Accompaniment processes, gender focus, and women in alcohol/drug consumption in pregnancy and motherhood: transdisciplinary keys and occupational therapies from the South¹

Abstract

Preliminary results of a research that seeks to characterize the intervention model of an Intensive Outpatient Program for the treatment of drug and/or alcohol use in pregnant and maternity women of the CRS of the Hospital El Pino, in the commune of San Bernardo, Chile, are presented. The objective is to describe the characteristics of the accompaniment process with a gender approach carried out by the health team working in the program and to consider its transdisciplinary character as keys to improving adherence, reducing dropout rates, favoring therapeutic discharges, promoting autonomy and the exercise of rights. The methodological design corresponds to qualitative research with an emic and intracultural approach, which seeks the point of view within the team. The sample is purposive, and the information was produced through nine participative group interviews with the work teams and an individual semi-structured interview with the head of the program, carrying out a thematic analysis of the experiences shared. The results indicate that the accompaniments from a gender and human rights perspective favor transdisciplinary work, key aspects to reduce equity gaps, and favor access to health for women in vulnerable conditions. Being the occupational therapies from the south are important to enhance these processes.

Keywords:
Occupational Therapy; Gender Equity; Alcoholism; Substance-Related Disorders; Pregnancy; Maternity

Resumen

Este artículo presenta resultados preliminares de una investigación que busca caracterizar el modelo de intervención del Programa Ambulatorio Intensivo de tratamiento del consumo de drogas y/o alcohol de mujeres en embarazo y maternaje del Centro de Referencia en Salud (CRS) del Hospital el Pino, Comuna de San Bernardo, Chile. El objetivo es describir características del acompañamiento con enfoque de género que realiza el equipo del programa, considerando su carácter transdisciplinar como claves para mejorar adherencia y favorecer altas terapéuticas, promoviendo autonomía y ejercicio de derechos. La metodología es cualitativa con enfoque emic e intracultural, La muestra es intencionada y la información fue producida a través de nueve entrevistas grupales participativas y una entrevista individual, realizando análisis temático de la información. Los resultados indican que los acompañamientos desde enfoques de género y derechos humanos, favorecen un trabajo transdisciplinar, aspectos claves para disminuir brechas de equidad y favorecer acceso a salud para mujeres en condiciones de vulnerabilización. Siendo las terapias ocupacionales desde el sur importantes para potenciar estos procesos.

Palabras-claves:
Terapia Ocupacional; Equidad de Género; Abuso de Alcohol; Trastornos Relacionados con Sustancias; Embarazo; Maternidades

Resumo

Este artigo apresenta resultados preliminares de uma investigação que busca caracterizar o modelo de intervenção do Programa Ambulatorial Intensivo para o tratamento do uso de drogas e/ou álcool em mulheres grávidas e maternidades no Centro de Referência em Saúde (CRS) do Hospital el Pino, San Bernardo, Chile. O objetivo é descrever características do acompanhamento com abordagem de gênero realizado pela equipe do programa, considerando sua natureza transdisciplinar como chaves para melhorar a adesão e favorecer as altas terapêuticas, promovendo a autonomia e o exercício de direitos. A metodologia é qualitativa com abordagem êmica e intracultural, a amostra é intencional e as informações foram produzidas por meio de nove entrevistas grupais participativas e uma entrevista individual, realizando-se a análise temática das informações. Os resultados indicam que os acompanhamentos das abordagens de gênero e direitos humanos favorecem o trabalho transdisciplinar, aspectos fundamentais para reduzir as lacunas de equidade e favorecer o acesso à saúde para mulheres em situação de vulnerabilidade. Sendo as terapias ocupacionais do sul importantes para potencializar esses processos.

Palavras-chave:
Terapia Ocupacional; Equidade de Gênero; Abuso de Álcool; Transtornos Relacionados a Substâncias; Gravidez; Maternidade

Introduction: Situation Presentation

The situation of problematic alcohol and/or drug use in women has several complexities from cultural and social stereotypes associated with the feminine since it transgresses expectations related to femininity, challenging the traditional role (Hernández, 2013; Valencia-Recabarren, 2015; Chile, 2016b). Due to this, they suffer higher levels of stigmatization and mistreatment, a situation that worsens during pregnancy, childbirth, postpartum, and maternity (Hernández, 2013), hindering access to treatment for fear of consulting.

In 2011, the National Service for the Prevention and Rehabilitation of Drug and Alcohol Consumption of Chile (SENDA ex CONACE²) was created in Chile. One of the lines of action of this service is the execution of treatment, rehabilitation, and social integration policies for people affected by drug and alcohol use (Chile, 2021). In the treatment modalities, there is a specialized line to provide care to pregnant and/or postpartum women who present problematic drug and/or alcohol consumption. From there derive the specific Intensive Outpatient Programs for Women (Programas Ambulatorios Intensivos específicos de Mujeres - PAI-M), which arise from the evidence that drug and/or alcohol consumption does not present the same physical, psychological, and social consequences in women, requiring differentiated interventions, which consider contextual and sociocultural aspects of their consumption situation (Valencia-Recabarren, 2015). SENDA has prepared various technical documents incorporating the gender approach, which guide the interventions of the teams, however, the data shows that it is necessary to continue strengthening the practices of the teams since it is still not possible to give an effective response to the obstacles to permanence and adherence to treatment.

According to data from SENDA (Chile, 2016b), the PAI-M of the metropolitan region in Chile, presents high dropout rates (42%) and a lower percentage of therapeutic discharges (27%), along with administrative discharges (24%) and referrals (7%). Regarding the sociodemographic characteristics, when comparing the group in treatment for problematic drug and/or alcohol use of pregnant and postpartum women with non-pregnant women, the first ones show signs of greater social deterioration and vulnerability: 51% of non-pregnant women have not completed high school, in the case of those in pregnancy and postpartum the figure rises to 64.4%; Similarly, 31% of non-pregnant women only reach basic education or less, however, for pregnant and postpartum women the figure increases to 39.4%; 30% of non-pregnant women have a paid job, and only 17.7% of pregnant and postpartum women have a paid job; 30% of women in treatment are unemployed and in pregnant and postpartum women the percentage is 33.7%.

