The psychosocial rehabilitation in the alcohol and other drugs treatment: the professionals' conception

Abstracts

Estudo exploratório de abordagem qualitativa que objetivou identificar as concepções de profissionais da saúde de um Centro de Referência para o tratamento dos problemas relacionados ao uso de álcool e outras drogas acerca da Reabilitação Psicossocial. Onze profissionais da saúde de nível superior foram submetidos à entrevista semi estruturada. Os dados foram analisados segundo os pressupostos da Hermenêutica Dialética, que originou a categoria Reabilitação Psicossocial. Os resultados evidenciaram que na concepção dos profissionais a Reabilitação Psicossocial se dá na realização de oficinas terapêuticas, atividades externas e no estabelecimento de parcerias com outras instituições. Conclui-se que o conceito de Reabilitação Psicossocial que mais se evidencia na concepção desses sujeitos, ainda está associado ao modelo psiquiátrico tradicional, ou seja, atrelado à lógica da normalidade social, sendo esse o principal desafio a ser superado quando se considera o modelo psicossocial de atenção aos usuários de álcool e outras drogas.

Serviços de saúde mental; Transtornos relacionados ao uso de substâncias; Reabilitação; Equipe de assistência ao paciente; Pessoal de saúde

ORIGINAL ARTICLE

The psychosocial rehabilitation in the alcohol and other drugs treatment: the professionals' conception

A rehabilitación psicosocial y la area de alcohol y otras drogas: la concepción de los profesionales

Paula Hayasi Pinho^I; Márcia Aparecida Ferreira de Oliveira^II; Divane de Vargas^III; Marilia Mastrocolla de Almeida^IV; Ana Lúcia Machado^V; Ana Luísa Aranha e Silva^VI; Luciana de Almeida Colvero^VII; Sônia Barros^VIII

^IPsychologist, M.Sc. in Nursing by School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

IIFree Lecturer, Associate Professor at Maternal-Infant and Psychiatric Nursing Department of School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IIIPh.D., Professor at Maternal-Infant and Psychiatric Nursing Department of School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IVOccupational Therapist, Doctoral student in Graduate Nursing Program at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VFree Lecturer, Associate Professor at Maternal-Infant and Psychiatric Nursing Department of School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VIPh.D., Professor at Maternal-Infant and Psychiatric Nursing Department of School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VIIPh.D., Professor at Maternal-Infant and Psychiatric Nursing Department of School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VIIIFree Lecturer, Associate Professor at Maternal-Infant and Psychiatric Nursing Department of School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^{Correspondence addressed to}

ABSTRACT

Exploratory study with qualitative approach that had as its main objective to identify the conception of the health professionals about Psychosocial Rehabilitation from a reference Center for the treatment of alcohol and other drugs related problems. The sample consisted of eleven health professionals with an academic degree, submitted to semi-structured interviews. The data analysis was made according to the hermeneutic dialectic method which originated the Psychosocial Rehabilitation category. The data demonstrated that in the professional's conception, the Psychosocial Rehabilitation is given in the realization of therapeutic workshops, outdoor activities, and the estabilishment of a partnership with other foundations. It is concluded that the concept of Psychosocial Rehabilitation that was made clear in the conception of these subjects is still associated to the traditional psychiatric model, which is attached to the logic of social normality, the main challenge to the psychosocial model of assistance to the alcohol and other drugs users.

Key words: Mental health services. Substance-related disorders. Rehabilitation. Patient care team. Health personnel.

RESUMEN

Estudio exploratorio de abordaje cualitativa cuyo objetivo fue identificar las concepciones de profesionales de un Centro de Referencia para el tratamiento de problemas relacionados con alcohol y otras drogas acerca de la rehabilitación psicosocial. Fueron entrevistados once profesionales de nivel superior, por medio de entrevistas semi-estructuradas. El análisis de los datos fue norteada por los presupuestos de la hermenéutica dialéctica, la cual originó la categoría rehabilitación psicosocial. Los resultados evidenciaron que en la concepción de los profesionales, la rehabilitación psicosocial se da en la realización de talleres terapéuticos, actividades externas y en el establecimiento de sociedades con otras instituciones. Se concluye que el concepto de rehabilitación psicosocial que más se evidencia en la percepción de esos sujetos está asociada al modelo psiquiátrico tradicional, arraigado a la lógica de la normalidad social, el problema principal a ser superado en la asistencia a los usuarios de alcohol y otras drogas.

Descriptores: Servicios de salud mental. Trastornos relacionados con sustancias. Rehabilitación. Grupo de atención al paciente. Personal de salud.

