Lunchtime as a therapeutic moment: a health education approach with alcohol-dependent women

Abstracts

El alcoholismo es un problema de importancia para la salud pública. El consumo etílico por mujeres va en incremento, al mismo tiempo que la búsqueda por su tratamiento. El estudio propone el re-significado del alimento como una estrategia para la reducción de daños. El objetivo de la investigación fue estudiar y discutir la experiencia de utilizar el horario del almuerzo como una condición terapéutica, siendo explicitados los supuestos teóricos, estrategias y resultados inmediatos. Fue utilizada la metodología clínica-cualitativa y el análisis de contenido. Los resultados, divididos en siete categorías, muestran el proceso de intervención educativa: el ambiente como facilitador; compartir los alimentos - volverse un compañero; ampliar la percepción del alimento; alimentos y sus significados; sexualidad; recaídas; depresión vs motivación. La educación en salud realizada durante el almuerzo es considerada una posibilidad de intervención terapéutica, desde el momento que se perciba al alimento en toda su multi-dimensionalidad, pues se considera tanto los aspectos nutricionales como los simbólicos, los cuales son relevantes para la formación de vínculos y como motivación para el tratamiento.

alimentación; nutrición; salud pública; enfermería; alcoholismo

O alcoolismo é problema relevante em saúde pública. O uso de etílicos por mulheres tem crescido e a procura por tratamento aumentado. O estudo propõe ressignificação do alimento para essas mulheres como estratégia de redução de danos. O objetivo da pesquisa foi estudar e discutir a experiência do almoço como momento terapêutico, explicitando pressupostos teóricos, estratégias e resultados imediatos. Utilizou-se método clínico-qualitativo e análise do conteúdo. Os resultados, divididos em sete categorias, referem-se ao processo de intervenção educativa: ambiência como facilitadora; compartilhar o alimento - tornar-se companheiro; ampliação da percepção do alimento; alimentos e seus significados; sexualidade; recaídas; depressão x motivação. A educação em saúde realizada durante o almoço é uma possibilidade de intervenção terapêutica desde que o profissional de saúde perceba o alimento na sua multidimensionalidade, que contempla tanto aspectos nutricionais como aspectos simbólicos, relevantes para a criação de vínculos e motivação para o tratamento.

alimentação; nutrição; saúde pública; enfermagem; alcoolismo

ORIGINAL ARTICLE

Lunchtime as a therapeutic moment: a health education approach with alcohol-dependent women

Silzeth Schlichting^I; Maria Cristina Faber Boog^II; Claudinei José Gomes Campos^III

^IRN, Caps ad II of the Municipal Government of Campinas, Brazil, M.Sc. in Nursing, e-mail: [e-mail]

^IINutricionist, PhD in Public Health, Professor College of Medical Sciences

^IIIRN, PhD in Medical Sciences, Collaborate Professor, Member of the Clinical-Qualitative Research Laboratory. State University of Campinas, Brazil

ABSTRACT

The alcoholism is a relevant problem in public health. The use of alcohol among women has increased as well as the search for treatment. This research proposes the resignification of food to these women, as a harm reduction strategy. The research aimed to study and to discuss the experience of lunchtime as a therapeutic moment, presenting theoretic assumptions, strategies and immediate results. The clinical-qualitative methodology and the content analysis were used. The results, divided in seven categories, refer to the educational intervention process: environment as facilitator; sharing food - becoming a partner; broadening the perception of food; food and its meanings; sexuality; relapses; depression x motivation. The heath education performed during lunch is a possibility of therapeutic intervention, provided that the health professionals perceive the multidimensionality of food, considering the nutritional aspects as much as the symbolic ones, which are relevant for the creation of bonding and motivation for the treatment.

Descriptors: feeding; nutrition; public health; nursing; alcoholism

INTRODUCTION

The consumption of substances that possess the capacity of altering states of consciousness and modifying behaviors seems to be a universal phenomenon in humanity. The use of certain substances that favor social relationships, mark festivities or mystical/religious rituals is observed in virtually all cultures at different points in time. Although society has been affected by its consequences for a long time, its recognition as a health problem is recent and national and international organizations, governments, universities and firms are attentive to the political, economic and social aspects of this issue^(1-11).

