Introduction
The Psychiatric Reform is a worldwide movement in the constant search of better mental healthcare conditions. From the 1960s, this reform became to realize through experiences ranging from changes within the mental healthcare institutions, to proposals referring to medical discharge, deinstitutionalization, mental healthcare institutions closures and the creation of a community level mental healthcare network.
At a local Brazilian level, the Department of Health promulgated the ordinance n.º 3.088/2011, which establishes the Psychosocial Care Network (PCN), aimed to people that suffers under mental disorders and crack, alcohol or other drugs addictions. The PCN is composed of several services and tools, such as: Psychosocial Medical Assistance Networks (PMAN), Therapeutic Residential Services (SRT), Coexistence and Culture Centers, Admission Units (AU) and the general assistance facilities (General Hospitals and PCCAD).
The PCN regulates and organizes the demands and flows of medical assistance, between the PMAN, emphasizing that only patients with drug-related problems will be admitted in the several assistance centers, according to the severity of their medical condition, with hospitalizations only being indicated in cases of severe life-threatening poisonings, abstinence or dependence syndromes, situations where the patient status cannot be resolved by the Out-Of-Hospital assistance level.
The PCN assumes the appropriate response to the patient’s need, finding the adequate resolution within the network. It is based on a close relationship and the mutual agreement, which is accomplished by the recognition and the commitment of every individual that takes part in, such as professional assistance, equipment and healthcare staff. Thus, enhancing the organization of work processes, access flows and users care.
However, there is still a notorious gap in the PCN regarding the adolescent drug user healthcare. Such argument is supported by the fact that specialized medical assistance to this population is still inadequate. The Child Psychosocial Health Center (CPHC) as well as the Psychosocial Care Center for Alcohol and Drugs (PCCAD) serve this group of patients, which consequently favors the fragmentation and a lack of responsibility for the assistance and healthcare.
According to this, a study conducted in the countryside of the state of Rio Grande do Sul, with healthcare medical professionals who work at a psychosocial assistance center dedicated to users of psychoactive substances, indicated that the service provided has a poor quality in relation to the structure, Human Resources and equipment. In addition, the study shows that the environment is unattractive to adolescent patients, as this group has unique characteristics and needs, as well the fragmentation of the healthcare network and a poor communication between the healthcare assistance providers.
Caring for adolescent drug users stands out as a urgent need, given the lack of adequate facilities and trained healthcare professionals to meet their demands. In addition, the prejudice and discrimination with those who use drugs such as crack, is another important issue since it causes the distancing of young people from medical assistance.
A research aimed at assessing the stigma and prejudice experienced by crack users in their social context showed that the society sees crack users as having a stigmatized identity of criminal, homeless and violent persons, resulting in the idea of a non-citizens, without the rights to belong to a social circle and therefore as persons who must be excluded. For this reason, the study proposes the fight against prejudice related to drug use without moral abuse, a fact that could result in greater access of users to care networks.7
Given the context, it is relevant to study the PCN, having in mind that the fragmentation between the healthcare network directed to the care of adolescent drug users, generates a vicious loop of continually single actions that lead to a loss of credibility inside the healthcare network.
Looking to think about on the way that the healthcare professionals aim the needs of adolescents patients and to enable the restructuring in their performance according to the needs of this group of people and the healthcare network, this study is targeted to analyze the trajectory of crack users until they get their treatment at the Psychosocial Care Center for Alcohol and Drugs (PCCAD).
Method
This is an exploratory and descriptive study with a qualitative approach, linked to a broad research project, which is entitled “Paths taken by the adolescent crack user in the Psychosocial healthcare network: contribution to nursing”, developed in a mid-size municipality in the interior region of Rio Grande do Sul, which is part of the “Crack can be beatable” program.
The PCCAD was chosen as a data collection place because it has some unique characteristics that differentiate it from other services of the municipals PCN. Most services are time limited, while the PCCAD gives a comprehensive and continuous healthcare assistance to people who depend on alcohol, crack and other drugs. Moreover, related to the reality of this local PCN, the cases of adolescents drug users directed and accompanied by the children’s PCC is small.