INTRODUCTION

In the current society, the phenomenon of psychoactive substance abuse has appeared as a complex problem and, despite distinctive historical-cultural transformation and technological innovations in recent years, practical approach conceptions and models have not made any significant advancements and demand studies and reflections about interventions, as well as about the policies and theoretical knowledge that have supported them⁽¹⁾. In a historical perspective, one may say that drugs became a public health problem as from the mid-19th century, and acquired their modern dimension with the progress of industrial chemistry, pharmacology and medicine⁽²⁾.

Nowadays, the fact that alcohol and other drugs use have become a severe public health problem in Brazil and around the world was verified through the proven relation between consumption of these substances and the social problems that result from or strengthen this consumption. Coping with this problem has turned into a global demand, as the World Health Organization (WHO) asserts that psychoactive substance abuse is present in 10% of people in urban centers around the world, independently of age, gender, education level and social class⁽³⁾. In Brazil, the latest home survey, carried out in the country's 108 largest cities, evidenced that lifetime use of alcohol amounted to 74.6%, with 12.3% of survey participants, between 12 and 65 years old, complying with criteria for alcohol dependence. The results of this survey also indicate that alcohol consumption has occurred in increasingly younger age groups, suggesting the need to reconsider control, prevention and treatment measures⁽⁴⁾.

Despite these percentages, with regard to care strategies for managing the problem, one important gap in the history of Brazilian public health gradually appeared and the drugs issue was left to legal, public safety, pedagogy, merit institutions and religious associations⁽⁵⁾. In Brazil, in the mental health area, the movement that started in the final decades of the 20^th century entailed new inquiries, which culminated in the approval of laws that favored the transformation of these practices and knowledge. Law No 10.216, issued in 2001⁽⁶⁾, served as a landmark by guaranteeing both mental health service users and patients suffering from alcohol and other drugs-related disorders the territorialization of care, based on the structuring of services closer to their users' social space. Also, care networks became more adequate to the different demands of this population segment.

At bottom, the main axis in this restructuring of the care model is Psychosocial Rehabilitation and the social reinsertion of users, integrated with the cultural context and the community they are inserted in, in line with the premises guided by the Psychiatric Reform principles. With regard to the concept of Psychosocial Rehabilitation, specialists agree that this is a strategy and a political will to take care of socially vulnerable people, so that they are capable of managing their lives more autonomously and with greater ability to make choices. This permits the process of social exchanges, as well as the full restitution of the rights, advantages and positions these people had or could have if barriers were minimized or disappeared^(7-11).

As to the Psychosocial Rehabilitation of alcohol and other drugs users, little has been produced on the theme and, according to international literature, no direct relation exists between the Psychosocial Rehabilitation concept and prevention or treatment of disorders linked with alcohol and drugs consumption⁽¹²⁾. Hence, for the Psychosocial Rehabilitation function to be possible in care delivery to alcohol and other drugs users, discussions are needed about the issues associated with the real variables, that is, the Psychosocial Rehabilitation service, the meaning of treatment itself; available resources - human, communitarian and material and the individual's life context⁽¹³⁾. In this perspective, the need to study and discuss human resources, health workers in this case, justified a study aimed at identifying how health professionals at a Reference Center for the treatment of psychoactive substance related problems conceive Psychosocial Rehabilitation.

METHOD

This exploratory research with a qualitative approach was carried out at a Reference Center for the treatment of psychoactive substance related problems in São Paulo State, Brazil. The sample consisted of eleven health professionals with a higher education degree. Data were collected in July and August 2008, using semistructured interviews with four guiding questions. The interviews were recorded and transcribed, and then read and reread several times, which permitted constituting the analytic corpus⁽¹⁴⁾. Data analysis was based on the premises of Dialectical Hermeneutics⁽¹⁴⁾ and two categories emerged: Psychosocial Rehabilitation and Institutional Therapeutic Project. This paper discusses the first category called Psychosocial Rehabilitation. To present the results, interviewees were identified with the letter E, followed by their number in the interview order. In compliance with ethical requirements⁽¹⁵⁾, this study was submitted to the Research Ethics Committee at the University of São Paulo School of Nursing (CEP-EEUSP), and approved on April 4th 2008 (protocol No 722/2008).

RESULTS

Characterization of research subjects

Eleven technical professionals with a higher education degree were interviewed, seven women and four men. The workers' mean age was 50 years, ranging between 34 and 59 years. Four psychologists were interviewed, one nurse, one nutritionist, one physical educator, two physicians and two social workers.