The CRIAD - Center of Reference and Information in Alcoholism and Drugs Addiction was created in October 1995 by the Municipal Health Secretary, aiming to provide specific care to patients with the diagnosis of dependence, defined as mental and behavioral disorder due to the use of psychoactive substances⁽¹²⁾.

Alcohol dependence entails a physical and clinical impoverishment for the user, which influences the success of the treatment, since alcohol use neglects the feeding habit. The nutritional state of those who seek the CRIAD demands care, while an expressive number of patients present pellagra, a kind of nutritional deprivation by the lack of niacin, generally combined with energetic-protein deprivation, which occurs by the abusive ingestion of alcoholic beverages. Alcoholism affects the quantity, quality and frequency of feeding and produces alterations in the metabolism of nutrients.

When this view is directed at women and dependence is confirmed, peculiarities are evidenced, linked to the differences between the female and male universes, of extreme importance for treatment success. Socially speaking, the woman's role is generally that of family caregiver, she transforms food into meal, as a care instrument. The feeding moment is an opportunity to exchange and strengthen important relationships for human beings, because "the subjectivity transmitted through feeding practices includes the cultural identity, social condition, religion, family memory and age"⁽¹³⁾. Additionally, there are organic differences between women and men that explain the prevalence of hepatic damage in women⁽¹⁴⁾.

Perceiving that alcoholism, as a social consequence, causes the interruption of family relationships and induces the reduction of the user's daily practices, including those related to feeding⁽¹⁵⁾, the use of lunchtime as a therapeutic moment was devised. By "eating together" with alcoholic women, emotions and affections could be released, contributing to the reestablishment of family bonds and self care. Having lunch together would also allow for nutrition education, understood as a "search shared between educators and learners, of new forms and new meanings for the act of feeding, which is processed in a determined time and place, through interaction and dialogue, through which one desires quality and plenitude of life"⁽¹⁶⁾.

When thinking about new forms of approaching the treatment of chemical dependence, we have the concept of Damage Reduction: "a public health alternative for the moral/criminal and disease models of drugs use and dependence"^(17). This proposal focuses on the minimization of damage, the redemption of civil rights, the improvement of self care and quality of life, re-inserting the drugs user into society and giving him(er) conditions to modify his(er) reality. In this sense, food can contribute to damage reduction because it is a strategic instrument in the improvement of clinical issues, besides facilitating social relationships, marking festivities and rituals, in the same way as alcohol, although without the adverse effects.

This study aimed to recover feeding and its meaning in the improvement of quality of life. As a facilitator in the teaching-learning process, it gave an opportunity for health education to occur outside the conventional pattern. For the educator, it is important to find spaces (s)he can use to provide for learning that changes the learner's thinking in a pleasant way because, when this happens, a stimulus to learn even more also occurs, that is, the reflection and construction of new behaviors, the education processes itself⁽¹⁸⁾.

OBJECTIVE

This research aimed to study and discuss the lunch experience as a therapeutic moment, presenting theoretical assumptions, strategies and immediate results.

METHODOLOGY

The strategy employed for the educative intervention was lunch time and group discussion, without a previously proposed theme. The theme emerged informally and spontaneously from the participants, allowing for the expression of not yet identified needs. As a participant observer, the researcher made interventions and asked questions, aiming to lead them to a reflection about what was being said and adding information in order to clarify knowledge and doubts.

Clinical-qualitative research, defined as a scientific research method, was used to attempt to interpret meanings and significations brought by the individuals in the study, about multiple phenomena pertinent to the health-disease binomial, using different theoretical references for discussion within an interdisciplinary framework⁽¹⁹⁾.

The sample chosen - called study group here - was composed of eight female patients, alcohol dependents, in treatment at CRIAD. This institution was chosen because the researcher has worked there for many years. Data collection was carried out in the period from October to December, 2003. The group was closed, that is, after the first lunch meeting, new participants were not allowed.

A total number of 12 group meetings was established, over a six-week period, at the institution, during two hours and coordinated by the researcher. To preserve the participants' identities, they received names of flowers.

For data collection, a recorder was used, positioned in the middle of the lunch table. Two observers were present, one of whom was the group researcher/coordinator herself.