The exposed antecedents show the particularities necessary to consider in the intervention, especially, the situation that women experience from a confluence of oppressions where gender, social class, education, nationality, raciality, and territorial origin, among others, intersect with problematic consumption and mothering (Casado & Blasco, 2003). This requires the coordination and pooling of the various institutional teams involved, to contribute to the timeliness and relevance of the actions contemplated in the accompanying strategies (Chile, 2008, 2016a), with transdisciplinarity being a political-epistemic position that allows a situated, multidimensional and complex approach that gives rise to plural and collective knowledge (Libreros Piñeros, 2012; Juns & Lancman, 2011; Lima, 1997; Lima & Ghirardi, 2008; Alburquerque et al., 2016).

The PAI-M of the Hospital and CRS El Pino, located in the commune of San Bernardo³, cares for women with characteristics similar to those already described, among them: 75% are single, live with relatives, and do not have paid work, in which 40% have incomplete secondary education and 25% did not finish basic education (Rowlands et al., 2018). However, the program presents percentages of adherence and treatment discharge above the average at the Metropolitan Region level, which is expressed in the following results for 2018 according to SENDA and its treatment management and registration system (SISTRAT): 25% of abandonment, 41% therapeutic discharge, 24% referral, 10% administrative discharge, obtaining a total of 35% of interrupted treatments (abandonment, plus administrative discharge), a figure that is notably far from the 66% obtained at the level of the Metropolitan Region⁴ (Chile, 2018a). According to the Systematization of the program carried out in 2018 by a teaching team of the Occupational Therapy Career of the University of Santiago de Chile (USACH), the following aspects are key to the good results of the PAI-M of the Hospital and CRS el Pino: Articulation of primary and secondary networks; participation of users in their therapeutic processes; consider the conditions of each place where the intervention is carried out; human rights perspective; link and therapeutic accompaniment (Beltrán et al., 2018). These aspects were considered for the design of this investigation.

For this article, we will emphasize the accompaniment processes, as ways of “accompanying” that respond to the following principles, as pointed out by Zousa (2015). In the first place, the accompaniment does not respond to a traditional intervention, since it is interested to dislodge whoever exercises this role from the specialist's place of power-knowledge. Also, they are guided by the principle of autonomy, “[...] what it means to be together with others, recognizing them as socio-historical and political subjects, with their resources and vision of the world, with the ability to create their projects and build towards the future” (Zousa, 2015, p. 16). In the same way, accompanying implies assuming a political position, in this case, committed to human rights and the genuine recognition of the women who participate in the program, being important that the accompaniment actions facilitate the unveiling of the patriarchal relations of power that cross life stories of women (Red Chilena contra la Violencia hacia las Mujeres, 2021, 2019; Quisbert, 2018). Therefore, in no way, it is possible to assume a neutral position (Najmanovich, 2012). Accompanying is always a reflective process, of problematization, in no case, of indoctrination or discipline, it is also a process that promotes integrality. Therefore, different knowledge, views, and tasks are articulated, requiring the incorporation of different dimensions of reality and different knowledge, which become trans-knowledge (Alburquerque et al., 2016) from transdisciplinary dialogues.

Finally, the accompaniment tries to visualize all the dimensions of the experience (Heller, 2002), including the analysis of the social, political, economic, cultural, neighborhood, and family context, which in various ways conditions the experience of consumption, mothering and the plot of women's life experiences. Interestingly, the violence and the concrete facts suffered in their daily lives be incorporated into the accompaniment processes, and the recognition of the different forms and levels in which the damage is expressed and the very resources that women and their networks of support, they have implemented to face them and become stronger (Zousa, 2015).

From a gender perspective, considering what we already exposed in the first article on this same research⁵, the team of occupational therapists of the PAI-M Program of Hospital El Pino points out that sexual and reproductive rights are a fundamental pillar of the processes of accompaniment. In the case of mothering, it is understood that they are situated and historicized experiences, where singularity demands a critical reading of reality, considering how the patriarchal, colonial and racial system expresses in their concrete possibilities and impossibilities. As we have pointed out, accompanying in these contexts implies facing a patriarchal society, which questions and punishes more rigorously the social imaginary based on the binarism of roles of women who present problematic consumption (Pardo, 2009). This does not only happen in the family-neighborhood space, but it happens, especially, in the same institutional networks that should act as guarantors of their rights and not reproduce structural violence (Segato, 2003). In the case of occupational therapy from the south, accompaniment practices are fundamental support strategies in women's institutional and territorial circuits (Pino et al., 2015; Sanz, 2016; Borba et al., 2017; Palacios, 2017; Bianchi, 2018), strengthen the transdisciplinary work of the team, specifically, creating spaces that facilitate the role of caring for their children, safeguarding their rights and making it easier for women who wish to do so to care, organize their daily lives and rethink their life project.

Structural violence is an issue that must be incorporated into the understanding of accompaniment processes with women (Díaz et al., 2021). Considering regional experiences, the Secretariat of Zacatecas Women in Mexico (Zousa, 2018) emphasizes that accompaniment of women who live in contexts of structural violence must be guided by specific principles, such as human dignity, equality, and non-discrimination. This means that the State and the intersectoral public network assume their protection and respect for the autonomy of women. It is also assumed that the teams that provide accompaniment should not criminalize or blame, on the contrary, accompaniment spaces should be provided respecting and allowing the effective exercise of their rights. Another characteristic of the accompaniments is the complementarity of the actions, both in the transdisciplinary and intersectoral spheres, understanding that they are always complementary and not exclusive. They must respond to due diligence, that is, they must be carried out within a reasonable time and permanently evaluate the impact on the singular accompaniment processes with each of the women. When the accompaniments are linked to mothering processes, the best interests of the child must also be incorporated at all times, a principle that must be analyzed with special care in the face of the conflict of rights (Etcheverry & Fuentes, 2017; Fondo de las Naciones Unidas para la Infancia, 2017).

