Family resilience: perception of family members of psychoactive substance dependents*

Objective: to understand the perception of family members of psychoactive substance dependents on the elements of the functioning of their family in family resilience. Method: a qualitative approach study, based on the theoretical interpretive framework of family resilience from a systemic perspective. The participants were eleven family members of psychoactive substance dependents from a Psychosocial Care Center - Alcohol and Drugs, from a city in the state of São Paulo. For data collection, semi-structured interview, genogram and ecomap were used. Data analysis was based on the Content Analysis technique, thematic category. Results: from the interviews, three thematic categories were formulated: mobilization in search of support and social support; positive perspectives that would strengthen the family, and assertive communication. These categories point to references to the mobilization and unity of the family in search of social support in the intra-family, extended family and extra-family contexts and positive perspectives, such as persistence, perseverance, hope, faith and religiousness. Conclusion: the situation of having a psychoactive substance dependent in the family seemed to mobilize coping devices and attempts to overcome them through the resilience forces. The results may favor the daily clinical reasoning of the health professionals, helping them to recognize and value the identified resilience attributes.


Introduction
The use of psychoactive substances (PAS) tends to have a negative impact on various aspects of the life of the dependent person and their family -family conflicts, domestic violence and changes in interpersonal relationships are common, for example (1)(2) .
National and international studies on family and PAS dependence usually approach the family as a risk factor or setting; therefore, a negative view of the dysfunctionalities of family relationships predominates (2)(3) .
However, functional aspects of family dynamics have been evidenced in the context of dependence on PAS (4)(5) . In this view, it is constructed, developed and lived in a relational context and experience throughout life.
Thus, family resilience, perceived in the family unit and its functionality, considers the way in which this group faces and deals with adverse situations, to reorganize itself effectively and to overcome such difficulties (6) .
International studies on family resilience point out that the families that experience situations of psychological distress reorganize their functional patterns by establishing daily routines, promoting regular events that minimize or alleviate stressful situations (6) , by providing intraand extra-family connections (6) and by seeking support resources and intra-and extra-family social support (6)(7) .
In Brazil, there are few studies on the theme of family resilience (8) and, in the context of mental health, the focus involves characteristics and individual resilience factors of the family members, which can influence another family member (8) .
National studies on resilience and consumption of PAS involve quantitative methods, with the application of scales with dimensions of family functioning to investigate the relationship between family resilience and problems arising from families that consume alcohol and other substances (9) , as well as validating a scale that involves dimensions of family functioning and resilience (10) . Both studies point to the recognition of resilience as a protective factor for the family members who experience problems with PAS (9)(10) . Such studies emphasize that experiencing situations of high vulnerability can awaken individual positive aspects that help the person to face and overcome adversities (9)(10) . Understanding the family's resilience process, from the perspective of the family member, will contribute to deepen the knowledge about the concept of resilience and its applicability to the Nursing practice. It is understood that such a practice consists of planning strategic Nursing care actions with the families, providing them with the tools to develop and strengthen their resilience, enabling them to respond as a functional unit.
Given the above, the questions that guided this research were: How have the family members of PAS dependents faced and overcome this problem? What coping strategies are used by these individuals and recognized by them as keeping them in resilience? What elements of family functioning contribute to the family resilience process, from the perspective of the family members? What are the forces recognized by these members that cause positive changes in the functioning of their family?
The objective was to understand the perception of the family members of psychoactive substance dependents on the elements of the functioning of their family in family resilience.

Method
A qualitative approach study carried out with family members of PAS dependents treated at a Psychosocial Care Center -Alcohol and Drugs (Centro de Atenção Psicossocial -Álcool e Drogas, CAPS-AD) in a city in the inland of São Paulo, Brazil. In this study, Walsh's concept of family resilience (6) was adopted, which values the way in which the family system faces adverse and challenging experiences, reorganizes itself efficiently and overcomes them, resonating such impacts in the entire family and in their relationships (6) .
The constituent elements of the concept of family resilience involve the belief system, organizational patterns and communication processes. Beliefs are related to the family's perceptions and understanding of the world. The family unit can extract positive meanings from an adverse situation to face and overcome it, through attitudes of perseverance and hope, in order to identify its strengths and its potential to solve problems (6) . The family can also use its religious and spiritual resources, such as faith, meditation and religious practices, as well as learning from adversity, which are important sources of resilience (6) . family members and the discovery and mobilization of their social, economic and labor resources (6) .
The communicative process consists of ways of communication that facilitate the functioning of the family (6) , which must be clear, enlightening, and enablers of the open expression of emotions and sharing of feelings, in order to decide and solve conflicts collectively (6) .
Eleven family members of PAS dependents indicated by the CAPS-AD health team participated in the study: a sister, a brother-in-law, a grandmother, four mothers and four fathers.
The inclusion criteria were the following: being a family member of a PAS dependent over 18 years of age; participating in family or individual care groups with health service professionals, considering these indicative of resilience, and living with the user at least twice a week. The exclusion criterion was being a family member with signs of PAS poisoning on the day of the interview.
Sampling was intentional and it was closed due to exhaustion, that is, when all the available and eligible families had been interviewed, according to the inclusion and exclusion criteria (11) . A semi-structured interview was conducted, using the genogram and ecomap (12) for the initial approach of The interviews were recorded, transcribed and analyzed according to the content analysis technique, thematic category (13) . The analysis process was carried out independently by two researchers, who met later to review, decide, validate and reach consensus on the reports with the meanings of the themes and categories.
The process consisted of: reading attentive to the details of each interview, identifying and coding relevant phrases/ paragraphs that pointed out the family's perceptions of the situation experienced, the coping and overcoming strategies for the adversities, and the positive forces used in the organization and functioning of the family.

