ABSTRACT

This article analyzes how workers experience the effects of the work process in an Alcohol and Drugs Psychosocial Care Center (Capsad). Observations, collective interview and in-depth interviews with workers were carried out. Among the effects, the most notable were wear, sickness, powerlessness of action and exhaustion. It is concluded that these affect the capacity to act, since, in order to collaborate in the production of the meaning of life of the other, in many cases, the employee does not offer nothing for himself, and this leads them to what Merhy calls combustion.

KEYWORDS:
Mental health services; Human resources; Professional exhaustion

Introduction

As western society developed, in the face of the transformations occasioned by the industrial revolution, work was placed as the principal and inductive commodity of the process of capitalist accumulation. Therefore, work became a central element in the understanding of society and the individual in social dynamics (CARDOSO, 2011CARDOSO, L. A. A categoria trabalho no capitalismo contemporâneo. Tempo Social, São Paulo, v. 23, n. 2, p. 265-295, 2011.).

For Marx (1996, P. 297, FREE TRANSLATION)MARX, K. O Capital: crítica da economia política. 10 ed. São Paulo: Nova Cultural, 1996., work is

For the author, human survival depends on the interaction of the individual with nature, so that the elements of this are always modified with a purpose, a goal. Therefore, the work process is a condition of human existence and it is through it that man is socially and culturally constituted. He further clarifies that the work process is the human activity (waste of energy) that transforms raw material into product, from the use of means and instruments. It is understood that the history of humanity passes through the work and the transformations that it accomplishes, so that understanding the work process becomes important for the understanding of society and social relations, including in the context of health work.

In Brazil, theorists such as Maria Cecília Donnângelo and Ricardo Bruno Mendes-Gonçalves were pioneers in introducing marxist theory in the field of health. Mendes-Gonçalves (1992)MENDES-GONÇALVES, R. B. Práticas de Saúde: processos de trabalho e necessidades. São Paulo: Centro de Formação dos Trabalhadores em Saúde da Secretaria Municipal da Saúde, 1992. (Cadernos Cefor, 1. Série textos). formulated the concept of a health work process, which refers to the way services are organized, to meet the health needs of the users, or, also, regards to the configuration and recognition of new necessities. Corroborating this idea, Peduzzi and Schraiber (2008, P. 323, FREE TRANSLATION)PEDUZZI, M.; SCHRAIBER, L, B. Processo de Trabalho em Saúde. In: Dicionário da educação profissional em saúde. 2 ed. 2008. Disponível em: <http://www.epsjv.fiocruz.br/dicionario/verbetes/traima.html>. Acesso em: 9 de abril de 2013.
http://www.epsjv.fiocruz.br/dicionario/v... affirm that the health work process

Thereby, according to Faria and Dalbello-Araujo (2010)FARIA, H. X.; DALBELLO-ARAUJO, M. Uma perspectiva de análise sobre o processo de trabalho em saúde: produção do cuidado e produção de sujeitos. Saúde e Sociedade, São Paulo, v. 19, n. 2, p. 429-439, 2010., the purpose of the health work process would be, for example, healing, rehabilitation and health promotion, which coexist in different forms of care production. It is highlighted that, based on Merhy, Feurwerker and Cerqueira (2010)MERHY, E. E.; FEUERWERKER, L. C. M.; CERQUEIRA, P. Da Repetição à Diferença: construindo sentidos com o outro no mundo do cuidado. In: FRANCO, T. B.; RAMOS, V. C. (Org.). Semiótica, Afecção e Cuidado em Saúde. São Paulo: Hucitec, 2010. p. 60-75., the production of care must be shared by all workers of a health service, since all acts of reception and listening are valid, of showing interest, so that the encounter can be comfortable, from different looks. Campos (2007, P. 22)CAMPOS, G. W. S. Um método para análise e co-gestão de coletivos. São Paulo: Hucitec, 2007. also affirms that "work in health is based on interpersonal relations all the time".

