causing harm to the subjects (Labate et al., 2008LABATE, B. C.; FIORE, M; GOULART, S. L. Tráfico, guerra, proibição. In: CARNETIRO, H. (Org.). Drogas e cultura: novas perspectivas. Salvador: Edufba, 2008. p. 23 -38.).

Corroborating this idea, the study by Oliveira and Nappo (2008)OLIVEIRA, L. G; NAPPO; S. A. Caracterização da cultura de crack da cidade de São Paulo: padrão de uso controlado. Revista de Saúde Pública, São Paulo, v. 42, n. 4, p. 664-671, 2008. on the predominant crack user profile identified a pattern of controlled use of this substance, as the subjects of this research maintained their social links with family, school and work and were not involved in crime.

An important aspect that should be considered when looking at the use of any psychoactive substance concerns the discussion on family relationships. In this sense, the family context can act as either a protection or a risk factor for drug taking behavior: this is what Schenker and Minayo (2005)SCHENKER, M.; MINAYO, M. C. M. Fatores de risco e de proteção para o uso de droga na adolescência. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 3, p. 707-717, 2005. affirm. The family, as well as the school and friends are considered to play a role in the first socialization of children and adolescents. Moreover, in out post-modern world, family structure can be arranged in several ways.

Family units, then, can be organized in different ways, varying from traditional combinations, such as the nuclear family, to the more complex arrangements that exist today. Blood ties have ceased to be the principle element in defining a family. Thus, terms such as kinship, affinity and cohabitation become part of the concept of family. It is important to emphasize that the form in which a family is structured does not define the pattern of functioning, in other words, remarried, single parent or single sex families do not have one typical way of functioning according to their composition (Wagner et al., 2011WAGNER, A.; TRONCO, C.; ARMANI, A. B. Os desafios da família contemporânea: revisitando conceitos. In: _______. (Org.). Desafios psicossociais da família contemporânea: pesquisas e reflexões. Porto Alegre: Artmed, 2011. p. 19-35.).

Corroborating what has been said above, Garcia et al. (2011)GARCIA, J. J.; PILLON, S. C.; SANTOS, M. A. Relações entre contexto familiar e uso de drogas em adolescentes de ensino médio. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 19, p. 753-761, 2011. Número especial., analyzing the relationship between substance abuse and nuclear family structure, found that a higher quantity of drug users in the study were from homes with a traditional nuclear family structure: father, mother and children, which contradicts the common belief that non-traditional family arrangements can lead to drug use. The above mentioned study also identified that, in families of psychoactive substance users, there was often violence, or drug use by other family members, suggesting that substance abuse is linked with conflict in family relationships rather than the construction of the family.

Ribeiro and Dualibi (2010)RIBEIRO, M.; DUALIBI, L. Avaliação de fatores de proteção e de risco. In: RIBEIRO, M.; LARANJEIRA, R. (Org.). O tratamento do usuário de crack. São Paulo: Casa Leitura Médica, 2010. p. 175-186. discuss how families are protective when they offer supportive, harmonious, stable and safe domestic environments, with clear rules of behavior and the parents involved in the children’s lives. They can, however, pose a risk when the domestic environment is chaotic, if there is drug taking, or favorable attitudes to drug taking, parents who do not provide support, lack of control and high or unrealistic expectations placed on family members. The authors highlight that it is not only family relationships which influence drug abusing behavior; other variables, related to the community in which the user lives, school, friends etc., are also linked.

Considering the role family plays in discussions of drug use, it is appropriate to look here at the ways in which families exercise their educational practices. Benchaya et al. (2011)BENCHAYA, M. C. et al. Pais não autoritativos e o impacto no uso de drogas: a percepção dos filhos. Jornal de Pediatria, Rio de Janeiro, v. 87, n. 3, p. 238-244, 2011., looking at the relationship between drug use and parenting styles, discuss how maternal and paternal styles perceived as negligent, indulgent and authoritarian are positively associated with drug use, and that authoritative parents are negatively associated. Parents who show low levels of responsiveness and demonstrating affection or control are considered negligent. Indulgent parents are very affectionate. But undemanding. Authoritarians are more demanding, as they impose more rules, and are not very affectionate. Authoritative parents show support and affection, while setting effective limits.