The participants of this study included 14 patients, 11 family relatives and 20 professional healthcare staff, who work at the PCCAD, resulting in 45 participants. The selection of participants was not randomized, according to the inclusion criteria and objectives of the research.
The user’s inclusion criteria were the following: to be an adolescent crack user under treatment at the PCCAD and to be between 10 and 20 years old. Regarding the first criterion, were considered adolescents, whose medical records mentioned drug use at least once time, regardless of how much time or how often they used it. Adolescents who were at the moment of the study hospitalized or participating in therapeutic communities and therefore unable to attend the interview, were excluded.
The inclusion criteria for relatives were the following: being at least 18 years old, being a user’s family relative and being responsible for the adolescent’s treatment at the PCCAD. Possible family caregivers were excluded from the study.
The inclusion criteria for the PCCAD healthcare professional staff were the following: to be a mid or high-level member of the medical staff and to have at least six months of job’s related experience. Professionals on vacation or under sick leave during the data collection period were excluded.
In order to guarantee the ethical principles related to the research that involves human beings, the participants were included in the study, only after expressing their agreement to participate by signing the Inform Consent Form (ICF) and the Voluntary Informed Consent, when under eighteen. In addition to this, the anonymity of the participants was preserved by using the letter “A” for PCCAD adolescent users, “F” for their relatives and “P” for healthcare professionals, followed by the interview number.
The number of participants was defined by data saturation, established at the moment when, during the researcher’s evaluation, there is some redundancy or repetition of the results, and it is not considerably relevant to insist in the inclusion of participants. Data collection took place in the first half of 2017, through semi-structured interviews conducted by a single interviewer, as this approach allows them to be as close as possible to the interviewee’s perspective.
Regarding the participant’s privacy, the interviews were conducted in a service room, respecting the availability and operation of the PCCAD. In order to preserve the original content and increase the accuracy of the data collected, the interviews were captured by an audio recorder and later fully transcribed.
For the organization and processing of the data, the QSR Nvivo 11 software was used, a program that assists in the analysis of qualitative material with coding and text saving tools. Later, the material was analyzed and categorized according to Thematic Analysis. The word cloud tool, created from the QSR Nvivo 11 software, was used to visualize the representativeness and occurrence in a given category, as this technique employs different font sizes and styles to emphasize the frequency of a word in a given text.
The ethical rules of conducting research involving human subjects were followed in accordance with the Resolution nº 466, of December 12th, 2012. The project was approved by the Research Ethics Committee under the certificate of presentation for ethical assessment nº 60649016.9.0000.5324, opinion nº 4/2017.
Results
Starting from the data analysis about the path of adolescents crack users to the treatment at the PCCAD, the following categories emerged: the way the adolescent crack user arrives at the PCCAD; reasons that lead an adolescent crack user to get treatment at the PCCAD and healthcare services used by the adolescents crack users until their admission at the PCCAD.
The way an adolescent crack user arrives at the PCCAD
Participants revealed there are several ways, how an adolescent arrives at the PCCAD. The most frequent are: spontaneous demand, accompanied by an entrusted person, who is responsible for his care or representatives of protection and justice agencies and finally referred by other services of the healthcare network (Figure 1).
Figure 1 – Frequency word cloud for sub-node coding “The way an adolescent arrives at the PCCAD” via QSR Nvivo.
The spontaneous demand is explained by: I asked, I wanted, I willingly accepted, the adolescent looks for help, spontaneous demand, spontaneous search. People accompanying the adolescent are their parents, family relatives, father or mother and shelter coordinator.
Representatives of protection and justice agencies include the tutelary council, guardian counselor, judge, justice, court order, bailiff, prosecutor, public defender, public prosecutor, juvenile court.