Following the proposal of the Secretariat of Zacatecas Women in Mexico (Zousa, 2018, p. 20), and from a southern perspective, the accompaniments must respond to a transformative approach. This means that the teams must make all efforts necessary to protect, care for and, above all, allow “[...] comprehensive reparation, aimed at eliminating patterns of discrimination and marginalization” that affect women. Finally, the accompaniments must guarantee the integrality, indivisibility, and interdependence of women's rights and have the necessary mechanisms for this [...] “You cannot guarantee the enjoyment and exercise of the same without at the same time all other rights are guaranteed. The violation of one right will jeopardize the exercise of others”. Finally, it is essential to deconstruct the stigmatization, prejudice, and subjective considerations that reproduce structural violence. This can become a veiled form of secondary victimization (Zousa, 2018), that is, they can aggravate their condition, establish requirements that hinder and impede the exercise of their rights, and may expose them to suffering new harm due to the actions or inactions of intersectoral care networks. For this, the accompaniments mustn't be understood as isolated actions but as accompaniment networks, with teams that are continuously in processes of self-reflection and training and promoting educational actions that involve women, their families, the territory, the networks institutions, communities, and civil society as a whole. Only in this way, it will be possible to ensure that the accompaniment processes point towards autonomy, self-determination, and the full exercise of their rights to resume their life project.

The accompaniments carried out from the health networks and with a transdisciplinary perspective, imply providing care spaces that consider the complexity of existence and the suffering that it produces, in this case, the consumption situation, other health situations, and their specific living conditions. As Lima & Ghirardi (2008, p. 154) point out, teams must implement transdisciplinary practices:

To provide a space for hybrid practices, we seek to discuss elements of daily non-work activities, with the potential to produce gaps in the disciplinary structure, opening a favorable provision for work organizations based on transdisciplinarity.

One of the characteristics of the work carried out by health teams that assume care practices, especially with women with problematic drug use during pregnancy or maternity, requires the consideration of different dimensions. It is not possible to reduce the support processes carried out by the different professionals to isolated fields or where coordination is only established to agree on certain benefits. Transdisciplinarity, following Lima & Ghirardi (2008, p. 157), alludes to a polyphonic field of knowledge and practices.

A transdisciplinary conception and the defense of a confluence of knowledge that contributed to the invention of new hybrid territories - those that abdicate the borders as control zones, favoring the constitution of border instability zones - is, therefore, increasingly a challenge for health training.

In the same way, Libreros Piñeros (2012, p. 625) proposes transdisciplinarity as an approach that “[...] is conceived as an emerging superior knowledge, the result of a dialectical movement of thought, which allows crossing the boundaries of different areas of disciplinary knowledge and creating images of reality more complete and more integrated”. In this way, it is about erasing the borders that are established between disciplinary fields, which does not mean leaving behind the singularities of each field, rather it is proposed transversality in the approaches or the modes of accompaniment, in such a way that the articulation process the meaning of the actions responds in a situated way to the complexities of life stories, where problematic consumption and mothering are inscribed.

The ongoing research aims to characterize the intervention model used in the PAI-M of Hospital el Pino. In the case of this article, we are interested in deepening the characterization of the support process carried out by the program's health team from a gender perspective and the contribution of Occupational Therapy to this transdisciplinary work as keys to improving adherence.

Methodological Procedures

The methodological design is of a qualitative nature (Alonso, 1998), addressing the understanding of the various intersubjective constructions of the participants (Haraway, 1995), of the health teams, regarding their accompaniment practices. It is characterized by approaching the field of research from the perspective of the research subjects, considering the strategies deployed by the CRS team of Hospital el Pino of PAI-M and PAIA⁶. Ibañez (1994) calls this practice the emic approach and points out that it is specific and intracultural, that it requires an internal point of view, -professional teams-, located in specific local contexts.

To recognize the perspective of the teams, an approach to reality is made from a descriptive analysis based on shared experiences, which in our study are co-elaborated by people from the teams in the specificity of their practice.

The information production technique is the participatory group interview, described by Rivas (2006), and the semi-structured individual interview (Canales, 2006). Professional teams are social groups, which identify themselves or self-categorize as belonging to the grouping that supports their practices (Morales et al., 1994). Therefore, this technique is pertinent since it allows knowing the opinions of a specific group of people about a common theme, based on questions formulated and answered in a conversation produced between people who know each other (Rivas, 2006). Regarding the semi-structured individual interview, this is defined as a double-type information production technique, since it allows access to oral information (words, meanings, senses) and gestural and corporal information, being an encounter aimed at understanding the perspectives that the informants have regarding the topic addressed (Canales, 2006). In both cases, the interview schedule included topics related to the characterization of the team, approaches, and support strategies.

We used intentional sampling in which the participants are chosen for their representativeness. The selection was oriented towards those who knew the situation to be investigated, being the most suitable and representative (Ruiz-Olabuenaga, 2003). Six group interviews were conducted with teams from the adult (PAI-M) and young women (PAIA) programs, three group interviews by status (social workers and rehabilitation technicians; psychologists and psychiatrists; occupational therapists and nursery educator), and a semi-structured individual interview with the team leader (Table 1). Each interview dealt with the same topics in a way that triangulates and gives greater depth to the information. We acted with the principle of saturation where the conversational processes began to redound without adding new categories to the analysis.

Table 1
Interviews and participants.

