Profile, feelings and participation of family members of homeless drugs users assisted in the Recomeço Família Program

Perfil, sentimentos e participação de familiares de usuários de drogas em situação de rua atendidos no Programa Recomeço Família

Abstract

Objective  To evaluate the sociodemographic profile, the feelings aroused by the use of drugs and the participation of the homeless drug users’ families who sought help in the Recomeço Família Program.

Method  This is a descriptive, secondary study that used 5,201 records of drug addicts’ family members. We collected sociodemographic data about the family and the addicts, as well as housing, drug use and treatment information and family feelings.

Results  Family members surveyed were women, adults, with low education, unemployed, and who were parents or guardians (40.9%). The substance users surveyed included 1,477 individuals with low schooling but having a job. Out of this number, 5.4% were homeless, 7.7% young, 6.9% without a partner, 15.4% crack users, with a significant prevalence of women. Family members reported pity, anguish, “pain in the soul” and shame.

Conclusion  The family members of homeless drug users showed intense suffering requiring formal assistance.

Keywords
Emotions; Family; Homeless individuals; Substance-related disorders

Resumo

Objetivo  Avaliar o perfil sociodemográfico, os sentimentos despertados diante do consumo de drogas e a participação de familiares de usuários de substâncias em situação de rua, que buscaram ajuda no Programa Recomeço Família.

Método  Trata-se de estudo descritivo, secundário, com 5.201 registros de familiares de dependentes de drogas. Foram extraídas informações sociodemográficas sobre o familiar e o dependente, bem como moradia, droga consumida, tratamento e sentimentos dos familiares.

Resultados  Os familiares eram mulheres, adultos, com baixa escolaridade, desempregados, pais ou responsáveis (40,9%). Entre os usuários de substâncias 1.477 homens jovens, sem companheira, com baixa escolaridade e trabalhavam. Desses indivíduos, 5,4% estavam em situação de rua, 7,7% eram jovens, 6,9% sem companheiro, 15,4% usuários de crack, com significativa prevalência de mulheres. Os familiares relataram sentimentos como pena, angústia, “dor na alma” e vergonha.

Conclusão  Os familiares de usuários em situação de rua apresentam intenso sofrimento e necessitam de assistência formal.

Palavras-chave
Emoções; Família; Pessoas em situação de rua; Transtornos relacionados ao uso de substâncias

Individuals who use psychoactive substances and are homeless constitute a clearly growing population. It is estimated that, in 2019, around 567,715 people were homeless in the United States (U.S. Department of Housing and Urban Development, 2020). In that country, around 78% of homeless individuals were monitored in the mental health system in connection with the use of psychoactive substances (Melo et al., 2018). In Brazil, despite the shortage of studies on the subject, the number of street dwellers increased considerably (140%), raising from 92,515 individuals in September 2012 to 221,869 in March 2020 (Natalino, 2020).

This population is considered a heterogeneous group, having complex peculiar needs in the framework of a history of victimization, low education and informal work, exposure to situations of violence, lack of access to services and different health problems, constituting a marginalized and stigmatized layer of the population (Archard & Murphy, 2015; Jutkowitz et al., 2019; Melo et al., 2018; Moreno Baptista et al., 2017; Paiva et al., 2016). In general, these people live with conflicting families and have had interrupted careers, breakdowns in intimate relationships, lack of support and precarious social support, which triggers negative feelings and turbulent interpersonal relationships, permeated by distrust, broken pacts and repeated lies and unfulfilled promises (Neale & Brown, 2016; Neale & Stevenson, 2015).

The quality of bonds established by family members of alcohol and/or other drug users living on the streets has so far, received little attention from society and the scientific community, mainly due to the outreach limitations and barriers of this population, that is unstable and fluctuating, and/or of their family members/networks, as both have little access to formal social and health services (Abdel-Baki et al., 2019; Wijk & Mângia, 2019). Often, the family’s sluggishness in identifying and/or admitting the problem delays the search for external and professional help, a fact that further contributes to the worsening of the situation and its consequences (Payá et al., 2017). Such particularities are the cause of the scarcity of discussions on the topic (family of street dwellers substance users) in epidemiological and clinical studies on substance use (Bower et al., 2018; Pacheco et al., 2020).