My parents and the guardian council brought me. They bothered me so much, then finally I came. My friends also died because of drug abuse, so I wanted help for myself. (A4)
I wanted to, I was the one who asked my mom for help. Then my mom helped me and brought me here. (A6)
The first time I arrived at the PCCAD was through the tutelage council. (F4)
The other time he ran away and didn’t want to comeback. Now, he is there again. He did go, but not because he wanted to, it was because we forced him. (F9)
There are several ways to refer adolescents to the PCCAD. The search for medical assistance happens through spontaneous demand, or referral from the care network: harm reduction, CRAS, CREAS, CASE, court of childhood and youth, guardian council, general hospital, psychiatric hospital among others. (P3)
They come or they are referred by the CRAS, or they are referred by the tutelary council, or after a discharge from the psychiatric hospital, or they arrive with a court order to admit and treat the adolescent, or even is the family that demands, or is the adolescent by himself who considers the PCCAD as an treatment alternative to recover from the dependence of chemical substances. (P11)
The healthcare network services and the social assistance network that made referrals to the PCCAD were the following: PCCAD i, basic units, harm reduction, Reference Center for Social Assistance (RCSA), Specialized Reference Center for Social Assistance (SRCSA), Student Healthcare Center (SHC), general hospital, psychiatric hospital, clinics, other services, network referral.
Reasons that lead an adolescent crack user to get treatment at the PCCAD
Participants revealed some reasons that lead the adolescents to get treatment at the PCCAD, such as the personally need for the very adolescent to invest in a better life project, demands for justice and especially behavioral problems.
Figure 2 – Frequency word cloud for sub-node coding “Reasons that lead an adolescent crack user to get treatment at the PCCAD” via QSR Nvivo.
The adolescent’s own need to invest in a better life project was revealed through the expressions: being able to improve my life and having a better life.
I myself looked up for a treatment because of my daughter. I came to the PCCAD to improve my life and at the same time to help my daughter, who is in a shelter, so the both of us can have a better life. (A2)
The demands of justice are revealed by compulsory hospital admissions:
Sometimes by the district attorney’s office, then the prosecuting attorney sues the tutelary council and he comes by court order, including compulsory medical admission. (P8)
The cases we follow the most are the cases of adolescents, cases sent by the defendant or by parents who ask for compulsory medical admission. (P2)
Behavioral problems are the main reasons that lead adolescents to be treated at the PCCAD, being mentioned: theft, household items sales, get arrested, drug use, drug use relapse, running away from home and stay on the streets, crisis events or outbreaks, drug dealers involvements, debt contraction, risk exposure, being persecuted, involvement in fights and trouble, problems and aggressions.
I had already been admitted here. I was discharged and went back to the shelter, only that I shouldn’t have been discharged because I was still wondering if I could stay clean, then I had a relapse and came back here. (A12)
I went crazy, then I got arrested and they sent me here because I was on drugs. (A5)
The search for treatment was because he had run away from home. He left home, got close to people who he shouldn’t, used drugs. (F8)
They come here in critical moments, when they sell everything or when they are impossible. (P7)
Sometimes the adolescent comes here and he is in risk, he is in debt to a drug dealer, he is being persecuted. There are many adolescents like that, who have problems out there with some factions, that as they report, they are in debt to them, they have been involved in fights with them. (P8)
Healthcare services used by the adolescents crack users until their admission at the PCCAD
The most commonly used healthcare services by adolescents crack users until their admission at the PCCAD reveal a culture of asylum treatment, where rare exceptions are triggered by public health protection and healthcare assistance present in the community (Figure 3).
Figure 3 –Frequency word cloud for sub-node coding “healthcare services used by the adolescents crack users until their admission at the PCCAD ” via QSR Nvivo.
The asylum services mentioned are: psychiatric hospital, asylum, farms and clinic.
I have been in farms, I have been in a lot of places. Now I don’t remember, but I spent quite a lot. (A11)
In the clinic, in the psychiatric hospital […] I was there 30 days. Later I was in the general hospital, I was there for 15 days, taking some medications. (A14)
I admitted him at the psychiatric hospital, I made a compulsory admission. Later I was told that as soon as he left the hospital, he should continue his treatment at the PCCAD. Then I returned to the PCCAD to continue the treatment. (F4)
We went to the sanatorium and after that, we left with a referral to PCCAD. (F6)
Usually, they get here after psychiatric hospital, because they go there first, straight to the psychiatric hospital. (P7)
The less frequently mentioned services are characterized as public protection and healthcare assistance present in the community, such as: postinho (Basic Healthcare Unit- BHU), CRAS, tutelary council and street doctor’s office.