These meetings are, therefore, essential in the health work process, and particularly important in the Alcohol and Drugs Psychosocial Care Center (Capsad), since this is a reference service in the network of attention to users of psychoactive substances, based on therapeutic and preventive activities to the community (BRAZIL, 2003BRASIL. Ministério da Saúde. A política do Ministério da Saúde para a atenção integral a usuários de álcool e outras drogas. 2. ed. Brasília, DF: MS, 2003.). Then, there are several possibilities for activities to be offered by Capsad, such as individual care, which includes medication; psychotherapy; orientation; group activities; therapeutic workshops; home visits etc. (BRAZIL, 2003BRASIL. Ministério da Saúde. A política do Ministério da Saúde para a atenção integral a usuários de álcool e outras drogas. 2. ed. Brasília, DF: MS, 2003.). These activities are based on interpersonal relationships and the encounter between worker and user.

Besides that, workers in Capsad experience a contradiction between two policies: the National Policy on Drugs linked to the Public Security (BRAZIL, 2002BRASIL. Ministério da Saúde. A política do Ministério da Saúde para a atenção integral a usuários de álcool e outras drogas. 2. ed. Brasília, DF: MS, 2003.) and the Policy of Integral Attention to Users of Alcohol and other Drugs, focusing on public health, emphasizing the need for diversity and plurality of actions in this field (BRAZIL, 2003BRASIL. Ministério da Saúde. A política do Ministério da Saúde para a atenção integral a usuários de álcool e outras drogas. 2. ed. Brasília, DF: MS, 2003.). This situation has a negative impact on the work to be performed at Capsad, obstructing interpersonal relationships, that are essential to care (WANDEKOKEN; DALBELLO-ARAUJO, 2015WANDEKOKEN, K. D.; DALBELLO-ARAUJO, M. Trabalho no Centro de Atenção Psicossocial Álcool e Drogas e as políticas públicas: que caminho seguir? Rev. Trabalho, Educação e Saúde, Rio de Janeiro, v. 13, supl. 1, p. 157-175, 2015.).

The theme of chemical dependence is directly bounded by social issues, such as criminality, prostitution, street situations, drug trafficking, the Acquired Immunodeficiency Syndrome (Aids), among others (KESSLER; PECHANSKY, 2008KESSLER, F. H. P.; PECHANSKY, F. Uma visão psiquiátrica sobre o fenômeno do crack na atualidade. Rev. Psiquiatr. Rio Gd. Sul, Porto Alegre, v. 30, n. 2, p. 1-3, 2008.). It is a fact that the professional dedicated to assisting the user of psychoactive substances should not only worry about the drug use, harm reduction and/or abstinence, but should perceive him as an individual who has a history, trajectory, desires, beliefs, values and potentialities, which makes this work even more complex.

With this in view, in this article, the harmful effects identified by workers in the work process of a Capsad are analyzed.

Methods

A qualitative research was performed with all the 28 workers of the service, including nurses, psychologists, administrative assistant, driver, receptionists, guards, general services assistant, pharmacist, physical educators, occupational therapist, manager, nursing technicians, social workers and physicians, since all are involved in the production of care of the health service (MERHY; FEUERWERKER; CERQUEIRA, 2010MERHY, E. E.; FEUERWERKER, L. C. M.; CERQUEIRA, P. Da Repetição à Diferença: construindo sentidos com o outro no mundo do cuidado. In: FRANCO, T. B.; RAMOS, V. C. (Org.). Semiótica, Afecção e Cuidado em Saúde. São Paulo: Hucitec, 2010. p. 60-75.).

For the selection of the research local, were analyzed the recent municipal information from the seven cities of the metropolitan region where the research was performed regarding the network of attention to users of psychoactive substances. It was decided, therefore, to investigate a municipality of 420 thousand inhabitants, with only one Capsad. As the focus was on analyzing the effects experienced by the workers, such choice was due to the belief that the precariousness of the network of attention in alcohol and drugs contributed to these findings.