In addition to parenting practices which are unfavorable, many families lack knowledge about the issue. The research by Brusamarello et al. (2008)BRUSAMARELLO, T. et al. Consumo de drogas: concepções de familiares de estudantes em idade escolar. SMAD - Revista Eletrônica Saúde Mental Álcool e Drogas, Ribeirão Preto, v. 4, n. 1, 2008. Disponível em: <http:// pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1806-69762008000100004&lng=pt&nrm= iso>. Acesso em: 10 abr. 2013. 
http:// pepsic.bvsalud.org/scielo.... , which aimed to investigate parents’ concepts of drug use, indicated that family members are still ill informed about types of drugs and also unaware how to prevent their use. Moreover, many families see drug use as something that does not affect them, something done by acquaintances or distant relatives.

The parents’ behavior should also be considered when discussing drug use by their children, as the family is the first nucleus of learning and of knowledge, beliefs and behavior which are constructed, shared and imitated in social existence. It is common to see people drinking alcohol in family events, such as weddings, birthdays and christenings. Thus, consuming alcohol is a frequent practice in this type of family event (Roehrs et al., 2008ROEHRS, H.; LENARDT, M. H.; MAFTUM, M. A. Práticas culturais familiares e o uso de drogas psicoativas pelos adolescentes: reflexão teórica. Escola Anna Nery Revista de Enfermagem, v. 12, n. 2, p. 353-357, 2008.).

It is this legal drug, alcohol, often deemed inoffensive in the view of various parents, which has a clear influence on the children’s behavior. Bernady and Oliveira (2010)BERNARDY, C. C. F.; OLIVEIRA, M. L. F. O papel das relações familiares na iniciação ao uso de drogas de abuso por jovens institucionalizados. Revista da Escola de Enfermagem da USP, São Paulo, v. 44, n. 1, p. 11-17, 2010., analyzing parents’ beliefs about drug use, found that many did not see alcohol as a dangerous drug and therefore this substance was part of everyday life for many families, present in leisure activities at weekends.

Nonticuri (2010)NONTICURI, A. R. As vivências de adolescentes e jovens com o crack e suas relações com as políticas sociais protetoras neste contexto. 2010. Dissertação (Mestrado em Políticas Públicas) -Universidade Católica de Pelotas, Pelotas, 2010. commented, on problems associated with drug use, that drug users’ family relationships can be marked by various types of situations, as there are cases in which the user prefers to hide the problem from the family; others come into conflict with their families, stealing form them. However, the most common situation is that of distancing themselves from family life, which contributes to breaking family ties.

To deal with conflicts between crack users and their families, treatments for drug use, such as those conducted by CAPSad, should include working with the user’s family, offering them support. The institution should also offer: a universal welcome to anyone who seeks their services; treatment for mild withdrawal in an outpatient setting; actions working together with other organizations offering care to crack users; regular care for users both when in crisis or otherwise; provide users who have dropped out of treatment with a living space, among other activities (Brasil, 2010BRASIL. Ministério da Saúde. Coordenação Nacional da Saúde Mental. Abordagens terapêuticas a usuários de cocaína/crack no Sistema Único de Saúde. Brasília, DF, 2010.).

The relationships between family and drug taking behavior mean it is important to analyze meanings, feelings and experience for families of crack users undergoing treatment.

Methodology

This was a qualitative study, looking for meanings, opinions and feelings to possibly understand (analyze) the social phenomenon and its relationships to the field of public mental health, with the aim of understanding knowledge, seeking the meaning and significance of the phenomenon studied (Minayo, 2006MINAYO, M. C. S.; DESLANDES, S. F. O desafio do conhecimento: pesquisa qualitativa em saúde. 8. ed. Rio de Janeiro: Abrasco, 2006.).

Qualitative research recognizes the existence of a relationship between the researcher and the object studied, in other words, interdependence between subject and object, established interpretively, without neutrality. The subject is part of the process: subject-observer, attributing meaning to the phenomena they interpret. The object is constructed, that is, it is signified in the direct relationship between it and the subject, based on discussion (Demo, 1989DEMO, P. Metodologia científica em ciências sociais. São Paulo: Atlas, 1989.).