Spreadsheets for each family were prepared in a Microsoft
Word file, containing notes that indicated emerging themes and their respective illustrative reports. Afterwards, the researchers read all the worksheets and sought to group and regroup the themes and reports of all the interviews, which were constituted in nuclei of meaning (considering both the frequency of occurrences and the inference of their importance for the interviewees). Subsequently, the classification of themes made it possible to formulate thematic categories (13) . From this process, three thematic categories were constituted, commented on in the next section of this article, which were interpreted through the elements present in the functioning of families, which help in family resilience, according to the Walsh model (6) , organizational patterns, belief systems and communication patterns.
The excerpts that illustrate the participants' reports were identified according to the following convention:  As a demonstration of concern and care, some family members gave up a job to accompany the dependent relative in the treatment.  Although negative feelings and emotions were exposed, faith and hope were reported that the dependent family member would recover, not returning to substance use and resuming old healthy habits and behaviors.

Discussion
In general, the literature highlights the predominance of the female figure in monitoring the treatment of PAS dependents, especially mothers, wives and grandmothers (14) . However, the data of the present study come from a sample that, although numerically reduced, was composed of a very close number of men and women (five and six, respectively); therefore, it presents balance from the point of view of family members in the perspective of gender.
Regarding the first category, it was observed that the participating families effectively and spontaneously mobilized in search of support and social support, reorganizing themselves to face the adversities, as occurs in other contexts already researched (7,(15)(16) .
The need to change the families' routine to accompany the treatment of their sick member demonstrates the www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2021;29:e3449.
presence of one of the attributes of family resilience to solve problems, as it required a new standard of functioning to meet new family needs, corroborating the literature (6) . According to the systemic framework of family resilience, when dealing with an adverse situation, the family can mobilize resources and reorganize itself, adapting to the new demands derived from the changed living conditions. The family unit seeks to reorganize itself in a flexible and stable manner, in order to preserve its good functioning (6) .
The data in this study pointed to the search for a functional family balance in the work dimension, when a family member had to give up their job to take care of the dependent relative. The literature emphasizes that the attributes of family resilience involve reorganizing living conditions and often abandoning personal desires or other needs to adapt to the new demands, with a balance between daily work and household (6) . However, the problems experienced in the family environment can also result from specific social and economic contexts, and it seems important that health professionals consider these broader dimensions that can impact on the family resilience process. A study highlighted the need for the services to create strategies that facilitate the participation of the family members in the treatment of their relative, while avoiding the interruption of the work and entertainment routine (17) .
In the view of the participants in this study, cohesion and the affective and emotional connection between family members strengthen them to face and overcome crisis situations, having maintained, in their evaluations, some balance in the family unit. In fact, the interviewed family members hinted that they felt united in times of crisis, respecting the differences between them (6) . The sense of connection allows the family to work as a team (6) , establish flexible alliances, review individual roles and responsibilities, and achieve goals (4) . Family resilience is strengthened when the family members support each other, collaborate and commit to the process of facing the crisis (5)(6) .
The participants expressed feeling the family group strengthened when experiencing the feeling of love permeating their relationships. In the same sense, a phenomenological study on the meaning of the family's daily living with a member dependent on crack pointed out that, despite the emotional and physical overload that the family experiences, it manages to express feelings of love (5) . Loving tolerance and mutual support seemed to be present in the participants' speeches, even when they experience possible contradictions (in F5-M's speech, for example, "we need to have love", there seems to be a tension between a feeling immanent to the participant and a speech that carries certain formality).
In the interviews, mention was made of promoting intra-family and extended family life, which would have provided moments of leisure and distraction. The literature points out that family resilience benefits from such strategies, which favor family connection and cohesion (6) .
In this way, the family would tend to perform better when balancing proximity and tolerance to differences (6) . Both in the intra-family environment and in the extended family, the moments of good mood and distraction seem to have been seen by the participants as factors that minimize distressing situations, possibly alleviating emotional overloads (5)(6) , and favor the expression of emotions and feelings related to the adverse situation, something more difficult to occur in other contexts (5) .