Data collection was performed between the months of january and april of 2014, based on three techniques: daily observation, team meetings and meetings with users; collective interview; and in-depth interviews. The technique of observation was important to identify unintended behaviors or subtle reactions and, thus, explore issues that people do not feel comfortable discussing, allowing to register behavior in the context in which it occurs (DALBELLO-ARAUJO, 2008DALBELLO-ARAUJO, M. Comunidade ampliada de pesquisa. In: ROSA, E. M.; SOUZA, L.; VELAR, L. (Org.). Psicologia Social: temas em debate. Vitória: GM. Editora, 2008. p. 109-126.). According to Dalbello-Araujo (2008)DALBELLO-ARAUJO, M. Comunidade ampliada de pesquisa. In: ROSA, E. M.; SOUZA, L.; VELAR, L. (Org.). Psicologia Social: temas em debate. Vitória: GM. Editora, 2008. p. 109-126., the collective interview is used when it is intended to facilitate access to the different points of view of the participants. The in-depth interview was used with 13 workers, starting with 'what do you think about working here?'All data were transcribed and discussed using the thematic analysis technique (BARDIN, 2009BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2009.).

It is emphasized that the participants voluntarily signed the Informed Consent Form, through which they had the guarantee of the confidentiality of their identity and the information provided. This way, the identification of the selected sections happened in three ways: 'Worker' or 'Worker in circle', when related to statements; and 'Field diary', when the excerpt of observation of the author was based on daily observation.

The prerogatives of the Resolution nº 466/12 of the National Health Council were met, and the research was approved, under the nº 16771113000005060, by the Research Ethics Committee.

Results and discussion

Among so many questions observed in the field of research, several difficulties presented by the workers were highlighted to understand the events of their demanding profession. It is highlighted the fact that the daily work has been marked by intense demands for care, by users with abstinence symptoms or in crisis. This makes it hard to be done, so that, among the effects are the wear, fear, sickness, feeling of uselessness and impotence of action, which eventually lead to exhaustion. These effects produce what Merhy (2004)______. O conhecer militante do sujeito implicado: o desafio de reconhecê-lo como saber válido. In: FRANCO, T. B.; PERES, M. A. A. (Org.). Acolher Chapecó. São Paulo: Hucitec, 2004, p. 21-45. describes as combustion. Still according to Merhy (2013)______. Os CAPS e seus trabalhadores: no olho do furacão antimanicomial. Alegria e alívio como dispositivos analisadores. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013. p. 213 - 225., combustion is the effect of health work, which consumes life in the act (at the moment the work is performed), since the worker, when performing health care, must offer the living work to give meaning to the life of the other. Thus, to assist in the production of the sense of life of the other, by offering vital energy, in many cases, the consumption of the worker occurs when, in the absence of anything for himself, he, in fact, goes into combustion. When experiencing these effects, the worker does not envisage possibilities to generate changes in work, in a way that he experiences an affective distancing (paralysis and automatism). Such concept is linked to the specificity of health work, since that, for the author, this effort to give meaning to another person's life, lending him the desire, can lead to combustion, when no measures of sharing and analysis of the work process are taken.

It is worth stressing, however, that this idea closely resembles the concept of psychic suffering postulated by Dejours (1994)DEJOURS, C. Itinerário teórico em Psicopatologia do Trabalho. In: DEJOURS, C.; ABDOUCHELI, E.; JAYET, C. Psicodinâmica do trabalho: contribuições da escola Dejouriana à análise da relação prazer, sofrimento e trabalho. São Paulo: Atlas, 1994., which has been studying, since 1980, especially in factory work, the effects of industrial organization for workers, seeking a better understanding of pain and suffering. It also reverberates the Burnout syndrome, one of the consequences of the state of constant emotional tension and chronic stress caused by exhausting working conditions, studied in Brazil, especially among teachers (CARLOTTO, 2002CARLOTTO, M. S. A Síndrome de Burnout e o trabalho docente. Psicologia em Estudo, Maringá, v. 7, n. 1, p. 21-29, jan./jun. 2002.).

For the organization of the discussion, following the referencial of the thematic analysis (BARDIN, 2009BARDIN, L. Análise de conteúdo. Lisboa: Edições 70, 2009.), the data collected were divided into categories, according to the identified effects: wear, fear, sickness, feeling of uselessness, action powerlessness and exhaustion.

Wear

As can be seen, wear was evidenced in many circumstances of work in Capsad, either when coordinating a group with adults, with adolescents or in daily service. It is observed that in all situations listed, the encounter with the other was essential, to require the worker to establish interpersonal relations and the involvement of his subjectivity (MERHY, 2002MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112.), which represents a source of depositions.