A family member who uses drugs almost always causes tension in his/her family relationships; it is a source of high level of stress, which can be aggravated if the drug user is homeless (Orford et al., 2019; Pacheco et al., 2020). Evidence shows that the impact of substance use causes the recurrent suffering that plagues the family, resulting in greater vulnerability to a number of negative feelings, such as anguish, sadness, anger, shame, humiliation, resentment, impatience, impotence, fear of the future and loneliness; guilt feelings coexist with shame due to the user’s state of fragility and physical and mental degradation, enhancing the emotional suffering of his/her family (Diehl et al., 2011; Payá et al., 2017).

Families of homeless substance users may require clear delimitation of social rules, routines and other requirements to accept their living with them, as daily life can become unbearable due to the conflicts generated by the situation. Family members can even be abusive towards their sick loved ones when imposing limits. Consequently, many substance users may turn to friends rather than family when they need help. Hence, they develop small culturally normative friendship networks, supported by routine and regular contacts (Neale & Brown, 2016; Neale & Stevenson, 2015).

Knowing and systematizing the formal and informal networks of homeless substance users that are generally invisible to health managers and health agents, is crucial due to their potential in expanding care giving and strengthen associations in the territory (Archard & Murphy, 2015; Peiter et al., 2019). In this framework, the following questions can be raised: what is the profile of the family member and their loved ones who use drugs on the streets? What are the drugs most used by the user? What are the feelings aroused and the level of treatment involvement and participation of family members of homeless drug addicts? Understanding the family framework of homeless substance users and their territorialities configured in everyday life contributes to the formulation of public policies that aim to ensure civil rights to people (users and their families) in situations of vulnerability, suffering and social exclusion (Peiter et al., 2019). Thus, the systematization of information that allows us to draw the characteristics of the psychosocial profile of the family setting that is affected by the consequences of a family member using substances and is enhanced by the problems caused by homelessness, is essential so that one can clinically understand the family problems and map potential resilience sources (Pacheco et al., 2020).

In this connection, the present study aims to evaluate the profile of the substance users’ family members who sought formal help in specialized services and whose loved ones are homeless, as well as identifying the type of substances used, the feelings aroused and the participation of family members in the Programa Recomeço Família (PRF, Family Fresh Start Program) in São Paulo, Brazil.

Method

Participants

The total sample included 5,201 records of family members who sought assistance in the program for the first time in the aforementioned services. The eligibility criteria for inclusion were: all medical records of both genders patients registered with the PRF regardless of age and type of substance used and who sought support for the first time in their lives.

Instruments

The standardized questionnaire from the Levantamento Nacional de Álcool e Outras Drogas (Lenad, National Survey of Alcohol and Other Drugs) and an instrument aimed at families (Levantamento Nacional de Famílias dos Dependentes Químicos – Lenad Família, National Survey of Families of Drug Dependents), from the Instituto Nacional de Políticas Públicas de Álcool e Drogas (Inpad, National Institute of Public Policy on Alcohol and Drugs) were used. The instruments contained (Pacheco et al., 2020):

1. Sociodemographic information about the user: gender, age, marital status, education, length of use, number of children, legal problems and occupational status.

2. Information about the substance user’s family member: gender, age, marital status, education, occupational status and job.

3. Housing situation: a direct question with a dichotomous answer requesting information about the drug user being homeless (yes/no).

4. Type of substance consumed: alcohol, tobacco, marijuana, cocaine and/or crack.

5. Information about treatment: degree of kinship of those who sought help from the program and participation in the treatment therapeutic modalities of the family member.