The study took place in the CAPSad in Executive Regional Secretariats (SER) IV and V of the municipality of Fortaleza – Ceará. SER IV had 280 thousand inhabitants and consists of 19 neighborhoods, and SER V has 570 thousand inhabitants and 76 neighborhoods (Fortaleza, 2008FORTALEZA. Secretaria Municipal de Saúde. Plano municipal de saúde de Fortaleza: 2006-2009. Fortaleza, 2008.). SER IV and V were chosen as they had agreements with the Municipal School Health System, in which the Universidade Estadual do Ceará (UECE) and the Fortaleza prefecture developed partnerships in socio-community training and activities.

CAPSad is the main health care strategy dealing with substance abuse and uses harm reduction strategies as tools in prevention and health promotion. Thus, CAPSad is a substitution service, according to the principles of the Psychiatric Reform, which recommend that treatment for drug dependency take place, if possible, in an open way, coordinated with the mental health network, emphasizing rehabilitation and social re-acceptance of users (Azevedo and Miranda, 2010AZEVEDO, D. M.; MIRANDA, F. A. N. Práticas profissionais e tratamento ofertado nos CAPSad no município de Natal-RN: com a palavra a família. Escola Anna Nery Revista de Enfermagem, Rio de Janeiro, v. 14, n. 1, p. 56-63, 2010.).

The participants were 14 health care workers, working in the CAPSad of SERs IV and V, 21 users receiving treatment for crack use in the CAPSad, and 4 family members. Inclusion criteria for the workers were: working with crack users undergoing treatment and having worked in the CAPSad for at least six months; for users: those who had been treated in the CAPSad for at least six months, those who were being treated for crack abuse and who were over the age of 18; for the family members: those who were accompanying a family member being treated at the CAPSad for crack abuse, although they did not necessarily have to be related by blood. Thus, 39 individuals took part in the study, including some workers. This number was due to the way in which data were collected and the phenomenon analyzed, as understanding and depth of investigation of the issues raised was judged using theoretical saturation.

A semi-structured interview was conducted with each of the participants, covering issues referring to the experiences of family members with relatives being treated for crack abuse in the CAPSad. The interviews took place within the service itself and were recorded, with permission previously obtained from the interviewees using a consent form conforming to the standards set by the Research Ethics committee of the Universidade Estadual do Ceará, record number: 10724251-6. The interviews were then transcribed and the data analyzed.

After transcription, the interviews were subject to skim and detailed readings, to know the material in depth. The information was analyzed using hermeneutic and reflective analysis, which enabled convergences, divergences and complementarities to be established, as well as clashes in opinions of the topic studied.

Results and discussion

Families’ experience of treatment for crack users: cultural and relationship feelings and meanings

The meanings the family members attributed to the drug were quite negative as, for them, this substance provoked feelings of sadness, shame, destruction and feeling at rock bottom. There were also instances of the relatives viewing the crack user as shameless and viewing them with suspicion, not believing that they would give up using crack.

The findings are in agreement with those of a study carried out by Nonticuri (2010)NONTICURI, A. R. As vivências de adolescentes e jovens com o crack e suas relações com as políticas sociais protetoras neste contexto. 2010. Dissertação (Mestrado em Políticas Públicas) -Universidade Católica de Pelotas, Pelotas, 2010., who comments that families often interpret drug abuse in family members as “shamelessness”, they cannot stand the violence within the home. Moreover, it often happens that the families forgive everything and it all starts all over again.

The negative feelings reported by family members are in concordance with the study by Brusamarello et al. (2008)BRUSAMARELLO, T. et al. Consumo de drogas: concepções de familiares de estudantes em idade escolar. SMAD - Revista Eletrônica Saúde Mental Álcool e Drogas, Ribeirão Preto, v. 4, n. 1, 2008. Disponível em: <http:// pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1806-69762008000100004&lng=pt&nrm= iso>. Acesso em: 10 abr. 2013. 
http:// pepsic.bvsalud.org/scielo.... on the parents’ perceptions regarding drugs, which indicate that parents understand that crack is something which provokes negative feelings, such as fear, a sense of danger, destruction. However, the authors highlight that the relationship between the user and the psychoactive substance needs to be considered, as the drug acts in a different way depending on the individual, and this is related to physical and social factors, among others.