For Onocko and Campos (2006)ONOCKO-CAMPOS, R. T.; CAMPOS, G. W. S. Co-construção de autonomia: o sujeito em questão. In: CAMPOS, G. W. S. et al. Tratado de Saúde Coletiva. São Paulo: Hucitec; Rio de Janeiro: Fiocruz, 2006. p. 669-687., the wear of a health worker is great, since there is a permanent contact with pain and suffering. The authors claim, also, that health workers do not realize that they spend their lives defending the lives of others. Thus, wear is a sign of combustion, as seen in speech "[...] it seems that the body also hurts. There are days I get exhausted at home" (Worker4).

Stress

In the testimony, it is observed that the situations of instability of the users, inherent to the treatment of chemical dependence, are sources of stress for the workers, since they experience these situations daily. Thus, the statement "you have to be a very balanced person" (Worker1) emphasizes that experiencing these situations is, in fact, difficult and requires some preparation of the worker so that there is no combustion.

There is also, as in the case below, the stress arising from interpersonal relations among workers:

Any worker is subject to experiencing episodes in which there are conflicts in the communication between the members of the team. However, the report above highlights an indignation because the fact has been occurred repeatedly, even more related to mental health care, which would require greater attention and empathy. As it is observed, the worker claims to have 'exploded' and punched the table - clear signs of combustion.

In this point, it is emphasized that the production of care in Capsad is based on the encounter and the establishment of bonds, however, combustion does not favor this production and, thus, implies difficulties in the encounter between worker and user.

Fear

Such effect was highlighted by those who perform external activities, such as taking users of daily attention to rides:

The phrase "What can happen outside, happens here, too" is highlighted, since it enlarges the situations of fear and, therefore, of combustion, due to the requirement of permanence in state of attention. Much of the testimony related to fear referred to the compulsory hospitalization activity, as described below:

According to Merhy (2013, P. 222, FREE TRANSLATION)______. Os CAPS e seus trabalhadores: no olho do furacão antimanicomial. Alegria e alívio como dispositivos analisadores. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013. p. 213 - 225., workers produce "relief in others, but they have no relief to look at and rethink work". In this sense, it is imperative that there be forms of relief for such workers, to increase their capacity to act. It is necessary to think of ways to articulate the intersectoral network, so that there is greater security, and to create ways of problematizing the practices so that these workers articulate tools against the demands of compulsory hospitalization.

Permanent Education in Health (PEH) is indicated as a possible path for the transformation of care production. From the PEH, learning and teaching are incorporated into the daily life of the service (BRAZIL, 2004______. Ministério da Saúde. Secretaria de Atenção à Saúde. Saúde Mental no SUS: os Centros de Atenção Psicossocial. Brasília, DF, 2004.). It is understood, therefore, that the proposal of the National Policy of Permanent Education in Health (NPPEH) is current and its implementation is necessary, but it is known that, for this to occur, it is necessary the involvement of workers and managers. It is worth mentioning, also, that PEH constitutes a strategy for the reorganization of the work process based on the problematization, that is, it goes far beyond the idea of offering training and courses, and it is a proposal of transformation in front of all the effects that will be seen next.

Action powerlessness

The 'action powerlessness' appears whenever professionals claim that there is nothing to be done to improve the bureaucratized, non-humanized attendance performed by some of the workers: "[...] this is very bad for patients! We were disappointed! But let's do what? X [the management] says that this is so" (Workers in circle).

It can be seen, therefore, that situations of powerlessness are expressed in interpersonal relations - be it between the worker and the user or between the workers themselves - and in the intersubjective relations - relational and affective. There is, apparently, awareness of the problems and a certain desire for change - however, extremely limited - to change the situation.

In the testimony above, it is perceived, still, a certain paralysis in the face of powerlessness. It seems that dialogue and listening were not considered as possible tools of change in the conduct of the professional in question. Because of it, the waiting for an attitude of management. And besides it, the management, personified in the person of the board, is always distant from the assistance. With this framework, it is very difficult to pay attention to the demands of the user and to establish "a permanent commitment to the task of receiving, taking responsibility, solving, autonomizing", as postulated by Merhy (2002, P. 82, FREE TRANSLATION)MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112..