The study participants and their family members were informed about the nature of the study and its procedures and signed the free and informed consent term. Some preliminary analyses of the collected material were made to categorize data around the verbalized and gestural content during and after lunch. The construction of data categories followed two criteria. Some of them were selected a priori due to relevant topics in literature. Others emerged from the data collection and were therefore collected a posteriori⁽¹⁹⁾. The analysis of the verbalized and gestural content during and after lunch provided seven categories: the ambience as a facilitator; sharing the food - becoming a companion; expansion of food perception; food and its meanings; sexuality; relapse; depression x motivation.

RESULTS AND DISCUSSION OF HEALTH EDUCATION

The educational program occurred in 12 meetings, as planned, and the health education was developed as the collaborators brought up questions for discussion. These themes were issues from their daily lives and the educational interventions happened during the activity, so as to rescue the knowledge each individual acquired during life and to reconstruct common and updated group knowledge. The most recurrent and mobilizing themes along the 12 meetings were grouped into categories of analysis. The demographic data of the group of study are presented in Table 1.

The ambience as a facilitator

In the first meeting, the research collaborators demonstrated satisfaction about having lunch differently from the previous pattern (with disposable utensils), about the pattern of the educational program, with a room prepared for the lunch, plates, stainless utensils, juice to accompany the meal and salad to taste, which suggested a welcoming and friendly tone for this daily practice, which often seems repetitive, mechanical and empty of meanings. The statements revealed that the participants valued the environment.

The table was very beautiful, the decoration so beautiful, you get hungrier with the table so neat. (Violet 1^st day)

Congratulations, a salad set like this is something else, you even get an appetite (Begonia 2^nd day).

The arrangement of the lunch ambience in a family is historically related to the female role of the wife-mother, to whom the function of home and family member caregiver is attributed⁽²⁰⁾. Some authors go further in their justification of women's role: "To feed is to nurture, to care, to reproduce. Women, by their physiological disposition, are those who also nurse people in their first months of life and, partially because of this, they end up taking care of the domestic group for the rest of their life cycle"⁽²¹⁾. When preparing the place and organizing the group feeding ritual, the researcher played the caregiver role. Authors who concentrate on the aspects of care and concepts of integrality and equity point to the importance of the professional being attentive and available for the bonding necessary to personalize the delivered care, as a strategy for the development of the client's autonomy and understanding of subjectivities. The autonomy would imply "the possibility of reconstruction, by the subjects, of their lives' meaning"⁽²²⁾.

Sharing the food - becoming a companion

The lunch setting raised the needs felt by these women, who manifested emotions in an almost puerile way.

Today is plate, today is plate, Silzeth. Today is sophisticated! (Orchid 1^st day).

The food is the same, but I liked us! (Daisy 1^st day).

In this statement, Daisy expresses her perception of the group's evolution. They felt valued by the fact that they were using stainless utensils instead of disposable ones. We can think that, through the recovery of using permanent utensils, symbolically, values like safety, dignity and citizenship are recovered. We can also infer that the subject introjects the meaning of temporariness the disposable object inspires and, in this same line of thought, we believe that the opposite is also true. This redemption of the "permanent" transmits a feeling of self respect that certainly contributes to the improvement of self-esteem.

When we think of these women's psychoactive substance dependency and attempt to understand the causes that lead to the consumption of a psychoactive drug, one important factor to be considered is the kind of pharmacological effects that are produced and the speed at which the psychic pain improves. Drinking together creates bonds, promotes connections, makes people feel close and, therefore, less fearful⁽²³⁾. This description reminds a lot the relation of eating together, because sitting together means letting aside the differences, and the place of the meal is where the relationship is fed and affection emerges⁽²⁴⁾. You cannot have a welcoming, reflexive and innovative posture without perceiving that the fact of sharing food shows the humane side of the professional, and this creates bonds and strengthens them, which is very important, especially for this pathology. When this relationship is understood (food/alcohol/affection), the posterior attitude is to interfere educationally and repeatedly, helping these women to experience new ways of relating and also to reproduce the experience in their domestic environment.