In order to understand this category of analysis, it is important to understand the terms senses and meanings. When discussing senses and meanings, Wazlawick et al. (2007)WAZLAWICK, P.; CAMARGO, D.; MAHEIRIE, K. Sentidos e significados da música: uma breve “composição” a partir da psicologia histórico-cultural. Psicologia em estudo, Maringá, v. 12, n.1, p. 105-113, 2007. used the ideas proposed by Vygotsky (1987, 1992 apud Wazlawick et al., 2007WAZLAWICK, P.; CAMARGO, D.; MAHEIRIE, K. Sentidos e significados da música: uma breve “composição” a partir da psicologia histórico-cultural. Psicologia em estudo, Maringá, v. 12, n.1, p. 105-113, 2007.) and Luria (1986 apud Wazlawick e col., 2007WAZLAWICK, P.; CAMARGO, D.; MAHEIRIE, K. Sentidos e significados da música: uma breve “composição” a partir da psicologia histórico-cultural. Psicologia em estudo, Maringá, v. 12, n.1, p. 105-113, 2007.). Thus, meaning refers to a system of relationships constituted objectively through an historical process, i.e., when the meaning of the word is assimilated, the social experience is learned.

Sense corresponds to the individual and may designate completely different things for different individuals and in different circumstances. These ideas are understood by Maheirie (2003)MAHEIRIE, K. Processo de criação no saber musical: uma objetivação da subjetividade a partir dos trabalhos de Sartre e Vigotsky. Psicologia em estudo, Maringá, v. 8, n. 2, p. 147-153, 2003., based on Vigotsky (1987, 1992 apud Wazlawick et al., 2007WAZLAWICK, P.; CAMARGO, D.; MAHEIRIE, K. Sentidos e significados da música: uma breve “composição” a partir da psicologia histórico-cultural. Psicologia em estudo, Maringá, v. 12, n.1, p. 105-113, 2007.), as a collective dimension, meanings experienced collectively. Sense corresponds to something experienced singularly. However, both terms are produced in the social context, as it is impossible to separate the subject from their context.

Thus, there are some issues that need to be explored in treatment for drug users, such as the senses and meanings attributed by the family to the user undergoing treatment. Working with the families should go beyond providing information on the problem, this requires the health care team to know the families’ needs, as well as their representations on crack use, seeking comprehensive care, subjectivity in the treatment process and the psychosocial dimension (Jorge and Pinto, 2010JORGE, M. S. B.; PINTO, A. G. A. Adoecimento mental e a família: representações e subjetividades. In: BOMFIM, L. A. (Org.). Família contemporânea e saúde: significados, práticas e políticas públicas. Rio de Janeiro: Fiocruz, 2010. p. 335-370.).

This research noted a change in the meanings attributed to the user when family members were engaged in the treatment, as they reported that, on starting treatment in the CAPSad, they got a different view of the user, stopped seeing them as someone sick who needed to be treated differently. The family members stated that, in the service, they learned to deal with the crack user better. The workers, meanwhile, reinforced that, in CAPSad, the families learned that using psycho-active substances is a disease.

The fact of receiving treatment in the CAPS contributed to changes in meaning. Azevedo and Miranda (2010)AZEVEDO, D. M.; MIRANDA, F. A. N. Práticas profissionais e tratamento ofertado nos CAPSad no município de Natal-RN: com a palavra a família. Escola Anna Nery Revista de Enfermagem, Rio de Janeiro, v. 14, n. 1, p. 56-63, 2010. commented that, in spaces of family participation, the CAPSad team should aim to deconstruct and re-create concept related to crack use and crack users, as family members involved in treatment, participating regularly in activities, such as: Family Group Therapy, Family Meetings, walks, parties and celebrations, have better expectations concerning the users’ treatment and learn to deal better with the problem of drug use.