Another attribute of family resilience identified by the family members in this study was support and extra-family support, involving community resources and the Psychosocial Care Network (Rede de Atenção Psicossocial, RAPS), which helped them to cope with the crisis and obtain informational, emotional and instrumental support. In fact, the family's well-being and resilience in contexts of adversity depend on access to formal and informal support devices and resources (7) and, in the opposite direction, on these devices transforming and adapting the family needs (7) . The CAPS-AD and its health professionals seem to have consisted of sources of informational and emotional support relevant to the respondents, particularly family groups. It is inferred that these families were able to recognize such relevance because, probably, such services enabled access and adapted to family demands. Such groups consisted, judging by the reports, of a welcoming space, listening and sharing experiences; being felt as promoters of mutual help, learning, re-elaboration of coping strategies, security and comfort. Thus, the family group seemed to strengthen family resilience, considering that group activities are usually recognized as a source of emotional support for the family members (18) , as the group's demands would tend to be understood and welcomed without trials (17) .
Groups can create and strengthen bonds between the (1,17) families and facilitate behavioral change through the development of patience, understanding and dialog (8) .
Possibly, they instrumentalize care for the dependent family member (17) .
Friends were also recognized as a source of support and strength, corroborating the systemic theory of family resilience (6) , which emphasizes that social networks also involve community and religious groups and friends (7) , which can offer security and encouragement. and promotes a protective environment, the perspectives are revitalized and reinforced (6) .
Perseverance, persistence, hope, faith, religiousness and trust seemed to be constituted as positive forces for coping and overcoming difficulties arising from the context of dependence on PAS, usually permeated by negative and pessimistic emotions.
The hope that the family member will recover generates motivational feelings, which mobilize and strengthen the family members. Initiative and perseverance are fundamental elements for family resilience, often stimulated by shared trust (6) . Hope consists of the belief in a better future, regardless of the context that the family lives in the present, encourages in facing adversity and motivates the identification of positive alternatives (5)(6)8) .
Families in difficult situations seek comfort and guidance when they connect spiritually with their cultural traditions, for example, spiritual and religious beliefs (6,8) .
For Christians, for example, and so all the research participants are considered, having faith and living spiritual experiences that they consider positive generate comfort (6) . Religious practices seem to constitute positive coping mechanisms about the life and treatment of people dependent on PAS (5,19) , as there would be a superior force that would help the family in overcoming crises (5) . In the sample, attending religious institutions, participating in their rituals, praying and meditating were the main sources of resilience considered; in these practices, the interviewees perceived relief and well-being, aspects that have been pointed out in other studies (4,6) . Family religious practices and beliefs seem to constitute mediating strategies for the health-disease process, as they promote resources for religious and spiritual coping and strengthen resilience (4,6) .
The third category pointed out that the families would have sought assertive communication to assist them in the resilience process, involving patient dialog, monitoring the tone of the voice, and maintaining calm.
Communication patterns strongly interfere in interpersonal relationships and can hinder or facilitate the management of the stressful situation (6) .
The adversity situation can promote family unity and connection, facilitating the sharing of feelings and open emotional expression (6) . However, the family that has the possibility to communicate in a thoughtful manner generally has better emotional conditions to experience the situation and solve their problems collectively (6,8) . The creation of spaces in the family context that facilitate emotional communication can promote resilience and minimize the negative impact in the face of adverse situations (20)(21) .
An affective and optimistic tone of voice can facilitate the coping process, as the family members manage to demonstrate emerging feelings. Although the messages may be unexpected, they can be conveyed in an empathetic and respectful manner (6) .
Among the limitations of this study, there is the impossibility of validating the analyses with the family members, justified by the lack of time to find the research participants; therefore, the solution to minimize the impact of this limitation was to search the literature for evidence on aspects of resilience to discuss the results.
The contributions of this study refer to the use of the fundamental elements of resilience in the process of assessment and intervention in the care of families, which can help health and nursing professionals to recognize and value family strengths, helping them in the process of functional (re)organization. With this attitude, one can avoid stereotyping and labeling the family as "dysfunctional", "codependent" or "resistant", but also perceiving it as a potentially active agent in the process.

Conclusion
This study made it possible to improve the understanding of some aspects of the perception of family members of PAS dependents about the elements of their functioning that help family resilience, going through their organizational patterns, their belief systems and their communication processes.
Although substance dependence has important repercussions on families, these adverse situations can also be seen as a challenge to be faced and overcome through the potentials and forces existing in the family system. Recognizing and strengthening these potentials seems important for the family to understand its role, as a unit capable of overcoming adversity and living healthier.