Expanded food perception

Expecting that they could experiment, besides the relationship, also a different way of seeing, feeling the food, the dishes were decorated and new flavors were introduced for them to try out.

Can we eat these greens decorating the dish? (Dahlia, 1^st day).

There is red lettuce, it is a different flavor (Rose 1^st day)

Aiming to create a stimulus for the practice of experimenting, during lunch, the participants had the opportunity to perceive new flavors through the introduction of new foods in their diet. This access to unknown flavors allowed them to expand their perception of food, since they had a set of new experiences: trying a new food, facilitated by the socialized space existent for the lunch. These moments of pleasure and sharing among equals modify and recreate the feeding pleasure⁽²⁵⁾.

Food and its meanings

At several moments during the lunches, pepper was tasted, offered, shared, reflected and, mainly, a controversial object.

In India, all dishes have pepper. Bahia, Pará (states of Brazil) the acarajé (Brazilian dish). In my brother's backyard, he has all kinds of pepper (Rose 6^th day).

Regarding the meanings of foods, what caught our attention was the varied ways in which we can interpret the symbology of pepper brought up by the collaborators. Differences in individual tolerance are evidenced by the superposition of family and cultural influences on the genetic heritage: the person entails differences in gustative sensibility, that is, the predispositions or competences to perceive different flavors⁽²⁵⁾. When understanding the influence of the family and cultural factors on the genetic clarifies the fact that this population recognizes and appreciates this food. In the statements, pepper was used to express three different intentions: the first was that, in sharing its use, the researcher would be closer to them, in a horizontal relation; the second was that, in sharing its use, the researcher could develop more empathy with the group; the third, in which these women would try to test the researcher's capacity to support heavy reports, called "spicy" in common language. These explanations go beyond the fact that alcoholics have atrophied gustatory papilla and, therefore, prefer strong substances.

Sexuality

To understand, address and demystify the alcohol/sexuality relation, it is important when dealing with this clientele to try and help these women reacquire an active sexual life. The reorientation of the sexual life is one of the guidelines of the therapeutic project and should include the prevention of transmissible sexual diseases, which has been a challenging topic for health professionals who work with this clientele. At the beginning of the activity, the researcher expected that the sexuality issue would somehow appear. At lunch, the theme flowed so well that, while talking, they tried to help each other, recalling orientations received from other professionals, which they had already put into practice with satisfactory results. During the activity, the researcher perceived that most collaborators sought, in that moment, a space to reflect, expressing doubts, difficulties, insecurities and prejudices, as follows.

I told the doctor that I had no pleasure. He told me that there is no such thing as a cold woman, only a badly loved woman. I didn't do any treatment. I met a man and he touched me and it was beautiful, wonderful (Daisy 4^th day).

The food also has its sex appeal since it presents a complexity of textures, colors, smell and temperatures⁽²⁶⁾. Sexuality permeates the human relations and the lunch time constituted a space - by the created intimacy and affinity inherent in "eating together" - to reflect, and express doubts, difficulties, insecurities and prejudices. The aphrodisiacal action, reported by several consumers about alcoholic beverage, permeates their valorization of alcohol. However, research data indicate that this substance (alcohol) seems to compromise sexual performance⁽²³⁾. Several authors point to the ambivalence alcohol causes: "The alcohol presents an essential peculiarity as a food: despite its imaginary virtues, it has physiological, behavioral and temporary psychological effects that are very real and almost immediate. The ambivalence of its social functions is appointed to these effects, since these are also ambivalent"⁽²⁵⁾.

Relapses

Bonding and group integration are important in this study because they indicate that the participants felt safe to talk about some taboos for chemical dependents, which are the desire to drink even in abstinence, dreaming about and feeling the drink's smell, waking up feeling drunk, as described in the following statements: I dreamt about the drink, it is like a worm. I wake up with the smell of the drink, dizzy. I feel like breaking everything (Rose 9^th day). Rose is abstinent for three years and, despite the long period without drinking, she has not forgotten the effects yet. These statements reinforce the need for the relapse issue to be addressed and discussed in the treatment group. It cannot be treated in a banal way, but needs to be put in a way for them to share the event and be able to maintain their abstinence. The relapse theme was also mentioned during the lunch time, allowing women to share their anxieties and emotions. After eating, people are not the same, because the level of intimacy and relationship allows imagination to come into action, masks fall off and what is forbidden appears⁽²⁶⁾. The treatment group the dependents participate in functions as a welcoming and modifier of feelings that emerge by the relapsing fact and collaborates through help, reflection and motivation to return to treatment. The introduction of education as a strategy in the control phase of the desire to drink guides the user to identify symptoms that can lead him(er) to alcohol use/abuse.