However, attributing the meaning of being ill to the user places them in a position of passivity, and not that of a citizen with rights. For Rosa (2010)ROSA, P. O. Uso abusivo de drogas: da subjetividade à legitimação através do poder psiquiátrico. Revista Pan-Amazônica de Saúde, Ananindeua, v. 1, n. 1, p. 27-32, 2010., looking at a psychoactive substance user as ill creates a stereotype of dependency, encouraging medical power and negating the subjects’ autonomy to the detriment of the idea of being cured. This fact becomes a simplistic problem when only the user’s organic state is taken into account, encouraging stigmatization.

In this context, the biomedical model’s limitation regarding its inability to deal with other human dimensions which also affect quality of life, such as relationships between the subject and the environment, is questioned (Ceolin et al., 2009CEOLIN, T. et al. A inserção das terapias complementares no sistema único de saúde visando o cuidado integral na assistência. Enfermaría Global, Murcia, n. 16, p. 1-9, jun. 2009. ).

Thus, it can be observed that the CAPSad bases its practices on a biomedical model, aiming to “cure” through abstinence. There is, therefore, a need to de-construct all practices aimed at the disease and reconstruct a health care model which no longer works through exclusion and little capacity to solve problems but rather guarantees the user’s dignity and that of their family (Santos et al., 2008SANTOS, A. M. et al. Vínculo e autonomia na prática de saúde bucal no Programa Saúde da Família. Revista de Saúde Pública, São Paulo, v. 42, n. 3, p. 464-470, 2008.).

Thus, the approach of Reducing Harm is shown to resolve problems better for crack users, as they cover a higher number of subjects, seeing as the abstinence model often excludes individuals who cannot stick to it. However, the therapy recommended in the Reducing Harm approach is considered to be “undemanding” as it is an obligatory requisite of the program that users abstain, although this does not mean that the treatment opposes abstinence as the ideal result. The focus of the strategy is on minimizing drug related social and health damage (Alves, 2009ALVES, V. S. Modelos de atenção à saúde de usuários de álcool e outras drogas: discursos políticos, saberes e práticas. Cadernos de Saúde Pública, Rio de Janeiro, v. 25, n. 11, p. 2309-2319, 2009.).

In addition, the practices in the Reducing Harm strategy base their practice and actions on a psychosocial and not just the biological understanding of the problem, considering the human being as a whole, endowed with subjectivity, knowledge and activities in the development process, seeking to break with the Cartesian biomedical model (Pratta and Santos, 2009PRATTA, E. M. M.; SANTOS, M. A. O processo saúde-doença e a dependência química: interfaces e evolução. Psicologia: Teoria e Pesquisa, Brasília, DF, v. 25, n. 2, p. 203-211, 2009.).

Another meaning attributed by family members was viewing the user as a problem from which they had to free themselves through hospitalization, this being the first alternative the family sought. The workers highlighted that the families are very shortsighted and seek rapid treatment, many of them do not become engaged in the therapeutic process and leave all of the responsibility for the health care service professionals. This meaning was also verified from the families’ statements.

Thus, research by Raupp (2006)RAUPP, L. Adolescência, drogadição e políticas públicas: recortes no contemporâneo. 2006. Dissertação (Mestrado em Psicologia Social e Institucional) - Universidade Federal do Rio Grande do Sul, Porto Alegre, 2006., aiming to identify and describe ways of the approaches of services belonging to the public health care network towards drug users, indicated that the majority of hospitalizations in the study were involuntary, through some form of coercion, without the consent of the patient or any explanation given about the treatment, and that it was mainly the family who were responsible for this.

It also happens that the family try to have the drug user hospitalized as kind of punishment for behavior associated to drug use (Sabino and Cazenave, 2005SABINO, N. M.; CAZENAVE, S. O. S. Comunidades terapêuticas como forma de tratamento para a dependência de substâncias psicoativas. Estudos em Psicologia, Campinas, v. 22, n. 2, p. 167-174, 2005.).