The postinho’s social worker indicated us. You should look for the PCCAD. (F8)
First I went to RCSA, I always ended up going to the RCSA. When I was there, I was indicated to come here [PCCAD]. (F2)
I went to the tutelary council and they told me, that I must to take him to the PCCAD. (F5)
Because of harm reduction and the street doctor’s office, every now and then, they come here, because they are right at the spot where dealers are, just where the adolescent lives. (P4)
Discussion
Some authors point out, that the spontaneous demand based on the user’s desire and motivation is fundamental for the treatment’s success. Besides, having the family support is another important factor to be admitted in a healthcare institution. In an integrative review of drugs users’ social network, the family was identified as the only support group, following the breakdown of other social bonds, such as workmates, relationships and friends.
A study conducted in the state of Bahía, with users of a PCCAD, found that the patient’s family is the main support for treatment adherence, as it is seen as a support, affection and guidance source, as well as the starting point to interact with others, thus becoming an active part in the rehabilitation process.
On the other hand, the healthcare admissions of adolescents through justice is a negative point, as it may reveal a late treatment search, a lack of information about healthcare services and/or complications in accessing and bonding with these institutions. The research points an existing gap between the adolescents and mental healthcare services. These gaps are directly linked to the lack of healthcare services focused to this population, the poor treatment adherence and the unfriendly way of treating with this group of people by the healthcare professionals, as well as the lack of their professional training, fragility in the dynamic relationship between healthcare, employment, education, sports and justice and also specific interventions/strategies oriented to young people and adolescents.
The current study pointed out, that one of the reasons that lead the adolescents to get treatment at PCCAD is behaviors problems, which favors conflicting situations within the family, including discussions and aggressiveness. Violent acts have also been evidenced in other studies, in addition to the issues of drug dealing and the public condemnation to the drug user by the society. These findings highlight the complexity of drug user’s care along with their families, because the suffering originated by drug abuse is a broad spectrum problem. In this sense, violent behavior, prejudice and familiar conflicts also become intervention goals by the healthcare staff.
Another reason that lead adolescents to get treatment at the PCCAD is related to find better living conditions. Researchers point out, that this searching of treatment may originate from external factors, such as a specific event and/or someone’s influence, for example: marriage conflicts and divorce petition, struggle to get along with relatives such as the children or even relatives or friends who have encouraged the drug user to look up to a treatment.
If the treatment may provide the adolescent a chance of better conditions, to look up to new ways of social reintegration, the court’s constant requests for compulsory medical admissions go against the psychiatric reform process and the free willing care. A documentary research carried out at the Child and Young Court of São Paulo, with the goal to ascertain the court decisions on cases for referral of child or adolescent drug users, to get treatment at mental healthcare assistance institutions, found contradictions between the socio-educational actions of admissions and treatment at the PCCAD.
The PCCAD as a mental healthcare service at a local community level, requires an appropriate place to develop its functions in an integral way. However, an adolescent who is admitted for a socio-educational reason, does not have the opportunity to benefit totally from this arrangement during the psychosocial rehabilitation process. This contradiction limits mental health treatment to a purely clinical and outpatient setting within the PCCAD facilities. Thus, it is necessary to approach this condition in a more accurate way, because the mere fact that an adolescent is referred to a PCCAD, does not reveal, that he will get an appropriate care, according to the psychiatric reform standards in a socio-educational way.
In addition, the fact that adolescents use the psychiatric hospital and the therapeutics farms as a gateway to PCCAD, raises some specific issues, such as the fire extinguishing policies that take out drug users from their social environment, a limited investment in the psychosocial healthcare network and an appropriate care at a local community level, enhanced by prevention and health promotion.
The municipality involved in this research has a substitute mental healthcare network, with a significant number of services. Nevertheless, the psychiatric hospital still takes part of the network, contrary to the law 10.2016 of 2016 about the asylum’s closure, mediating the formation of replacement services. In this sense, some questions are relevant to answer, for example: why the structure of the psychiatric hospital still remains in the municipality? Are substitute services being effective?