Category I- Psychosocial Rehabilitation Concept

The analysis of Category I - Psychosocial Rehabilitation Concept, resulted in two subcategories: therapeutic workshops and external activities and/or partnerships, which are presented next.

Therapeutic workshops

The interviews revealed the professionals' understanding of Psychosocial Rehabilitation. It was observed that, according to them, Psychosocial Rehabilitation is associated with the organization of therapeutic workshops, external activities and/or the establishment of partnerships. The workshops the interviewees mentioned (quilting and tapestry, music, art therapy and baking) were considered therapeutic interventions that promote users' socialization and independence, skills development, access to latent symbolic contents, and also represent a leisure and an income-producing/professional development activity. This psychosocial rehabilitation concept, associated with the workshops, is evidenced in the following statement:

... we also talk a bit during the workshop, the basic intent is to sing really, but we try to use this liking, this desire they have and then direct it a bit towards treatment (E3.35).

Professionals conceive the manual learning of handicraft techniques as a rehabilitation resource that can contribute to users' independence.

From my point of view, here at the Centre, the most successful rehabilitation area is the quilting and tapestry workshop, because it ends up contributing to make the patient more independent... (E10. 2).

Rehabilitation actions do not only contribute to user independence, but also permit circulation through the territory and expansion of the social and cultural network. Asopposed to previous discourse, however, one interviewee did not associate its practice with Psychosocial Rehabilitation. Instead, the work with psychic and symbolic contents present in the production of art therapy workshops was emphasized.

... We constantly visit the museum, the picture gallery, the park, and then we discuss it, we do this reading of images and then, during the workshop, we also work with decoding, that's how I work, decoding images, I discuss the image of the popular, the image of the collective, which is more connected with the Jungian theory I work with (E5.13).

According to some statements, professionalizing workshops were considered a form of rehabilitation because they develop the learning of some craftsmanship with a view to professionalization. They were associated with social inclusion in the sense of Psychosocial Rehabilitation, as they promote a change in users' social role, stimulating their registration as autonomous artisans, so that they can produce and sell their products in on craftsmanship fairs.This conception is evidenced in one subject's statement, who says:

...We organize professionalizing workshops here, they learn quilting, tapestry, craftsmanship in general, baking, and we end up taking these patients to get their register as craftsmen, they go and get it, demonstrate the technique, get the registration saying that they are craftsmen (E4.37).

The product obtained in the baking workshop, however, which could be used as a social and material exchange resources, as illustrated by the above statement, does not have an income generating and, consequently, Psychosocial Rehabilitation function, as it is not traded on the consumption market. In this respect, one of the subjects comments:

They don't even sell it to employees yet, they don't sell, but we advise them about what they can do, that they can do it and sell it at home, I know that many of them are already doing it for their family (E2. 27).

External activities and/or partnerships

Another activity promoted by the service which, according to the subjects, is associated with Psychosocial Rehabilitation, refers to external activities and partnerships the institution establishes with other institutions and which, according to the professionals, can equip subjects to regain their capacity to act in society and conquer their autonomy. This conception is evidenced in the following statement;

... the institution's offering of external things, related to that thing of patients being again included in society. I think that's very important, places we have a partnership with for an informatics course, to know how to put on a computer, to know how to send an e-mail, to make a good curriculum (E6. 11).

We always have to attempt to close partnerships with places outside the institution because, if not, we are at risk of making them dependent on our institution (E10.16).

External partnerships, mentioned in the interviewees' statements, reveal that a wide range of sectors contact the service, concerned with improving satisfaction of the population's needs attended by the service. This demonstrates that different social areas can contribute to the inclusion of alcohol and other drugs users in diversified social activities. In this respect, the subjects comment:

...telecenters in São Paulo, we work a lot with one nearby in Rua Prates, which offers many courses (E6.20);

...we also close partnerships with some NGOs that offer professional training (E4.31);

...we closed a partnership with the Volunteering Association of São Paulo and participate in some activities by the Citizenship Counter, which is a counter some shopping malls give us room to install, where we take patients to expose their work (E8.41).