Complementing the meaning of the user as a problem, families often also believe that crack users are incapable of feeling affection for anyone or anything apart from the drug and for this reason living with them is difficult, with family members preferring to distance themselves from the user. Nonticuri (2010)NONTICURI, A. R. As vivências de adolescentes e jovens com o crack e suas relações com as políticas sociais protetoras neste contexto. 2010. Dissertação (Mestrado em Políticas Públicas) -Universidade Católica de Pelotas, Pelotas, 2010. comments that emotional numbness is not the rule, but may exist, when using crack, in other words, inability to feel, to relate to other people, making empathy impossible and making it difficult to form ties of affection. However, this difficulty in relating to others does not only affect the crack user, but is also associated with various social obstacles which users face.

Faced with these difficult family relations and the negative senses and meanings attributed to crack users by the family, another situation which was observed in the interviewees’ statements was a loss of family ties.

(De)Construction of family ties with users

The family members report that, when there is a crack user in the family, relationships are permeated with much suffering, due to the user’s behavior. Often, the family end up by losing patience and act in a quite aggressive manner to subjects abusing drugs.

Such attitudes on the part of the family members is in agreement with the literature studied, as Nonticuri (2010)NONTICURI, A. R. As vivências de adolescentes e jovens com o crack e suas relações com as políticas sociais protetoras neste contexto. 2010. Dissertação (Mestrado em Políticas Públicas) -Universidade Católica de Pelotas, Pelotas, 2010. comments that these attitudes of striking hard or giving up are common in families living with a drug user, as attempts to help the family member are often fruitless.

The family members also report users acting often aggressively towards their families and involvement in crime, such as stealing, in order to buy crack. Criminal behavior may be related to the cravings that crack creates, as Oliveira and Nappo (2008)OLIVEIRA, L. G; NAPPO; S. A. Caracterização da cultura de crack da cidade de São Paulo: padrão de uso controlado. Revista de Saúde Pública, São Paulo, v. 42, n. 4, p. 664-671, 2008. indicate that this effect is worth highlighting, as it can lead users to illicit practices in order to obtain the substance, as this is associated with an uncontrollable urge to use crack, which can mean users becoming involved in risky behavior.

However, Minayo and Deslandes (1998)MINAYO, M. C. S.; DESLANDES, S. F. A complexidade das relações entre drogas, álcool e violência. Caderno de Saúde Pública, Rio de Janeiro, v. 14, n. 1, p. 35-42, 1998. consider that drugs or alcohol are involved in many cases of violence, although it cannot be affirmed that this is a causal relationship. Moreover, the authors believe that the idea that illegal substances and poverty are the main causes of violent events is a fallacy, as other variables, depending on each context, should also be analyzed.

The workers, as with the family members, associated the crack user with difficult family relationships, as they perceive that drug use means the family and the users are in constant conflict. Moreover, they believe that many family members do not know how to deal with users and do not even respect their individuality. Raupp (2006)RAUPP, L. Adolescência, drogadição e políticas públicas: recortes no contemporâneo. 2006. Dissertação (Mestrado em Psicologia Social e Institucional) - Universidade Federal do Rio Grande do Sul, Porto Alegre, 2006. discusses how family relationships when there is a drug user are generally permeated by fights and arguments, which contributes to emotional distance:

Moreover, the workers believe that the family is the main reason for relapses, as they notice a lot of resentment in family relationships. Seleghin et al. (2011)SELEGHIM, M. R. et al. Family ties of crack cocaine users cared for in a psychiatric emergency department. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 19, n. 5, p. 1163-1170, 2011.  comment that conflictive family relationships are associated with drug using behavior: this was shown by the authors, who sought to discover users’ family relationships, as the majority of subjects who use drugs have a history of intra-family violence, such as fights, arguments and drug use by other family members.

Faced with conflictive relationships between crack users and their families, CAPSad workers believe that users suffer a loss of family ties and that this also happens as the family have already tried, more than once, to help the user, who repeatedly relapses. Then, the family feels helpless and end up giving up on that family member and, often kick them out of the home, which makes treating them more difficult. Almeida (2010)ALMEIDA, R. B. F. O caminho das pedras: conhecendo melhor os usuários de crack do município de Recife-PE. 2010. Dissertação (Mestrado em Psicologia Clínica) - Universidade Católica de Pernambuco, Recife, 2010. comments how it is common to lose family ties and, because of this, the user feels desperate, as they believe the family no longer respect or trust in their current attitudes, much less in their promises to stay clean.