Number of Group Interviews	Number of participants	Position/Profession	Program/Area
EG1	12	3 Occupational Therapists 2 psychiatrists 1 psychologist 2 Social Workers 3 rehabilitation technicians 1 Early Childhood educator	PAIM- PAIA
EG2	12	3 Occupational Therapists 2 psychiatrists, 1 psychologist 2 Social Workers 3 rehabilitation technicians 1 Early Childhood educator	PAIM- PAIA
EG3	8	2 Occupational Therapists 2 psychiatrists 1 psychologist 1 Social worker 2 rehabilitation technicians	PAIM
EG4	7	2 Occupational Therapists 1 psychiatrist 1 social worker 2 rehabilitation technicians 1 nursery educator	PAIA
EG5	8	2 Occupational Therapists 2 psychiatrists, 1 psychologist 1 Social worker 2 rehabilitation technicians	PAIM
EG6	7	2 Occupational Therapists 1 psychiatrist 1 Social worker 2 rehabilitation technicians 1 nursery educator	PAIA
EG7	5	2 psychiatrists and 3 psychologists	Psychiatrists and psychologists area
EG8	5	2 social workers and 3 rehabilitation technicians	Social workers and rehabilitation technicians area
EG9	5	4 Occupational therapists and 1 nursery teacher	Occupational Therapist and Early Childhood Educator area
EI 1 (Entrevista individual)	1	Head of program/psychiatrist	Psychiatrist

• Own source.

The call was made with the authorization of the leadership, trying to generate heterogeneous groups in professions, ages, and working time, to ensure a plurality of voices. The informed consent letter was presented, with the voluntary signature. There were no rewards or penalties. The research was approved by the ethics committee of the University of Santiago de Chile and the Southern Health Service to which the CRS Hospital El Pino belongs.

The analysis was carried out using the thematic analysis technique (Díaz, 2018), which implies the identification of three elements: the sampling unit, the registration unit, and the context unit. The first corresponds to the realities observed that were analyzed separately (the teams of each subprogram, the groups by status, and the head of the program). The registration unit is the part of the interviews that can be considered analyzable because the references that respond to the research objectives appear (Delgado & Gutiérrez, 1994). According to Delgado & Gutiérrez (1994), it is also necessary to locate them (context units); in this case, the implementation of the program is in the CRS of Hospital el Pino. Once the registration and context units were determined, the coding phase was passed, which were related in thematic categories. Abela (2000) points out the identification and thematic classification, in this case, at the beginning the concepts were defined -accompaniment, gender-transdisciplinarity- to specify the units of analysis. To organize the registration units, the analysis elements were selected according to previous axes in response to the research objectives, indicated in the introduction and which are developed in the following section.

Results

The results that we present are preliminary and are organized around describing the team's accompaniment practices and identifying the actions with a gender approach that favors adherence. For this, we analyze the characteristics of the accompaniments described by the team, considering a transdisciplinary, gender, and human rights perspective, as keys that allow improving adherence, reducing dropout rates and favoring therapeutic discharges, promoting autonomy and the exercise of rights of the women who participate in the program.

Key 1: Accompaniment processes from transdisciplinary work

A very important and recurring element in the vision of teamwork is that the accompaniments must be supported by all the members of the team. This requires a horizontal organization based on the recognition of the trajectories, decisions, and purpose of the team. Those who assume leadership (management positions) are relevant figures since they favor this type of organizational structure and promote autonomy, proactive organization, and the strengthening of various accompaniment spaces.

That has to do with leading a more flexible vision, a vision closer to people, a less judgmental and respectful vision of people's decisions and the teams I've been in, I've always tried to get them to take that course (EI 1).

This type of accompaniment is based on a collective identity that understands the accompaniment processes from a perspective that conceives women in a broad, integrated, and humanized way, which arises from a coordinated work that is permanently intertwined.

[...] in general, there is a fairly comprehensive view of the human being in the program. [...] many times we collect the same information and it is how we have to agree among ourselves in the meetings, [...] and the roles are intertwined perhaps a little and I think that for me is something very positive and I think that's how it has to be [...] if we segmented the human being I think we would again make a very profound mistake (EG7).

There is a transdisciplinary perspective, which allows for joint work that is implemented in the team's practice spaces. This contributes to addressing the complexities experienced by women from the specificities of each disciplinary field, especially since it is a highly invisible and vulnerable group.

There are certain elements within the development of the programs [the three] that realize that one is impregnated beyond theory and realizes that together we are addressing from the different areas the inequalities that are expressed in discrimination, in social exclusion, especially in this sector where people are so invisible and from there we stop from that path (EG8).

Trust and belonging to the team are fundamental aspects, as this favors the development of accompaniments through different types of interactions and daily exchanges. This generates a “work environment” that allows conflicts to be faced, a key issue to maintain a transdisciplinary perspective, considering the specificities of each disciplinary field and the complexities of the situations that affect women.

[...] the work environment is super relevant, like the interaction that usually occurs, such as from the development of cases to the daily life, it will also enhance their sense of belonging to the team, it is super relevant, I also compare it with other previous experiences such as other work with teams, but here it happens with a super good climate. Usually, if conflicts arise, they are dealt with directly [...] (EG7).

As indicated by the team, these forms of work that have been incorporated over time are highly valued and transferred from those who have longer careers to those who are joining the team. A practice that is key in the process of forming and growing the team is its permanent training, with the necessary spaces and times for this. Also, to receive and incorporate new members, they can understand the scenario in which the program is located, and learn the ways of doing the team as a whole and each one of its members. The main result of this way of understanding the formation of the team generates trust and understanding of the meaning of the program.

M is teaching us this way… [...] at first I remember that we walked like chickens behind him and it was like, we all did it, the 4 of us, deep down because he wanted us to learn that way in which he approached a certain situation and that I also believe that it was vital to form the team and like these confidences, understanding what the other is doing [...] (EG1).

Another point that stands out is related to conceiving that the program provides opportunities for learning and growth, which allows the display of inventive, creative capacity and the possibility of projection, considering that it is a flexible space, in permanent movement, and training and transformation.

[...] being in a program where you have opportunities for development and growth, for innovation, I mean, something occurs to me and it's like I'm crazy... you have to implement it [...] and that is also obviously very gratifying, as one never gets bored [...] (EG1).

In the same way, there are spaces to address the tensions that occur during the accompaniment processes in the face of the stories lived by the women who participate in the program. Their lives condense a series of experiences of suffering, abandonment, inequality, and structural violence, both in the family, community, and institutional networks. Given that the team witnesses this structural violence during the accompaniment processes, it is discussed, welcomed, accompanied, and even when necessary, relay systems are produced focused on caring for the team.