6. Question on the feelings of mothers/fathers and other family members: Which of these feelings can you detect in your daily life? The answers were pity, “pain in the soul”, anguish, shame, sadness, guilt, irritation, anger, loneliness, fear, impotence, disappointment and others as well as physical symptoms.

Procedures

This is a descriptive study based on secondary data, using a quantitative approach. The survey was carried out in all 14 service units that serve the PRF, located in seven municipalities in the State of São Paulo, Brazil. Data collection was carried out considering the period from February 2014 to December 2018, following the evaluation of family users served in the program.

The purpose of the PRF is to provide support and guidance to substance users’ families. This is an inter-secretariat initiative of the State Government, in partnership with the State Department of Health and the Department of Justice and Citizenship, within an agreement with the Associação Paulista para o Desenvolvimento da Medicina (SPDM, São Paulo Association for the Development of Medicine), in 11 Centros de Integração à Cidadania (CICs, Citizenship Integration Centers), except in the Centro de Referência de Álcool, Tabaco e Outras Drogas (CRATOD, Reference Center for Alcohol, Tobacco and other Drugs), Helvétia and Ermelino Matarazzo units.

Ethical Aspects

The study was approved by the local Research Ethics Committee (CCAE: 90411318.2.0000.5505), complying with the guidelines set forth by Resolution 466/12 of the National Health Council which regulates human research, the Ministry of Health and the 2013 Helsinki Declaration of the World Medical Association.

Statistical Analysis

The data were initially organized in an MS-Excel^® spreadsheet, and double entry was a way of checking data accuracy and consistency. Then, the data were evaluated using the IBM Statistical Package for the Social Sciences (SPSS, version 26) IBM^®SPSS^® (version 26) for Windows. Exploratory data analysis was performed using frequencies (n) and percentages (%), to allow comparison of the sociodemographic characteristics. The chi-square test was performed to test the significance of the relationship between qualitative variables, as well as to compare possible differences between the observed and expected frequencies for each event. For all the tests, a significance level of 95 was considered. The analysis was carried out based on the number of answered data.

Results

Sociodemographic Characteristics of Families and of the Substance Users Living on the Streets

Characteristics of family members (n = 4,697) who sought assistance from the PRF: over 50 years of age, mostly female, with a partner, low level of education and unemployed; 2,130 (40.9%) were parents or guardians. In this group, family members of homeless individuals using substances differed from the general sample because they were adults (75; 7.2%), older adults (58; 7.2%), with a low level of education (60; 5.1%), illiterate (140; 9.6%) and did not work (125; 6.8%), all values statistically significant at (p < 0.05) (Table 1).

Table 1
Sociodemographic characteristics of homeless individuals and their families who sought assistance, São Paulo (SP), Brazil (n=4,697)

Variable		Homeless user						User’s family
		Yes (n = 279)			No (n = 4418)			Yes (n = 279)			No (n = 4,418)
		n	%		n	%		n		%	n	%
Age group (years)*
	< 17	18	3.1		562	96.9		8		5.0	153	95.0
	18-29	114	7.7†		1,363	92.3		21		3.7	552	96.3
	30-39	86	7.2		1,115	92.8		38		4.3	847	95.7
	40-49	28	4.1		651	95.9		63		6.3	940	93.7
	50-59	21	5.3		376	94.7		75		7.2‡	970	92.8
	> 60	2	1.1		175	98.9		58		7.2‡	751	92.8
	Did not answer	10	5.4		175	94.6		16		7.2	205	92.8
		< 0.001†						0.015‡
Gender*
	Male	188	5.0		3,540	95.0		38		4.9	737	95.1
	Female	82	10.0†		735	90.0		235		6.2	3,571	93.8
		< 0.001						0.173
Marital status*
	No partner	269	6.9†		3,638	93.1		95		6.0	1,478	94.0
	With partner	10	1.3		780	98.7		91		4.9	1,765	95.1
		< 0.001†						0.143
Literate*
	No	14	7.7‡		168	92.3		140		9.6†	1,322	90.4
	Yes	112	3.9		2,794	96.1		139		4.3	3,094	95.7
		0.011‡						< 0.001†
Education level*
	Elementary School	42	5.0†		795	95.0		60		5.1†	1,109	94.9
	High school	33	3.0		1,052	97.0		33		3.5	897	96.5
	University education	2	1.4		138	98.6		13		3.5	360	96.5
	Did not answer	202	7.7		2,433	92.3		173		7.8	2,052	92.2
		< 0.001†						< 0.001†
Occupational status*
	Works	105	4.0		2,493	96.0		154		5.4	2,702	94.6
	Does not work	138	9.1†		1,374	90.9		125		6.8‡	1,716	93.2
		< 0.001†						0.048‡