Additionally, the permanence of the psychiatric hospital in the local healthcare network, leads many people to use it, influenced by cultural and historical reasons. Moreover, it may reveal a lack of information by local families about the substitute mental healthcare network, as well as a lack of bonding to these institutions.
These contradictions, present in a daily basis in the labor environment and the complexity of the child and youth mental healthcare area, are the result of historical inheritance of the assistance model focused on alcohol and drug users. By the way this model is formed, it can be identified closed institutions, which have historically grown focused on the criminalization and repression of alcohol and drug users, and also institutions whose healthcare is operated in a mental healthcare network, consisting of open equipment (PCCAD), that operates under a harm reduction logic, derived of the psychosocial care model.
The research’s results show that the psychosocial model and the asylum model are related, requiring a greater investment in healthcare at a local community level, prevention practices and healthcare promotion. Harm reduction as a healthcare strategy and at the same time guiding the National Mental Health politics can result in innovations in health prevention and promotion, in territories with a high social vulnerability and drug dealing problems.
To make it possible, more investment is required in harm reduction teams, in healthcare strategies at a local community level and in continuous training for the professionals who take part in these actions, in order to enhance the understanding, communication and deep analysis skills, avoiding the risk to perform old practices, which are related to life’s penalty and segregation.
Final considerations
The analysis of the paths taken by the crack users until they get treated at the PCCAD, pointed the importance of knowing the way they arrive at the service, the reasons that led them to get treatment and the services used until they got here.
The way the adolescent crack user arrives at the PCCAD showed that a PCN necessarily requires intersectional collaboration, as young people is admitted into the service not only spontaneously, but mainly due to referrals made by the protection and justice agencies and also the social assistance network. The own adolescent’s desire to seek a better life, justice claims, and behavioral problems stand out among the reasons that lead an adolescent crack user to get treatment.
For this reason, it is imperative that the PCCAD promotes actions to prevent substance abuse and health promotion, along with existing services present at a local community level (schools, basic health units, family health strategy, social assistance reference center, among others), studying and valuing the adolescents’ life projects, so that they can visualize real possibilities of make them true and reinsert themselves socially.
The services frequented by adolescents crack users until reaching the PCCAD, reveal a tradition of asylum treatment, in which the psychiatric hospital becomes the main entry point into the service, often associated with requests for compulsory medical assistance admission, made by a court. This goes against the psychiatric reform standards and the free willing healthcare.
In order to overcome exclusionary and retrograde healthcare practices it is important an investment in services and practices developed by the PCN, allowing them greater capabilities and access to young people, as well as continuous training of their professional staff focused on developing skills and competences to look up to new way of the adolescents’ social reinsertion.
The present study has as its limitation, the fact that it portrays just a local reality and, although the data here presented may reflects conditions present in other locations, it cannot be generalized due to the specificities of the municipality under study.
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Corresponding author
Juliane Portella Ribeiro
E-mail: ju_ribeiro1985@hotmail.com
Endereço: Gomes Carneiro, nº1, 2º andar. Universidade Federal de Pelotas, Faculdade de
Enfermagem - Centro, Pelotas – RS.
CEP: 96010-610
Authors Contributions
1 - Juliane Portella Ribeiro –
Conception, design, analysis, interpretation of data and final approval of the version to be published.
2 - Giovana Calcagno Gomes –
Conception, design, analysis, interpretation of data and final approval of the version to be published.
3 - Adriane Domingues Eslabão -
Article redaction and critical review of the intellectual content, as well as the final approval of the version to be published.
4 - Naiana Alves Oliveira –
Article redaction and critical review of the intellectual content, as well as the final approval of the version to be published.
How to cite this article
Ribeiro JP,Gomes GC, Eslabão AD, Oliveira NA. The Trajectory of adolescent crack users until their admission at the Psychosocial Care Center for Alcohol and Drugs. Rev. Enferm. UFSM. 2019 [Acess at: 2019 jun 15];vol ex:p1-p21. DOI:https://doi.org/10.5902/2179769232526