Users comment that the experience of living with a crack user often makes families ill, making them “codependent”, as they recognize that it is very difficult to live with them and their families suffer a lot. The term “codependence” used by the users also demonstrates the biomedical understanding of family conflicts associated with drug use.

Users also reported that many family members, including those closest to them, such as children, did not want any type of link with them. Seleghim et al. (2011)SELEGHIM, M. R. et al. Family ties of crack cocaine users cared for in a psychiatric emergency department. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 19, n. 5, p. 1163-1170, 2011. , analyzed crack users’ family ties in a psychiatric institution, and discovered that the majority of those who had been institutionalized did not have any contact with their parents and that this link had generally been broken from adolescence onwards, and that ex-companions had often become distant due to relationship conflicts. Moreover, the majority did not have any contact with their children.

Despite loss of connection with family members being a common occurrence in the life of users, they report that they found support from their families and that this was often the driving force in seeking treatment:

The users told how they sought help through family intervention. And CAPS workers confirmed this statement, describing how, generally, users turn up for their first day of treatment accompanied by a family member and that, in the majority of cases, the idea of treatment came from the family.

Family members also reported giving users support on starting their treatment at CAPS, according to them, the treatment lead to a change in behavior on the part of the problematic member, improving relationships between them.

The family being viewed as a support agrees with the literature studied, as, according to Almeida (2010)ALMEIDA, R. B. F. O caminho das pedras: conhecendo melhor os usuários de crack do município de Recife-PE. 2010. Dissertação (Mestrado em Psicologia Clínica) - Universidade Católica de Pernambuco, Recife, 2010., the family can be a driving force in seeking treatment and a support in facing the challenges in the struggles against the compulsion to use crack. Users, when aware of the suffering of their family, seek treatment. Thus, when users perceive that they can regain their family ties, their motivation to have treatment becomes more apparent. Family participation in users’ treatment is, therefore, a decisive factor.

The CAPS workers emphasized how CAS treatment only succeeds with family participation, although many are dysfunctional and show resistance to becoming engaged with the treatment. Schenker and Minayo (2005)SCHENKER, M.; MINAYO, M. C. M. Fatores de risco e de proteção para o uso de droga na adolescência. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 3, p. 707-717, 2005., Sousa et al. (2006)SOUSA, J.; KANTORSKI, L. P.; MIELKE, F. B. Vínculos e redes sociais de indivíduos dependentes de substâncias psicoativas sob tratamento em CAPS. SMAD - Revista Eletrônica Saúde Mental Álcool e outras drogas, Ribeirão Preto, v. 2, n. l, p. 1-17, 2006. Disponível em: <http://pepsic. bvsalud.org/pdf/smad/v2n1/v2n1a03.pdf>. Acesso em: 2 abr. 2013.
http://pepsic. bvsalud.org/pdf/smad/v2n1... , Azevedo and Miranda (2010)AZEVEDO, D. M.; MIRANDA, F. A. N. Práticas profissionais e tratamento ofertado nos CAPSad no município de Natal-RN: com a palavra a família. Escola Anna Nery Revista de Enfermagem, Rio de Janeiro, v. 14, n. 1, p. 56-63, 2010. agree that treatment for drug taking should include the family:

Matos et al. (2008)MATOS, M. T. S.; PINTO, F. J. M.; JORGE, M. S. B. Grupo de orientação familiar em dependência química: uma avaliação sob a percepção dos familiares participantes. Revista Baiana de Saúde Pública, Salvador, v. 32, n. 1, p. 58-71, 2008. also agree with the family being included in drug related treatment. And they add that the families come to better understand drug abuse and are better able to deal with the user; this was demonstrated in studies of authors, evaluating the perceptions of families members who participated in a CAPS orientation group designed to educate and inform.