• Note:
• ^*
  Chi-square test.
• ^†
  p-value ≤ 0.001;
• ^‡
  p-value < 0.05.

The results also show that the families reported that their substance-using loved ones were young (18 to 29 years old), male, lived without a partner, had a low level of education and were working. Among these individuals, 279 (5.4%) were homeless, 114 (7.7%) had peculiar characteristics that differed from the sample because they were young (18 to 29 years old), 82 (10.0%) were females, 269 (6.9%) lived without a partner, 14 (7.7%) were illiterate, 42 (5.0%) completed elementary school and 138 (9.1%) were not working, according to the information provided by their family.

The medical records indicated that the total number of assisted family members was 2,130 of which 43.6% were mothers/fathers or guardians who sought family assistance at the PRF. The majority was seeking some type of family assistance for the first time, in the following modalities: 42.4% (n = 1,992) individual family assistance, 12.6% family psychoeducation group and 13.5% family group. Out of the substance users population (n = 4,697), only 759 (16.2%) were in treatment and 325 (6.9%) of the addicts had been referred for treatment through the family (Table 2).

Table 2
Characteristics of the family member and involvement in assisting the homeless person, São Paulo (SP), Brazil (n = 5,201)

Kinship and treatment	Variables	Family having a homeless person						Total (n = 4,697)		p-value
		Yes (n = 279)			No (n = 4,418)
		n	%		n	%		n	%
Family member who sought assistance (n = 3,875)	Parents/guardians	168	7.9		1,962	92.1		2,130	43.6	< 0.001*
	Grandparents	6	6.5		86	93.5		92	1.9
	Brothers	37	5.9		589	94.1		626	12.8
	Cousins	3	5.7		50	94.3		53	15.5
	Children	11	4.1		260	95.9		271	5.5
	Spouse	13	1.8		690	98.2		703	14.4
Individual family service† (n = 4,697)	Yes	85	4.3		1,907	95.7		1,992	42.4	< 0.001*
	No	194	7.2		2,511	92.8		2,705	57.6
Family psychoeducation group† (n = 4,697)	Yes	23	3.9		570	96.1		593	12.6	0.023‡
	No	256	6.2		3,848	93.8		4,104	87.4
Family group† (n = 4,697)	Yes	25	3.9		611	96.1		636	13.5	0.021‡
	No	254	6.3		3,807	93.7		4,061	86.5
Drug addicted person is in treatment† (n = 4,697)	Yes	41	5.4		718	94.6		759	16.2	0.787
	No	206	6.0		3,211	94.0		3,417	72.7
	Did not answer	32	6.1		489	93.9		521	11.1
Referral for treatment was carried out through the family for the person with chemical dependency† (n = 4,697)	Yes	6	1.8		319	98.2		325	6.9	0.001*
	No	273	6.2		4,099	93.8		4,372	93.1

• Note:
• ^*
  p-value ≤ 0.001;
• ^†
  chi-square test;
• ^‡
  p-value < 0.05.

Homeless individuals’ families differed from the others due to the fact that the parents had been seeking assistance from the PRF (168; 7.9%); besides the majority was out of the treatment offered in the program, whether in individual assistance, in the family group or in psychoeducation. Furthermore, the referral of the substance dependent individual was not made by family members (statistically significant values (p < 0.05)).