We are very attentive to that [...] we accompany each other a lot to be able to have a space to talk about the tensions that these stories generate because they are very difficult stories as we have already mentioned before, so how do we accompany each other in saying well I knew this is difficult, I don't know let's relieve this work now I'll do it, you rest, watch out for this [...] (EG9).

The main approaches that guide the team's transdisciplinary actions are given by the rights, gender, networks, and community approach. These are issues on which the team emphasizes: understanding that women are holders of rights, that gender strongly conditions the possibilities they have to face inequalities and the specific processes of consumption, pregnancy, and motherhood, and understanding that it is a problem that should lead to the activation of networks of all kinds and that this is only possible to the extent that actions are carried out in the territories where the women who attend the program live and circulate.

[...] we have talked about, that in reality, we do work under a model or a legal approach, mainly a gender approach and a community model [...] I believe that these are the 3 important things and that they also come a little to break this model as more biomedical to which we have been [...] exposed throughout our training and our entire lives [...], it is a deconstruction almost like machismo, more or less the same, as the biomedical up to the right approach and I think it is impossible to think of a job like the one we do with a user profile like the one we have if we do not position ourselves from that model, because deep down none of our patients would adhere [...] (EG7).

Therefore, a fundamental characteristic of the team is the capacity for transdisciplinary work, based on certain approaches that are integrated into a permanent dialogue about the understandings of the women that it accompanies.

Key 2: The accompaniment processes from the rights and gender approaches

In the context of the inequalities and inequities experienced by women, the human rights approach and, in a cardinal way, the gender approach from a feminist perspective, are fundamental keys within the accompaniment processes.

Yes, regarding the gender approach, perhaps in… I think that we, because sometimes there are people who misunderstand the gender approach; like there is differentiated care for men and women, yes? I think that in this sense we understand the inequities and inequalities due to the fact of being a woman, understanding that it is different to be a woman who consumes and has children and/or is pregnant, to be a man who consumes and has children, for example (EG2).

The gender approach is not assumed as a technical matter but as a struggle or a commitment that goes through accompaniment practices, especially when it is women who accompany other women.

The theme, for example, of feminism is something that questions each of us, [...] I think if there is, I don't know, a day against violence against women or gender violence, I think that all of us have been involved [...] on a personal level there is a struggle [...] that permeates all our areas of daily life so I think that from there we are always trying to bring that to that accompaniment that we do with the women with whom we work (EG9).

It is suggested that the strategies must be situated from a therapeutic accompaniment with an affectionate and genuine commitment. In this process, the support strategies with mothering and parenting carried out by occupational therapists in the space of early stimulation workshops are key, which are understood as collective care tasks that include the team and families when this possibility exists to be accompanied collectively, an issue that enhances the team's transdisciplinary work.

Wherever I went, I talked about early stimulation from day one [...] and what it has to do with the bond, attachment, mothering, and early stimulation, right? So how did that favor, thinking about consumption, favored a woman who reduced consumption or who preferred not to consume because this new motherhood [...] generated a different meaning because someone was also accompanying her in mothering, understanding that mothering was not only of the woman but of that group that she was accompanying, which is generally made up of other relatives who are also women, so from those places, it is true as if situating that story (EG9).

The team understands that adherence to the program is conditioned by the life stories of each woman and her support networks, and also by the relationship strategies that the institutional networks establish with them, how the objectives are established and the meaning it has for their lives, the co-construction of the accompaniment process being central.

[...] it is equally important to make people, especially the children, active in their process, from there it is interesting, also the issue of being able to perhaps incorporate as co-constructed objectives. I think it is also very important. [...] afterward, I don't know, reviewing what has happened with a certain objective [...] because finally they are people who are making sense of what they are working on and I think that contributes to adherence (EG7).

In this sense, strategies based on the gender approach, on the recognition of the different ways of being a woman and of being a mother, and that promote autonomy, are very decisive in favoring adherence.

I don't work based on perfect motherhood, which is what many ask for in these programs dedicated to children, [...] I don't work from that guilt, right? There are different ways of being a mom and different ways of being a dad, and we can adapt a little, yes? The issue is that we have a common path, a common goal [...], making sense of it supports us to have this voluntary process (EG9).

In the process of accompaniment towards autonomy - a key and decisive issue to favor adherence - the same team becomes a node of the support network, support space for it.

Many times we become a little knot in the network of people we accompany, but we are attentive to the issue of the autonomy of these people, so we are also very attentive to the fact that this is a process in which we want the women we accompany and the young women we also accompany [...] they are more autonomous, but we understand that it is a process and therefore we are accompanying that [...] (EG9).

Another key aspect of the accompaniments is that they are based on voluntariness, breaking with the punitive logics usually present in social imaginaries at a general level, including health, judicial and social protection networks.

I think that volunteerism is a central thing and also this break with the punitive logics that exist in other health devices, especially in the office, for example, or in maternity hospitals like and… I think it is something that we have talked about in the other interviews about the stories of violence that these users have, so I think that first moment that first reception is key (EG9).

The team understands that it is incorporated into the life stories of women, where the first meeting is a key aspect to generate a committed bond and identifying situations of vulnerability, associated with previous experiences of abandonment, neglect, and institutional violence.

Perfect, yes, but there are people who come to our program that no one has ever asked them if they have sexual relations with someone or if they have ever gone to control with a midwife and they come from hospital teams where they have been for years, yes or the issue of pension, that is, we received a person from… with schizophrenia who has not worked for ten years, which is not true due to his health condition and nobody has managed the basic solidarity pension, so you say, hey, what happened to this person (EG9).

In their family networks, it is common that there is also transgenerational damage, associated with stories of poverty, social exclusion, violence, and abandonment, among others. Therefore, this process is often experienced by women without any type of family support. Acknowledging these situations allows us to understand why the team assumes support strategies that start by giving protection, containment, and resignification to the life projects of women.