DISCUSSION

The results of this research evidenced that, according to the interviewees, therapeutic workshops and external activities or partnerships are actions aimed at the Psychosocial Rehabilitation of alcohol and other drugs users attended by the service, in the context of the Brazilian psychiatric reform. Workshops are considered the main treatment forms offered by services that replace psychiatric hospitals⁽¹⁶⁾. With regard to the partnerships established between the service and social institutions, one may say that these are in line with the recommendations of the new care model proposed by the Psychiatric Reform, which seeks more socially integrating forms of treatment, allowing service users to circulate through the city without suffering the prejudice that distances them from society. In this scenario, workshops also start to play an important role, as a therapeutic element and also as a promoter of social reinsertion, through actions that involve work, the creation of a product, income generation and production of autonomy⁽¹⁶⁾. The goal of this process is to permit individuals to have access to the right for an affective, relational, material, occupational and habitational constitution, being socially inserted⁽⁸⁾. In the same sense, to guarantee the principles of Psychosocial Rehabilitation beyond practice during workshops, it is the role of professionals to present exhibitions, concerts and other cultural and artistic activities to users, taking them outside the institution, allowing them to circulate in the city's cultural environment, presenting a new social condition and creating new sociocultural values that need to be learned⁽¹⁷⁾.

The Psychosocial Rehabilitation process implies a change in mental health service policies, that is, in the programs through which these policies are applied and put in practice, and that is exactly what should be modified⁽⁹⁾. The hospital-centered culture in mental health is changed not only by setting up new services, but also by transforming practices. Articulation among services is needed with a view to constructing technicians' new professionalism and put it at the users' disposal⁽¹⁰⁾. In this context, team members should be strongly committed to the goals they themselves have established, daring to put in practice initiatives that promote the subject's emancipation⁽¹⁸⁾.

In the research scenario, professionalizing workshops most closely approached the aims of Psychosocial Rehabilitation. In the rehabilitation perspective, however, these activities do not express their actual premises, as they do not present the subject socially in the social exchange process, functioning as an intermediary between the subjects and people they relate to⁽¹⁹⁾.

It was observed in this research that the workshops' rehabilitation process remains linked with one of the main characteristics of traditional psychiatry, which is entertaining the patient. Entertaining means having inside and also spending a nice time, hoping for the patient to improve or get worse. Until a change occurs in that person's state, (s)he remains entertained through medication, talks, leisure and occupational therapy activities, which are not able to transform users' lives⁽¹³⁾. This is in accordance with the premises of WHO when it appoints the emphasis on Psychosocial Rehabilitation, which should guide the construction of new practices whose primary goal is: user empowerment; prevention and fight against stigma and discrimination; development of social skills and creation of a continued support system (in the medium and long term). These strategies should be achieved by articulation between social and health systems⁽³⁾. Therefore, a promotion, prevention, treatment and education policy directed at the use of alcohol and other drugs should be constructed at the intra-sector interfaces, either of the Health Ministry itself in relation to other Ministries or of governmental and non-governmental organizations and other representations and sectors of the organized civil society⁽⁵⁾.

Thus, like the Psychosocial Rehabilitation of people with mental disorders, the construction of a theoretical guiding reference framework in this area, and specifically in the field of psychoactive substances, remains a complex process that involves different instances, ranging from the micro - individual/family/institutional to the macro level - community, society and mental health policies. Hence, this is practice that awaits theory, a transitory situation, as one should not think that practices go on eternally without theories⁽¹⁰⁾. It is in the dialogue between scientific and political knowledge and the practices they support that a new order will be established for mental health care⁽²⁰⁾.

FINAL CONSIDERATIONS

Although part of the interviewed professionals' discourse is aligned with the Psychosocial Rehabilitation process recommended by the Ministry of Health, mainly with regard to inter-sector actions, the Psychosocial Rehabilitation concept that most clearly appears is still associated with the traditional psychiatric model, that is, linked with the logic of social normality, which is the main challenge to be overcome when considering the psychosocial care model. The service should be committed to the transformation of users' living conditions, deconstructing the psychiatric paradigm of exclusion and social control, so that the rehabilitation actions at the service do not strengthen the regulatory nature.

Hence, each institutional project should preferably be linked with the issue of human beings' fundamental rights. The right to work in mental health services needs to go beyond therapy itself and attempt to reinsert the people they take care of into production, exchange and consumption networks. The right to leisure, art, culture and education should be another distinguishing axis of user-oriented projects, just like the fundamental right to freedom and respect for human dignity and integrity should constitute the base for the set of therapeutic strategies used for welcoming, treating and accompanying these subjects. Thus, one may say that therapeutics itself is undeniable associated with the actual acknowledgement of health service users as subjects with rights, as citizens, in an environment that favors creative autonomy and democratic participation.

REFERENCES

Received: 09/15/2009

Approved: 11/18/2009

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Correspondence addressed to:

Paula Hayasi Pinho

Av. Dr. Éneas de Carvalho Aguiar, 419 - Cerqueira César

CEP 05403-000 - São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  07 Apr 2010
• Date of issue
  Dec 2009

History

• Accepted
  18 Nov 2009
• Received
  15 Sept 2009