Regarding the type of substance used, family members mentioned that alcohol (70.8%), cocaine and/or crack (62.0%) and other illicit drugs (77.2%) were the most commonly consumed substances by their loved ones. Among the homeless individuals, there was a predominance of crack use (194; 15.4%), or the use of crack and/or cocaine (235; 8.1%) and the use of other illicit drugs, except alcohol and tobacco (247; 6.8%), but not the use of alcohol (110; 8.0%). All values were statistically significant (p < 0.05) (Table 3).

Table 3
Types of substances used by homeless individuals, São Paulo (SP), Brazil (n = 4,697)

Type of drug		Homeless individual						Total (n = 4,697)		p-value
		Yes (n = 279)			No (n = 4,418)
		n	%		n	%		n	%
Alcohol*
	Yes	169	5.1		3,156	94.9		3,325	70.8	< 0.001†
	No	110	8.0		1,262	92.0		1,372	29.2
Tobacco*
	Yes	105	6.5		1,506	93.5		1,611	34.3	0.226
	No	174	5.6		2,912	94.4		3,086	65.7
Marihuana*
	Yes	133	6.4		1,940	93.6		2,073	44.1	0.220
	No	146	5.6		2,478	94.4		2,624	55.9
Cocaine*
	Yes	154	6.3		2,275	93.7		2,429	51.7	0.230
	No	125	5.5		2,143	94.5		2,268	48.2
Crack*
	Yes	194	15.4		1,062	84.6		1,256	26.7	< 0.001†
	No	85	2.5		3,356	97.5		3,441	73.3
Cocaine and/or crack*
	Yes	235	8.1		2,676	91.9		2,911	62.0	< 0.001†
	No	44	2.5		1,742	97.5		1,786	38.0
Illicit drugs (except alcohol and tobacco)*
	Yes	247	6.8		3,377	93.2		3,624	77.2	< 0.001†
	No	32	3.0		1,041	97.0		1,073	22.8

• Note:
• ^*
  Chi-square test;
• ^†
  p-value ≤ 0.001;
• ^‡
  p-value < 0.05.

The results presented in Table 4 describe the family members’ feelings, such as pity, “pain in the soul”, anguish and shame, which were experienced and manifested by parents and other family members in relation to their loved ones, for being homeless and being crack users. Feelings such as pity, “pain in the soul” and anguish appear at higher rates among parents whose children lived on the streets and were crack users. However, shame was the most prominent feeling among family members in connection to having their loved one homeless.

Table 4
Comparison between feelings of parents and other family members regarding the family member being homeless and being a crack user, São Paulo (SP), Brazil (n =5,201)