We take a more protective role, yes? of containment and sustaining the emotional and about that of working on the autonomy of the girl because it means, you know what? if you are alone, because deep down you cannot lie, so what do we do with that loneliness, where do we look or how do we build the life project (EG4).

The foregoing requires that these first encounters be oriented towards recognizing these experiences and progressively generating instances of damage repair.

Sure, one works with them but for me it is still sad to have to inform them, preparing them for such a violent act, that is what happens to me because I say there are girls who have done a super good process that although at some point they had some problematic use, this baby or this pregnancy is a bit like fixing it up and it becomes such an important project for them that they stop using, they start working on not repeating violent behavioral patterns in the family, because finally, they see a hope, they were worth it through this pregnancy and that all of that is ruined by such a coercive action (EG1).

Unquestionably, undertaking accompaniment processes with women with problematic drug use during pregnancy and postpartum, as indicated, requires a critical view of the team on the global situation in which the experience is inscribed, essential because that is where the patriarchal, colonial, class logic, among others, and their actions within the team.

Discussion

In the exposed results, we can identify that the accompaniment practices are fundamental within the PAI-M, considering a series of learnings produced from joint actions, within an institutional matrix (Martínez, 2007). The actions, knowledge, and learning of the team form a system that acquires coherence and articulation (Martínez, 2007), organizing a way of working that builds accompaniment practices situated in the reality of the women who are part of the program. It is also possible to identify a map of common criteria, where the beliefs, assumptions, convictions, and knowledge of the team members that guide decision-making are found (Martínez, 2007). This map is strongly marked by previous work trajectories, and by biographies.

As Martín-Baró (1990) states, every group process starts from an activity, where a process that generates action and political praxis that starts from the organization's reality, this makes it possible to build group identity and develop the exercise of joint power. Given the cohesion of the team in aspects such as intervention approaches, vision of the people with whom it works, and the centrality of the gender and human rights approach, among others, this group is configured as a community of practice in which the accompaniment strategies in a transdisciplinary way. Skills and knowledge are tuned in, learning from each other and developing a sense of belonging, identity, and socio-affective support that decisively influence the way of working (Martínez, 2007).

The gender approach is closely related to the human rights approach, an interdependence necessary to promote access to rights, accounting for the inequities in the development of the life trajectories of the users (Pautassi, 2007), especially due to structural violence and institution that affects them. In line with what Fals Borda proposes in Martín-Cabrera (2014), the complexity of social systems is visualized by the team, who are recognized as part of that reality that challenges them and inevitably generates prejudices, desires, and emotions, things to be aware of.

In the case of occupational therapy practices, the accompaniment in the daily life of the users is configured as a tool that promotes the development of a vital project from the use of the person's circulation space, facilitating the social bond (Mauer & Resnizky, 1999) and generating conditions to sustain everyday life and its emergent. The accompaniment in mothering from occupational therapy is a central element that enhances transdisciplinary work in the face of the particular reality of each woman, which often allows unraveling the obstacles that occur in everyday spaces that hinder access and participation in their process.

Accompanying becomes a political ethical project towards good living (Gómez, 2006) for women, children, and close networks. This way of working questions the hegemonic view that sometimes exists in programs of this type and public policies, bringing them closer to the territory with strategies that promote access to basic rights such as health, housing, social protection and education, and the development of autonomy in achieving them.

Experience shows that the accompaniment of the team and in particular from an occupational therapy from the south must start by deconstructing the stigmatization, prejudice, and subjective considerations that reproduce structural violence (Segato, 2016; Parra & Tortosa, 2003) since this can become a veiled form of secondary victimization (Zousa, 2018). being able to aggravate their condition, establish requirements that hinder and prevent the exercise of their rights, and expose them to suffering new damage due to the actions or inactions of the intersectoral care networks.

It is necessary that the accompaniments in occupational therapy from the south are not understood as isolated actions but as accompaniment networks, together with teams that are continuously in processes of self-reflection and training, and promoting educational actions that involve women, their families, the territory, institutional networks, communities and civil society as a whole. Only in this way, it will be possible to ensure that the accompaniment processes point towards autonomy, self-determination, and the full exercise of their rights to resume their life project.

Conclusions

This article aims to deepen the characterization of the support process carried out by the program's health team from a gender perspective and the contribution of Southern Occupational Therapy to transdisciplinary work as keys to improving adherence. Regarding the first key, we can say that the characteristics of the team's accompaniment practices that favor women's adherence to treatment are closely related to the characteristics of the team's composition and organization, with the transversal approaches that guide its practices and with the accompanying strategies that are deployed. These include transdisciplinary work, shared leadership, and the perception that the team is a space for growth and learning, maintaining a permanent dialogue that contributes to generating possibilities for mutual care that sustain the practice. Regarding the second key, the gender and human rights approaches are the ones that transversally guide the accompaniment strategies. These constitute a transdisciplinary base where other approaches and models are intertwined.

These approaches materialize in accompaniment strategies that favor adherence, highlighting the accompaniment made by occupational therapists of the program in spaces of daily life, support for parenting, network management, and a respectful linkage towards autonomy and good living of users and their families.

With these keys for the accompaniment of pregnant and/or postpartum women with problematic alcohol and/or drug use, who live in conditions of vulnerability, it is intended to contribute to the work of other intensive outpatient programs that work with women, to the technical standards and the public policy of the MINSAL-SENDA programs, making recommendations that favor accompaniment processes based on dignified, timely and situated care.

Acknowledgements

Proyecto InvClínica_DICYT, Código 022091PT_MED, Vicerrectoría de Investigación, Desarrollo e Innovación.