Depression x Motivation

Many times, depression is a consequence of the habit to use alcohol beverages, which is a depressive drug of the central nervous system. In addition, recent studies have shown that many people start to use alcohol as medication to inhibit an already existent depression, because alcohol acts as a stimulant in the first hours. The lunch time provided these women with the possibility to share their feelings and to feel mutually supported:

Silzeth, I feel bad. Ah, I don't know, feel like leaving everything behind and disappearing. But I don't have anywhere to go. We work and keep nothing, I'm mad at myself (Daisy 3^rd day).

The dependent's family is very important for treatment success but that does not mean it is essential. It is important for family members to be advised not to perpetuate crises in the domestic environment and also to identify factors that could lead to the use of the substance (such as the abstinence syndrome, among others). Involving the family in the treatment process of their member does not avoid suffering, but the reasons to drink start to be removed, and this involvement also modifies the view of the problem. When the dependent's family (children and parents) participate in the treatment, this contributes to an excellent prognosis, like in the prevention of new cases of dependency in the family⁽²⁷⁾. Feeding care is a way for the family to collaborate with the treatment.

I am like this, sometimes I'm not hungry, but my daughter prepares a good meal and I eat it (Rose 5^th day).

CONCLUSION

More than as an instrument to attend to a physiological need, the food must be perceived as a possibility - through eating together - of transforming the sick body into a healthy body, not only from the physical but also from the psychological point of view. Emotions are mobilized and reorganized around the table, creating and strengthening bonds among patients, with the therapist in service, facilitating adherence to and motivation for treatment. The food can be considered a damage reduction strategy since, when feeding, the chemical dependent minimizes the physical damages of the substance in the organism. The intervention of nutrition education covers the subjective components of feeding and the relationships around it.

It is interesting to point out that the established affinity, which could be perceived during the lunch time, is facilitated by the food. It is differential because it presents relevant therapeutic properties for treatment, which indicates the need to be attentive not only to nutritional, but also to ambience, organoleptic and esthetic aspects of the food. The pleasure of tasting the food in group allowed for the emergence of feelings and thoughts, favoring the education process.