Kinship and feeling			In a street situation						Crack users
			No			Yes			Yes			No
			n	%		n	%		n	%		n	%
Parents	Pity	Yes	96	10.8*		790	89.2		349	36.5*		607	63.5
		No	69	5.8		1,126	94.2		335	25.7		968	74.3
			< 0.001†						< 0.001†
Relatives	Pity	Yes	50	5.1		923	94.9		288	27.0*		779	73.0
		No	42	3.5		1,144	96.5		288	20.9		1,093	79.1
			0.067						< 0.001†
Total	Pity	Yes	146	7.9*		288	27.0		637	31.5*		1,386	68.5
		No	111	4.7		2,270	95.3		623	23.2		2,061	76.8
			< 0.001†						< 0.001†
Parents	Pain in the soul	Yes	86	10.3*		747	89.7		312	34.8*		584	65.2
		No	79	6.3		1,169	93.7		372	27.3		991	72.7
			0.001†						< 0.001†
Relatives	Pain in the soul	Yes	26	3.9		634	96.1		200	27.1*		537	72.9
		No	66	4.4		1,433	95.6		376	22.0		1,335	78.0
			0.623						< 0.001†
Total	Pain in the soul	Yes	112	7.5†		1,381	92.5		512	31.4*		1,121	68.6
		No	145	5.3		2,602	94.7		748	24.3		2,326	75.7
			0.004‡						< 0.001†
Parents	Anguish	Yes	127	9.2†		1,253	90.8		479	32.3†		1,004	67.7
		No	38	5.4		663	94.6		205	26.4		571	73.6
			0.003‡						0.004‡
Relatives	Anguish	Yes	56	4.4		1,212	95.6		349	25.1†		1,042	74.9
		No	36	4.0		855	96.0		227	21.5		830	78.5
			0.670						0.037‡
Total	Anguish	Yes	183	6.9†		2,465	93.1		828	28.8*		2,046	71.2
		No	74	4.6		1,518	95.4		432	23.6		1,401	76.4
			0.003‡						< 0.001†
Parents	Shame	Yes	62	8.2		697	91.8		253	30.7		571	69.3
		No	103	7.8		1,219	92.2		431	30.0		1,004	70.0
			0.759						0.739
Relatives	Shame	Yes	21	2.6		794	97.4		201	22.5		693	77.5
		No	71	5.3†		1,273	94.7		375	24.1		1,179	75.9
			0.003‡						0.355
Total	Shame	Yes	83	5.3		1,491	94.7		454	26.4		1,264	73.6
		No	174	6.5		2,492	93.5		806	27.0		2,183	73.0
			0.098						0.687

• Note:
• ^*
  Chi-square test;
• ^†
  p-value ≤ 0.001;
• ^‡
  p-value < 0.05.
• The numbers and rates were presented according to the number of respondents, using the total sample of 5,201.

Discussion

The profile of the sample that sought family assistance in the aforementioned service does not differ from other investigations on the subject: the majority of the sample was composed of women, who appear as a group with a high level of psychosocial vulnerability, with important characteristics of life precariousness; they are practically the only caregivers or guardians of the individual who uses drugs and is homeless. Therefore, this profile is also observed in studies with the family members of drug users, regardless of whether they are homeless (Piña Cabrera, 2019; Schenck et al., 2017; Seleghim et al., 2019; Sharma et al., 2019).

Studies show the dialectical relationships between being homeless and the use of psychoactive substances, often associated with social and economic conditions, such as poverty, social precariousness, mental disorders (comorbidities), intra-family relational problems, domestic violence, abandonment of their homes and distance from family members (Ciapessoni, 2019, DiGuiseppi et al., 2020; Melo et al., 2018, Moreno Baptista et al., 2017; Wang et al., 2019). The homeless − substance use binomial is a growing phenomenon, considered a social challenge for health and social assistance professionals, being an important public health issue (Roca et al., 2019).

Evidence has shown that this group requires a higher rate of hospitalization of young people (Chang et al., 2018) and uses emergency mental health services more frequently (Moulin et al., 2018). Given the complexity of the clinical condition and the relational difficulty that is also reflected in the relationship between the health care professionals and the street dwellers who are substance users, the bonds established between patients and the network of health workers are fundamental to determining the quality of the professionals’ performance (Bittencourt et al., 2019).

As to the characteristics of the homeless substance users, our investigation differed from other studies, inasmuch as the substance users included a significant number of women. This is a surprising finding, as generally, the rate of women found in this situation tends to be lower, with a higher prevalence of males, with a predominance of substance users and, mainly, living on the streets, as described in the literature (Piña Cabrera, 2019; Schenck et al., 2017). Therefore, this finding may denote a tendency for modification in the proportionalities found between the genders. On the other hand, the hypothesis can be raised that these women who are in a double vulnerable situation – being on the streets and being drug users – stir greater concern in their families, leading them to seek support in view of the anguish of seeing their female substance-dependent loved ones homeless. However, this is a topic that should be better addressed in future studies.