• 1
  This article is the second one that we present as part of a research project called “Modelo de Intervención con Enfoque de Género Programa Ambulatorio Intensivo de alcohol y/o drogas para mujeres en embarazo y/o post parto”. Project InvClínica_DICYT, Code 022091PT_MED. The first article that will be published in the Revista Cadernos Brasileiros de Terapia Ocupacional, titled Reflexiones desde las Terapias Ocupacionales desde el Sur: violencia estructural, derechos humanos y género en procesos de acompañamiento de mujeres durante el embarazo y maternaje
• 2
  National Council for the Control of Narcotic Drugs created in 1990.
• 3
  Commune of the southern sector of the Metropolitan Region.
• 4
  The Metropolitan Region is one of the 16 regions in which the country is divided, home to the capital of the country -Santiago- it is one of the most important economic poles, it has the largest number of inhabitants (Chile, 2018a).
• 5
  The article is entitled “Reflections from Occupational Therapies from the South: structural violence, human rights and gender in processes of accompanying women during pregnancy and maternity” (“Reflexiones desde las Terapias Ocupacionales desde el Sur: violencia estructural, derechos humanos y género en procesos de acompañamiento de mujeres durante el embarazo y maternaje”) and is in the process of being published in the Revista Cadernos Brasileiros de Terapia Ocupacional.
• 6
  Intensive Outpatient Program for adolescents.
• How to cite: Palacios, M., Díaz, M. M., Aracena, P., Palomino, T., & Quintana, N. (2022). Accompaniment processes, gender focus, and women in alcohol/drug consumption in pregnancy and motherhood: transdisciplinary keys and occupational therapies from the South. Cadernos Brasileiros de Terapia Ocupacional, 30, e3228. https://doi.org/10.1590/2526-8910.ctoAO246732282

• Funding Source

  The project has been financed by the fund of the Dirección de Investigación y Tecnología de la Universidad de Santiago de Chile. This background did not influence the investigation.