On the importance of including the family in treatments for drug use, Schenker and Minayo (2005)SCHENKER, M.; MINAYO, M. C. M. Fatores de risco e de proteção para o uso de droga na adolescência. Ciência & Saúde Coletiva, Rio de Janeiro, v. 10, n. 3, p. 707-717, 2005. state that it is essential that family members are engaged in users’ treatment and analyzed some types of family involvement, based on the premise that family members can help the user by becoming involved in the treatment in various ways, working with the family’s social abilities and operationalizing conduct. However, the authors believe that the most efficient treatment is that which includes the family as directly implicated in forming the problem and which takes into account the formation of family ties in the appearance of the problem.

However, it may be difficult to include the family in the treatment due to distance between the user and their family. Nevertheless, even if ties have been weakened, it is important for the health care service to try and re-establish them, as the family is the user’s most important network of social support (Moura et al., 2009MOURA, Y. G.; SILVA, E. A.; NOTO, A. R. Redes sociais no contexto de uso de drogas entre crianças e adolescentes em situação de rua. Psicologia em Pesquisa, Juiz de Fora, v. 3, n. 1, p. 31-46, jan./jun. 2009.).

Due to social losses, the family and the health care service are often the only network of support, as was shown in the research by Sousa et al. (2006)SOUSA, J.; KANTORSKI, L. P.; MIELKE, F. B. Vínculos e redes sociais de indivíduos dependentes de substâncias psicoativas sob tratamento em CAPS. SMAD - Revista Eletrônica Saúde Mental Álcool e outras drogas, Ribeirão Preto, v. 2, n. l, p. 1-17, 2006. Disponível em: <http://pepsic. bvsalud.org/pdf/smad/v2n1/v2n1a03.pdf>. Acesso em: 2 abr. 2013.
http://pepsic. bvsalud.org/pdf/smad/v2n1... , seeking to analyze the social links and networks of CAPSad users, indicating that some ties are undone due to drug abuse and that the CAPSad is the main operating network within the subject’s connections. The study also showed that the family was the only support network on which the CAPSad user could count, as friends did not play a central role, as the subjects explained that they needed to stay away from their friends in order to avoid taking drugs.

From this perspective, a health care system is needed which works to reinforce the user’s social support network, getting rid of worn out links and creating healthy new ones. Sousa et al. (2010)SOUSA, L. M.; PINTO, A. G. A.; JORGE, M. S. B. Tecnologia das relações e o cuidado do outro nas abordagens grupais do centro de atenção psicossocial de Fortaleza - Ceará. Texto Contexto-Enfermagem, Florianópolis, v. 19, n. 1, p. 147-54, 2010. consider that, in producing health, it is essential it be based on light technologies, which they deem to be relationships resulting from health care work producing links and welcoming, which comes into being based on the implicit care of working in health care. Thus, the service would effectively be a care producer, aiming to establish intra and/or inter institutional connections based on basic strategies, such as support in social insertion and in strengthening family ties.

Final considerations

According to the statements of family members, workers and users, it was observed that the senses and meanings which family attributed to the drug user can be related to fairly conflictive experiences of living together and may lead to the loss of family ties. In addition, the senses and meanings the users attribute to their families may lead to the former relapsing, although, when worked on, can facilitate adherence to treatment.

Before attending CAPSas, the family members generally had negative senses and meanings towards the user, which made family relationships complicated. However, when the family became a target of intervention by the service, meanings attributed to the users changed significantly and, consequently, their way of dealing with the problem and their expectations regarding the treatment, contributing to healthier family relationships and, principally, creating a more supportive environment, encouraging the user to seek and adhere to treatment. Though the seeing the user as ill, a meaning reported by family members participating in CAPS treatment, may be questioned, it was reinforced by the workers at the service, as this way of viewing the patient placed the user in a position of passivity with regards to the problem, and contributed to the hegemony of medical power.

To conclude, it is important that the senses and meanings of family members towards the user are taken into account in interventions aimed at the families of those who are undergoing treatment in the health care services. Although more studies are necessary to show how such interventions can be carried out.

References

Publication Dates

History