The reality of women living in these conditions was discussed in a study carried out in the so-called Cracolândia area, a deteriorated region downtown São Paulo, showing an increase in the number of drug addicted women, with an average age of 34.6 years, rising from 16.8 %, in 2016, to 34.5%, in 2017 (Unidade de Pesquisa em Álcool e Drogas, 2021). This is a very complex social issue, because, considering the exposure of these women in the streets setting, the risk of suffering psychological, physical and sexual violence is greater, with the consequent potential exposure to Sexually Transmitted Infections (STIs) and other illnesses, such as tuberculosis (Bingham et al., 2019; Nunes & Andrade, 2009).

Regarding the participation of family members seeking treatment for themselves, the PRF offers assistance specifically focused on the emotional aspects of family members, aiming to provide conditions for a healthy and dignified life for this population. Regarding treatments, women are generally directly responsible for the health care of the other family members (Bortolon et al., 2016; Pacheco et al., 2020; Sharma et al., 2019); they also fully support drug users to seek treatment (Orford et al., 2019). It is clear that female family members of substance users also ought to be taken care of, since living with a drug addict drastically increases the chances of suffering and illness, for reasons connected with the use of substances and its psychosocial repercussions (Júnior et al., 2016).

Family members usually focus on the substance user’s care and neglect self-care (Horta et al., 2016), experiencing self-sacrifice, which further increases their mental suffering (Bortolon et al., 2016). Drug users’ family members are affected by a high incidence of psychiatric comorbidities, triggered or intensified by their loved one using substances (Bortolon et al., 2016; Mattoo et al., 2019). A study reported that families of substance users typically present different feelings aroused by the situations they experience, which results in or enhances reactions to stress, such as suffering, sadness, guilt, frustration, failure, disappointment, worry, fear, uncertainty, embarrassment, faith, hope and love (Rodrigues et al., 2018). Thus we can claim that the inevitable involvement with the loved ones results in a condition that eventually requires health services for the family.

Another important finding is the minor inclusion of both the families and their loved ones who use substances and are homeless in the treatment process, regardless of the modality suggested. Parents or guardians are those who generally play the role of caregivers and were those who took the initiative to seek family assistance. However, the majority of their substance-using loved ones and those who were also homeless were out of treatment. Therefore, both groups had complex social and health needs and had limited social support. In addition this fact could have often occurred, due to a lack of options in the health care network, offering specific assistance to family members, given the few years of the PRF program availability. Furthermore, it is also necessary to consider the reasons inherent to families, such as the delay in becoming aware that drug dependence can also trigger illness in all the family members involved. This is also true for the delay in identifying and subsequently accepting chemical dependency of some family member (Sakiyama et al., 2015; Seleghim et al., 2019); in other words, social tolerance means that drug use is not always understood as a health problem causing the development of the individual’s defense mechanisms and the illness of this family member (Sakiyama et al., 2015).

In connection with the use of substances, it is noteworthy that family members indicated that alcohol was the substance most consumed by their loved ones, although alcohol is not always consumed alone. High rates of cocaine and/or crack, as well as other illicit drugs use (except alcohol and tobacco) is observed among homeless individuals. These findings are indicative that the use of cocaine and/or crack may be associated with problems experienced in the family setting, which may have motivated the family to look for family care and treatment. The same finding can be seen in another study (Orford et al., 2019), which showed that basically, the same substances were reported by the drug users’ families in cities in the five macro-regions of the Brazilian territory, with the following rates of use: cocaine (61%), crack (41.7% ), alcohol (62.1%) and marijuana (68.4%).