Referencias

• Abela, J. A. (2000). Las técnicas de análisis de contenido: una revisión actualizada. Fundación Centro Estudios Andaluces, 10(2), 1-34.
• Alburquerque, D., Chaná, P., & Guajardo, A. (2016). Los transaberes y la construcción conjunta de la salud. In S. S. Algado, A. G. Córdoba, F. C. Oliver, S. M. Galheigo & S. García-Ruiz (Eds.), Terapias ocupacionales desde el sur: derechos humanos, ciudadanía y participación (pp. 129-140). Santiago: Editorial USACH.
• Alonso, L. E. (1998). La mirada cualitativa en sociología. Madrid: Fundamentos.
• Beltrán, P. A., Carrasco, A. P., & Astudillo, C. Z. (2018). Caracterización de la experiencia del Programa Ambulatorio Intesivo Mujer (PAI-M). Santiago: Editorial USACH.
• Bianchi, P. C. (2018). Dos entrecruzamentos da terapia ocupacional e o território: reflexões a partir da prática profissional na atenção básica em saúde. Revista Argentina de Terapia Ocupacional, 4(1), 40-46.
• Borba, P. L. O., Costa, S. L., Savani, A. C. C., Anastácio, C. C., & Ota, N. H. (2017). Entre fluxos, pessoas e territórios: delineando a inserção do terapeuta ocupacional no Sistema Único de Assistência Social. Cadernos de Terapia Ocupacional da UFSCar, 25(1), 203-214.
• Canales, M. (2006). Metodologías de la intervención social: introducción a los oficios. Santiago: LOM Ediciones.
• Casado, D. P., & Blasco, J. M. T. (2003). Violencia estructural: una ilustración del concepto. Documentación Social, 131, 57-72.
• Chile. Ministerio del Interior y Seguridad Pública. Servicio Nacional para la Prevención y Rehabilitación del Consumo de Drogas y Alcohol de Chile – SENDA. (2018). SISTRAT Santiago de Chile. Recuperado el 10 de febrero de 2021, de http://sistemas.senda.gob.cl/sistrat/
  » http://sistemas.senda.gob.cl/sistrat/
• Chile. Ministerio del Interior y Seguridad Pública. Servicio Nacional para la Prevención y Rehabilitación del Consumo de Drogas y Alcohol de Chile – SENDA. (2021) Recuperado el 5 de marzo de 2021, de https://www.senda.gob.cl/senda/quienes-somos/
  » https://www.senda.gob.cl/senda/quienes-somos/
• Delgado, J. M., & Gutiérrez, J. (1994). Métodos y técnicas de investigación en ciencias sociales. Madrid: Ed Síntesis.
• Díaz, C. (2018). Investigación cualitativa y análisis de contenido temático. Orientación intelectual de Revista Universum. Revista General de Información y Documentación, 28(1), 119-142.
• Díaz, M., Palomino, T., Quintana, N., Palacios, M., & Aracena, P. (2021). Reflexiones desde las terapias ocupacionales desde el Sur: violencia estructural, derechos humanos y género en procesos de acompañamiento de mujeres durante el embarazo y maternaje. Cadernos Brasileiros de Terapia Ocupacional, 29, 1-12.
• Etcheverry, L., & Fuentes, C. (2017). El derecho de los niños a ser oídos. In A. Quesille (Ed.). Constitución política e infancia: una mirada desde los derechos de los niños, niñas y adolescentes en Chile Santiago: UNICEF. Recuperado el 5 de marzo de 2021, de https://www.unicef.org/chile/media/1381/file/constitucion_politica_e_infancia.pdf
  » https://www.unicef.org/chile/media/1381/file/constitucion_politica_e_infancia.pdf
• Fondo de las Naciones Unidas para la Infancia – UNICEF. (2017). El derecho de los niños a ser oídos. In L. C. Etcheberry & C. M. Fuentes (Eds.), Constitución política e infancia: una mirada desde los derechos de los niños, niñas y adolescentes en Chile (pp. 111-147). Santiago: UNICEF. Recuperado el 5 de marzo de 2021, de https://www.unicef.org/chile/media/1381/file/constitucion_politica_e_infancia.pdf
  » https://www.unicef.org/chile/media/1381/file/constitucion_politica_e_infancia.pdf
• Gómez, D. L. (2006). Continuidad de cuidados y desarrollo de sistemas de apoyo comunitario: atención a personas con trastorno mental severo en el medio rural. Rehabilitación Psicosocial, 3(1), 17-25.
• Haraway, D. J. (1995). Ciencia, cyborgs y mujeres: la reinvención de la naturaleza. Madrid: Ediciones Cátedra.
• Heller, A. (2002). Sociología de la vida cotidiana. Barcelona: Ediciones Península.
• Hernández, A. L. (2013). Estudio de caso acerca de la incorporación de perspectiva de género en el tratamiento para personas con problemas derivados del consumo de alcohol u otras drogas en un centro de salud mental comunitaria (Tese de mestrado). Universidad de Chile, Santiago.
• Ibañez, J. (1994) El regreso del sujeto: la investigación social de segundo orden. Santiago: Editorial Amerinda.
• Juns, A. G., & Lancman, S. (2011). O trabalho interdisciplinar no CAPS e a especificidade do trabalho do terapeuta ocupacional. Revista de Terapia Ocupacional da Universidade de São Paulo, 22(1), 27-35.
• Libreros Piñeros, L. L. (2012). El proceso salud enfermedad y la transdisciplinariedad. Revista Cubana de Salud Pública, 38(4), 622-628.
• Lima, E. M. F. A. (1997). Terapia ocupacional: um território de fronteira? Revista de Terapia Ocupacional da Universidade de São Paulo, 8(2-3), 98-101.
• Lima, E. M. F. A., & Ghirardi, M. I. G. (2008). Transdisciplinaridade e práticas híbridas em saúde mental. Revista de Terapia Ocupacional da Universidade de São Paulo, 19(3), 153-158.
• Martín-Baró, I. (1990). Acción e ideología: psicología desde Centroamérica. El Salvador: UCA Editores.
• Martín-Cabrera, L. (2014). Ciencia, compromiso y cambio social. Textos de Orlando Fals Borda. Polis, Revista de la Universidad Bolivariana, 13(38), 637-641.
• Martínez, V. (2007). Modelos operativos, modelos de acción y comunidades de prácticas en los programas de intervención social. In J. A. Inzunza & H. B. Torres (Eds.), Trayectoria de la psicología comunitaria en Chile (pp. 187-214). Valparaíso: Universidad de Valparaíso.
• Mauer, S. K., & Resnizky, S. (1999). Acompañantes terapéuticos actualización teórico-clínica. Buenos Aires: Paidós.
• Morales, J. F., Moya, M., Gaviria, E., & Cuadrado, I. (1994). Psicología social. Madrid: McGraw-Hill.
• Najmanovich, D. (2012). El mito de la objetividad. Buenos Aires: Editorial Biblos.
• Palacios, M. (2017). Reflexiones sobre las prácticas comunitarias: aproximación a una terapia ocupacional del Sur. Revista Ocupación Humana, 17(1), 73-88.
• Pardo, L. S. (2009). Drogas y perspectiva de género: plan de atención integral a la salud de la mujer de galicia: género y drogas. Galicia: Xunta de Galicia.
• Parra, D., & Tortosa, J. (2003). Violencia estructural: una ilustración del concepto. Documentación Social, 131, 1-16.
• Pautassi, L. C. (2007). El cuidado como cuestión social desde un enfoque de derechos. Cuadernos de la CEPAL. Serie Mujer y Desarrollo, 87, 1-50.
• Pino, J., Ceballos, M., & Sepulveda, R. (2015). Terapia ocupacional comunitaria crítica: diálogos y reflexiones para iniciar una propuesta colectiva. TOG (A Corunã), 12(22), 1-20.
• Quisbert, M. (2018). La acción colectiva transnacional feminista de la red de salud de las mujeres latinoamericanas y del caribe: politización de los derechos sexuales y reproductivos (Tese de mestrado). Facultad Latinoamericana de Ciencias Sociales, Ecuador.
• Red Chilena contra la Violencia hacia las Mujeres. (2019). Violencia estructural y feminismo: apuntes para una discusión. Santiago.
• Red Chilena contra la Violencia hacia las Mujeres. (2021). Violencia estructural: intersecciones (in)visibles. Santiago.
• Rivas, M. M. (2006). Hacer para transformar: el método en psicología comunitaria. Buenos Aires: Paidós.
• Rowlands, M., Miranda, I., & Arcila, M. (2018). Caracterización de mujeres en embarazo y post parto con consumo de alcohol y sustancias. Santiago: SONEPSYN.
• Ruiz-Olabuenaga, J. I. (2003). Metodología de la investigación cualitativa. Bilbao: Universidad de Deusto.
• Sanz, S. (2016). Pasos hacia una terapia ocupacional de base comunitaria: una aproximación conceptual al enfoque comunitario en la disciplina en terapia ocupacionales desde el sur derecho, ciudadanía y participación. In S. S. Algado, A. G. Córdoba, O. F. Corrêa, S. M. Galheigo & S. Garcia Ruiz (Eds.), Terapias ocupacionales desde el Sur: derechos humanos, ciudadanía y participación (pp. 225-243). Chile: Usach.
• Segato, R. (2016). La guerra contra las mujeres: traficantes de sueños. Madrid: España
• Segato, R. L. (2003). La Argamasa Jerárquica: violencia moral, reproducción del mundo y la eficacia simbólica del derecho. Brasília: Serie Antropología.
• Valencia-Recabarren, P. (2015). Involucramiento parental y consumo de drogas en escolares de Chile. Boletin - Instituto de Estudios de Poblacion y Desarrollo, (19), 1-7.
• Zousa, L. (2015). Claves hacia el acompañamiento psicosocial (Cuadernillo Principal de la Serie “Claves hacia el Acompañamiento Psicosocial”). Benito Juarez, Mexico: Aluna Acompañamiento Psicosocial.
• Zousa, L. (2018). Protocolo de acompañamiento a mujeres en situación de violencia. Estado de Zacatécas, México: Secretaría de las Mujeres.

Edited by

Section editor

Profa. Dra. Daniela Testa

Publication Dates

• Publication in this collection
  02 Sept 2022
• Date of issue
  2022

History

• Received
  11 Dec 2021
• Reviewed
  20 Jan 2022
• Accepted
  02 Feb 2022