On another occasion, workers reported the impotence of action in the face of a case:

At first, it agrees with Merhy (2002)MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112. when he argues that there should be, in the teams, referencing professionals for each user, so that the workers develop closer bonds and, thus, better interpret their demands. However, as can be seen, situations of powerlessness seem to imply a situation of paralysis, in which the worker prefers to stop exercising his function because he does not know what to do. It should be pointed out that such withdrawal was not even analyzed by the group that opted for the exchange of the worker who performed the role of reference technician of the user in question.

The paralysis observed seems to result from the combustion experienced by the workers, reflected in the lack of implication of the team in relation to the production of care. Thus, the existence in this service, of militant subjects, can be questioned, as described by Merhy (2004)______. O conhecer militante do sujeito implicado: o desafio de reconhecê-lo como saber válido. In: FRANCO, T. B.; PERES, M. A. A. (Org.). Acolher Chapecó. São Paulo: Hucitec, 2004, p. 21-45.. For us, to be involved means to be active, to put oneself as someone who affects and is affected, as one who produces and who is produced; to put yourself as a worker, as a subject. It is necessary to open the way to new senses, because, in this context, repetition no longer works.

In discussing impotence, it should be pointed out that, according to Merhy (2002, P. 61, FREE TRANSLATION)MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112., the worker has a high degree of freedom in the production of health care, in order to exercise a certain self-government of his practices. Thus, for the author, considering the micropolitics of living labor, the notion of impotence does not fit, since

In this sense, it must be considered that creativity is one of the possibilities to make the workers less impotent, so that they can invent new work processes.

Feeling of uselessness

It is perceived that the feeling of uselessness experienced by workers is related to their working methods that are very different from hospital procedures and techniques, as described by Merhy (2002)MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112.. According to Franco and Merhy (2005), there are ideas that associate technological complexity with the quality of care, configuring the illusory image of resolving. However, it is known, based on these authors, that the most relational work process implies high sophistication and requires great energy from the workers. Even because this complexity is based on the networks of relations focused on the know-how of the workers and not on the technological input. Thus, it is agreed that the attentive eye, the listening, the touch work together with the knowledge and, undoubtedly, collaborate in the constitution of greater workability in health (FRANCO, 2013FRANCO, T. O trabalhador de saúde como potência: ensaio sobre a gestão do trabalho. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013.).

In addition to these questions, it can be noticed, in the testimony, some suffering and, in fact, combustion, when the worker states: "I can not bear not to speak what I think". This speech reveals that the worker seems to have no implication with listening, in the encounter with the other, and that he only supports experiencing these encounters in the daily work, which has repercussions in the production of a less welcoming care.

Sickness

There were several testimonies that pointed to sickness as an effect of the work process in Capsad. It is known that work alone is not a disease factor, but, rather, certain conditions and contexts in which it is performed, which may imply situations that directly interfere with the production of care and only reinforce the realization that combustion is experienced in the daily life of most of the service workers. This way, it is necessary to think of ways to generate relief for workers so that they produce life in themselves (to offer to the other) and to themselves (to offer to oneself), according to Merhy (2013)______. Os CAPS e seus trabalhadores: no olho do furacão antimanicomial. Alegria e alívio como dispositivos analisadores. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013. p. 213 - 225..

It is already an effect, and the only identified, that has to do with the increase of the capacity to act is the 'professional accomplishment', mentioned by some workers:

Exhaustion

It is emphasized, due to the exhaustion effect - which includes frustration, wear and stress -, the case of the team members who say they do not support the work in daily care (daily care modality based on therapeutic workshops for Capsad users who are in intensive care):

It is observed that the encounter with the user in daily attention is painful. All professionals scaled to work in daily attention, without exception, said they did not like to act in it. What is most impressive is the fact that this activity has great importance, since it is the encounter with users in intensive care. Thus, attention is paid to the speech of the workers, when they are asked about working in daily attention. They answered, together, that:

Intensive care users often are those who are still in continuous use of the substance and are advised to remain without the drug for an entire day - otherwise, they will not be able to remain in Capsad's activity. Thus, it is understood the difficulty of being in abstinence, which leads to aggression and lack of interest in any activity, aspects inherent to this state. However, these issues imply the exhaustion of the worker, who begins to experience, in intensive care, an activity that exhausts him.