Alcohol being a low-cost and accessible substance, its use is consistent among street dwellers as it quenches hunger, induces sleep and alleviates the different sufferings that precarious living conditions cause. Aggravations resulting from alcohol use, such as dependence on alcohol and other drugs, were identified in homeless individuals (38.0% and 25.0%, for alcohol and drugs respectively). Furthermore, alcohol was considered the cause that kept individuals living on the streets (Alessandrini et al., 2018), which, when combined with other drugs use, constitutes an aggravating factor, indeed a highly prevalent condition in this population (Moreno Baptista et al., 2017; Roca et al., 2019). A Canadian study identified a prevalence of 37.9% for alcohol dependence in the homeless population, a rate that is quite high when compared to the rates in the general population, in which it is between 3% and 4% (Pauly et al., 2019). Furthermore, 46.9% of the crack users in the Cracolândia area used alcohol associated with another drug, being dependent on both substances (Unidade de Pesquisa em Álcool e Drogas, 2021). The use of alcohol is often masked by the use of other substances, giving the impression that, among the main problems, alcoholism would come last. The use of substances is recognized as a factor that weakens the health of homeless individuals, who acquire greater susceptibility to other morbidities, have reduced possibility of engaging in permanent work, suffer physical exhaustion and risk of accidents (Botti et al., 2010).

As in other studies, the feelings of parents and family members regarding the user’s situation manifest themselves in an ambiguous way, with expressions of love and hate. Family members commonly express compassion, ignominy, disgust, fear and humiliation. Parents of homeless drug addicts expressed more intense feelings, which can be explained by the debauchery of emotions and thoughts provoked in family members, when faced with the trade-off that substance users make between the comfort of their home and dwelling in the streets (Horta et al., 2016), with an emphasis on the feeling of shame.

For parents, their children’s illness due to drug use profoundly affects their self-esteem. They are led to experience deep changes in their lives, which cause imbalance in the entire family structure. It is common for bonds to be broken between family members, since the emergence of the problem can be seen as an indication that there have been failures in the family system. In this connection, reactions of fear, uncertainty, depression, among other negative and stigmatizing feelings tend to proliferate (Rodrigues et al., 2018).

The psychological condition that results in recurrent suffering, which ends up jeopardizing the quality of life and well-being (Vederhus et al., 2019), can normally be seen in drug addicts’ families. They are affected in different ways by their loved one’s addiction, and may experience psychological distress, physical symptoms, social isolation and exclusion (Pacheco et al., 2020; Rodrigues et al., 2016). Parents’ feelings towards their drug-using children are a fundamental component in the motivational process that will allow them to establish behaviors that can help them make the decision to seek ways to discontinue drug use (Muchiri & Santos, 2018).

Finally, it is important to reflect that the family plays a basic role in the addict’s treatment process, but is also weakened by the adversities it faces in living with the sick person and by the stigma to which it is subjected in the social setting (Mattoo et al., 2019; Sim & Hwang, 2018), causing the family to have its quality of life at stake (Vederhus et al., 2019).

Conclusion

Family members who are drug users and live on the streets, constitute an extremely vulnerable group, since youngsters who are substance users and homeless, concomitant with the entry into old age of the caregiver who sought support in the RF, yields a relational dyad that, even if it were devoid of other problems, it would already entail major challenges, given the natural intergenerational conflicts. We can anticipate, then, the complexity resulting from the combination of the characteristics of the dyads found. Therefore, we understand that there is a huge challenge in the structuring of health care networks, especially to help in the implementation of public health policies to address drug dependence.

Acknowledgements

To SPDM, for opening the doors for this investigation and to the professors and professionals of Escola Paulista de Enfermagem, Federal University of São Paulo, for their technical support in the preparation, implementation and development of this investigation.

• How to cite this article: Barros, G. M., Pillon, S. C., Silva, C. J., Horta, A. L. M. (2025). Profile, feelings and participation of family members of homeless drugs users assisted in the Recomeço Família Program. Estudos de Psicologia (Campinas), 42, e220136. https://doi.org/10.1590/1982-0275202542e220136

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Edited by

• Editor
  André Luiz Monezi de Andrade

Publication Dates

• Publication in this collection
  31 Mar 2025
• Date of issue
  2025

History

• Received
  16 Dec 2022
• Reviewed
  30 June 2023
• Accepted
  04 Mar 2024