Recebido em: 7.12.2005

Aprovado em: 11.12.2006

• 1. Mendes IAC, Villar Luis MA. Use of psychoactive substances: a new-old challenge. Rev Latino-am Enfermagem 2004 março-abril; 12(número especial):295-300
• 2. Wright MGM, Chisman AM, Mendes IAC, Villar Luis MA, Carvalho EC, Mamede MV. The role of technical & financial cooperation to advance nursing profession in the area of demand reduction in Latin America: challenges and perspectives. Rev Latino-am Enfermagem 2004 março-abril; 12(número especial):301-6
• 3. Villar Luis MA, Mendes IAC, Carvalho EC, Mamede MV, Wright MGM, Chisman AM. Partnership between a university and an international organization with a view to drugs research training for Latin American nursing teachers. Rev Latino-am Enfermagem 2004 março-abril; 12(número especial):307-15
• 4. Mendes IAC. Nursing integration in Latin America and challenges to prepare leaderships for drugs research development. Rev Latino-am Enfermagem 2005 setembro-outubro; 13(número especial):765-70
• 5. Magallón TJC, Robazzi MLCC. Alcohol consumption among industrial workers in Monterrey , Mexico. Rev Latino-am Enfermagem 2005 setembro-outubro; 13(número especial):819-26
• 6. Aguilar LR, Pillon SC. Perception of temptations to use drugs among persons under treatment. Rev Latino-am Enfermagem 2005 setembro-outubro; 13(número especial):790-7
• 7. Mendes IAC, Villar Luis, MA. Interinstitutional partnerships: the investment in the construction of multicenter projects on legal and illegal drugs. Rev Latino-am Enfermagem 2005 novembro-dezembro; 13(número especial 2):1089-94
• 8. Wright MGM, Caufield C, Gray G, Olson J. International research capacity-building programs for nurses to study the drug phenomenon in Latin America: challenges and perspectives. Rev Latino-am Enfermagem 2005 novembro-dezembro; 13(número especial 2):1095-101
• 9. Wright MGM, Caufield C, Gray G, Olson J, Luduena AC, Musayon Oblitas FY, et al. International nursing leadership related to the drugs phenomenon: a case study of the partnership experience between the Inter-American Drug Abuse Control Commission (CICAD) and the University of Alberta - Faculty of Nursing. Rev Latino-am Enfermagem 2005 novembro-dezembro; 13(número especial 2):1102-17
• 10. Bernal Roldán MC, Galera SAF. Perception of the mothering role of women who live in a context of drugs and violence. Rev Latino-am Enfermagem 2005 novembro-dezembro; 13(número especial 2):1118-26
• 11. Galera SAF, Bernal Roldán MC, O'Brien B. Women living in a drug (and violence) context: the maternal role. Rev Latino-am Enfermagem 2005 novembro-dezembro; 13(número especial 2):1142-7
• ¹²
  Organização Mundial da Saúde. Classificação mundial de saúde. Classificação estatística internacional das doenças e de problemas relacionados à saúde. Décima revisão. Genebra: OMS; 1995.
• 13. Garcia RW. Um enfoque simbólico do comer e da comida. Rev Nut PUCCAMP 1992; 5(1):70-80.
• 14. Reis NT, Rodrigues CSC. Nutrição clínica: alcoolismo. Rio de Janeiro (RJ): Rúbio; 2003.
• 15. Martins ERC, Corrêa AK. Lidar com substâncias psicoativas: o significado para o trabalhador de enfermagem. Rev Latino-am Enfermagem 2004 março-abril; 12(número especial):398-405.
• ¹⁶
  Educação nutricional:orientação e o papel dos nutricionistas na mídia. [videocassete]. São Paulo (SP); 1998.
• 17. Marlatt GA. Princípios básicos e estratégias de redução de danos.In: Marlatt GA, editor. Redução de Danos: Estratégias práticas para lidar com comportamento de alto risco. Porto Alegre (RS):Artmed; 1999.p 45-58.
• 18. Alves R. Livro sem fim. São Paulo (SP): Loyola; 2002.
• 19. Turato ER. Tratado da metodologia da pesquisa clínico-qualitativa: Construção teórico-epistemológica discussão comparada e aplicação nas áreas da saúde e humanas. Petrópolis (RJ): Editora Vozes; 2003.
• 20. Woortmann K. Casa e família operária. Rev Ciên Hum 1980; 2(3): 119-50.
• 21. Gracia-Arnaiz M.Paradojas de la alimentación contemporánea. Barcelona (ES): Içaria; 1996.
• 22. Cecílio LCO. As necessidades de saúde como conceito estruturante na luta pela integralidade e eqüidade na atenção em saúde. In: Pinheiro R, Mattos RA, editores. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro (RJ): IMS-UERJ-ABRASCO; 2001. p.110-25.
• 23. Masur J. Conjecturas sobre o uso milenar de bebidas alcoólicas. Ci Cult 1977; 30(5):531-4
• 24. Jackson E. Comendo em companhia. In: Jackson E. Alimento e transformação: imagens e simbolismo da alimentação. São Paulo (SP): Paulus; 1999.
• 25. Fischler, C. El (h)omnívoro: el gusto, la cocina y el cuerpo. Barcelona (ES): Editorial Anagrama; 1995.
• 26. Lima NC. A festa de Babette : consagração do corpo e embriaguez da alma. Horizonte Antrop 1996 janeiro-junho; 2(4):71-83.
• 27. Payá R. Abordagem familiar em dependência química. Curso abordagem familiar em dependência química. São Paulo (SP):UNIAD; 2004.

Publication Dates

• Publication in this collection
  12 July 2007
• Date of issue
  June 2007

History

• Accepted
  11 Dec 2006
• Received
  07 Dec 2005