Besides it, it is noticed, as well, that the difficulty of listening to the demands of the users and the difficulty of treating them as subjects - with desires, beliefs and values - has implied damages, not only for the user but for the worker, that feels limited to deal with such issues, which have led to the automatism in the encounter with the other - which describes the situations in which the worker becomes indifferent and distances himself from the everyday, being taken by events without bonding and assuming the passivity of the user, as seen in the speech "Therefore, I ask nothing, I speak to myself..." (Worker8). And these situations are not at all encouraging, since workers come to see users as potential stressors, which makes the encounter exhausting.

Therefore, when exhaustion is experienced through automatism, the worker contributes so that the production of care is not centered in the user. And when the professional moves away from the daily activities, other issues are given priority, such as the protocol and the completion of the medical record, among other things contrary to what Merhy (2002)MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112. suggests. In this case, it is clear that only the know-how of the professional matters, and thus, actions centered on the worker cause the user to be attended based on hard technologies (equipment, instruments, protocols, etc.) and/or light-hard (structured knowledge, of the various knowledge about health), without attention being given to light technologies, which refer to the relations built between two people, in effect, and produce a relation of bond and acceptance - as described by Merhy (2002)MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112. ) -, essential to meet in Capsad.

Another issue that arises in the exhaustion category is mentioned by the workers:

Each Capsad user should have a Unique Therapeutic Project (UTP), that is,

A UTP must be carried out in the user's reception in the service and should be monitored periodically by a referencing professional, together with the user (BRAZIL, 2004______. Ministério da Saúde. Secretaria de Atenção à Saúde. Saúde Mental no SUS: os Centros de Atenção Psicossocial. Brasília, DF, 2004.).

This way, the fact that UTP has never been evaluated is difficult to understand. It is perceived that the encounter with the user, who has been in the same activity for so long, can only produce exhaustion, not only in the worker but also in the user, who ends up manifesting it, either through involvement in fights or aggression (through words or gestures). Thus, exhaustion and, consequently, combustion contribute to a state of paralysis, which the worker ends up distancing himself affectively, even though he is present in the daily life of the service, and, with this, situations arise like these observed: users for more than six months in the same kind of care and approach without at least one evaluation. However, the workers did not explain this issue.

It is observed that the meetings in the daily attention, in its majority, exhausts the worker, so that, when he is not in this activity, he shows great relief. There was, then, a reflection on the fact that these workers go every day to this activity, already exhausted, frustrated and uncertain about what will happen, and may experience episodes of outbreaks, crises or convulsions of users. In these cases, the worker responsible for the activity of the day will have to act directly in the case, using his abilities to offer a singular care that is a promoter of bonding, welcoming, listening and resignification, as proposed by Merhy (2002)MERHY, E. E. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: MERHY, E. E.; ONOCKO, R. (Org.). Agir em saúde: um desafio para o público. 2 ed. São Paulo: Hucitec, 2002, p. 71-112.. But, how?

In this point, it is highlighted, also, that another reason for exhaustion in daily attention is related to the supposed lack of interest of users raised by the workers of Capsad, which generated a series of discussions throughout the field of research:

The fact that some people only endure being in daily attention and others do not, is serious. It is observed that some activities do not seem to be interesting to be developed with young adults and adults in abstinence, but that, even in these cases, responsibility for lack of interest is attributed only to the user. Thus, it is identified that an adequate training is needed to the workers to know how to deal with the wasting inherent to the intensive care in a Capsad.

However, according to Merhy (2005)______. O desafio que a educação permanente tem em si: a pedagogia da implicação. Interface (Botucatu), Botucatu, v. 9, n. 16, p. 161-77, 2005., there is no reason to believe that the low effectiveness of health actions is only related to the lack of competence of the workers, which can be supplied through courses. This would be a simplistic view of the issue, that would only generate small changes in the daily production of care. On the contrary, Merhy (2005)______. O desafio que a educação permanente tem em si: a pedagogia da implicação. Interface (Botucatu), Botucatu, v. 9, n. 16, p. 161-77, 2005. points out that the worker must be protagonist in the process of transforming his practice. In the same way, Carvalho and Ceccim (2009)CARVALHO, Y. M.; CECCIM, R. B. Formação e Educação em Saúde: aprendizados com a Saúde Coletiva. In: CAMPOS, G. W. S. et al. (Org.). Tratado de Saúde Coletiva. São Paulo, Hucitec; Rio de Janeiro: Fiocruz, p. 1-35, 2009. affirm that the worker must evaluate its action and direct critics in relation to it.

It is also highlighted that, paradoxically, there is also some personal realization in the workers, with the development of activities, but this must to be strengthened. It is observed that when health work has the effect of this realization, the worker presents a greater degree of power to account for his activities and, as a consequence, he feels more satisfied, which favors the creation of bond and has a positive repercussion on the production of care. However, it can be affirmed that, to have well-being at work, constant satisfaction is not necessary, it is only necessary that there be hope, goals, desires.

It is known that the desire makes workers have greater capacity to act, in agreement with what Franco says (2013)FRANCO, T. O trabalhador de saúde como potência: ensaio sobre a gestão do trabalho. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013., when he says that it is necessary to stimulate the workers so that they become desirable subjects, since all have the capacity to execute changes in the reality that they experience since they have capacity for self-management and self-analysis. The first one, relates to the work of the worker with a focus on live work in act and is conducted based on the subject, who makes the other connections with the other workers, and can perform the production of the care in a differentiated way. The second one, has to do with the valorization of the worker's knowledge, creativity and initiative, desires and needs. This knowledge of the self, associated with the reality of the daily service in which it is inserted, gives the worker the possibility to intervene in the production of more welcoming, more connected and user-centered services (FRANCO, 2013FRANCO, T. O trabalhador de saúde como potência: ensaio sobre a gestão do trabalho. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013.). Thus, the ideas of Franco (2013)FRANCO, T. O trabalhador de saúde como potência: ensaio sobre a gestão do trabalho. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013. are still corroborated when it is affirmed that the greatest challenge in the management of health work is to keep workers with high capacity to act.

For this purpose, Merhy (2013)______. Os CAPS e seus trabalhadores: no olho do furacão antimanicomial. Alegria e alívio como dispositivos analisadores. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013. p. 213 - 225. points out that it is necessary to institute in the daily life of the health services means that move towards self-management and self-analysis, to allow workers to deal better with their sorrows and sufferings, and to produce self-care. Because, as seen in a large part of the testimonies, the daily life in Capsad consumes the worker in life and in act, as an anthropophagic being (MERHY, 2013______. Os CAPS e seus trabalhadores: no olho do furacão antimanicomial. Alegria e alívio como dispositivos analisadores. In: FRANCO, T.; MERHY, E. E. Trabalho, produção do cuidado e subjetividade. São Paulo: Hucitec, 2013. p. 213 - 225.) and, in the face of this, it is necessary to have contexts, in everyday life, in which the worker can talk about their issues, opening opportunities and possibilities for them to increase their capacity to act, which favors the production of care.

Conclusions

Many were the reports about the exhausting effect generated by the act of welcoming the other, in this place; about the exhaustion, the frustration and the fear in front of the crises of the users, full of offenses, curses and episodes of aggressiveness. In this context, the encounter with the user becomes difficult. Thus, a reflection on the work in a Capsad reveals that it is essential to think about the care for the worker, once this, when satisfied and accomplished, experiences his work with pleasure, which has a positive impact on the production of a care with greater production of bond. And, on the contrary, when he feels exhausted, he can show difficulties in feeling empathy for the suffering of the other, which can lead to an affective estrangement and negatively affect the production of care.

For this purpose, before the identified effects, there must be ways of relief that avoid combustion, favoring the capacity to act, so that the work process is favorable not only to users, but also to workers. Among these forms, permanent education, self-management and self-analysis stand out, favoring the existence of spaces for workers to express themselves and seek possibilities, with a view to increasing their capacity to act and generating changes in their work.

References

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