Daily life of women with alcoholic companions and the provided care

the study aimed to know the daily life of women with alcoholic companions and the provided care. this is a comprehensive-interpretative, qualitative study, guided by the thematic Oral History method. Data collection occurred by semistructured interview. the empirical material was subjected to content analysis under the light of the King’s theory of Goal Attainment. Women are frustrated and frightened by the alcoholic companion’s behavior and lifestyle, and still feel judged by society. Many abandon their life projects and self-care due to the overload caused by the companion’s absence in the care of home and children. the family care they develop focuses on maintaining the family and protecting from further damage. the study revealed that these women are sick due to the companion’s dependence and, even supporting a type of family care, they cannot control the effects of the alcohol in the family. This reinforces the need for health professionals’ greater bond and involvement, establishing therapeutic projects in which women feel involved and, at the same time, supported.


INTRODUCTION
According to the World Health Organization, the harmful use of alcohol causes about 3.3 million deaths each year.In Brazil, in 2014, 16.5% of adults (≥ 18 years) from Brazilian capitals reported abusive alcohol consumption.this proportion was higher in the population from 25 to 34 years (23.2%),male (24.8%) and among people with higher education (19.5%) with 12 years or more of study (Brasil 2015).
Alcoholism is a problem that affects the individual's physical and mental well-being.It is one of the main factors of social grievance, mainly in the domestic context (OMS 2018).Several factors can influence it, including amount and frequency of alcohol use, genetic, psychosocial and environmental factors.the dependency is characterized by the strong desire to ingest alcohol, imbalance over the consumption of drinks and progressive increase of tolerance (CISA 2016).
Alcoholism does not affect only the alcoholic, but people around him. the family context usually becomes weakened, with problems in interpersonal relations, arising from the user's prevailing addictive behaviors.Functional changes give rise to inconsistencies and weaknesses in its understanding and culminate in distancing of pairs and disruption of affective and social links (Ferraboli et al. 2015).
However, some families value and accept alcohol use among men as a factor of social interaction.they deny or do not realize that problems faced in the family's routine associate with this practice and seek other reasons for the frequent conflicts, which affects everyday life of women and children (Silva et al. 2014).
the companions experience problems such as episodes of violence, changes in maternal role, conflict of roles (being a mother or the companion's wife), physical and mental illnesses, triggering a crisis in the relationship.Given the demands generated by the companion's addiction, many end up burdened with the extra function of caregivers and, sometimes, evade their needs, dreams and family projects, in attention to other priorities related to the companion (Souza et al. 2012).And because they are not seen as people at risk of illness due to their dependence on the partner, they do not receive the attention of the health services.
Some community-based public health services present themselves as a possibility to receive families of alcohol users and dependents, such as Centers for Psychosocial Care of Alcohol and other Drugs (CAPS AD). this specialized service intends to provide these customers multidisciplinary treatment and follow-up to promote recovery from addiction.In addition to the CAPS AD, the Family Health Units (USF), understood as a gateway to all public health demands in Brazil, have a territorialbased care strategy, which indicates a greater knowledge of community vulnerabilities and, consequently, possibility of intervention.However, these units do little to insert the partners of the users in the Singular therapeutic Project (PtS), giving the opportunity of co-participating in the treatment of their partner and learning about the disease and its overcoming, depriving them from also receiving care, sharing their sufferings and understanding their situation (Carvalho and Menandro 2012).
A Brazilian systematic review that assessed mental health services in Brazil (Costa et al. 2015) found contradictory results regarding the insertion of the family in the treatment, whereas some studies showed it as a positive practice, others signaled the difficulty preparing family members to the user's shared treatment.
this indicates the need to invest in this subject, with researches whose scientific evidence supports health professionals' actions with the family and bases new and creative strategies, allowing care to all members involved in the family context.
Thus, as a first investigative step, the study aimed to know the daily life of women with alcoholic companion and the provided care.

MATERIALS AND METHODS
this study had a comprehensive and interpretive character, with a qualitative approach, with the methodological path guided by the thematic Oral History (OH) method.this consists of a set of procedures started from the development of a project, continuing with the definition of the group of people that will be interviewed, in which recordings, transcription and verification of statements will be planned, with the authorization for use and subsequent seeking clarification on a certain fact and details of the individual's history, interested in only revealing aspects of interest to the target thematic information (Meihy 2005).
the study was conducted in 2017 at three USF located in a municipality of northern Mato Grosso, with 33,334 inhabitants, 175.3 km away from the state capital, Cuiabá, Brazil.Since 1980, when immigrants arrived, investing in the sugar cane and livestock, the municipality's economy has grown, especially the industrialization of sugarcane (IBGe 2010).
the selection of the FHU based on the inclusion criteria: urban units in operation for at least 36 months and with alcoholics in their coverage area.Units without the minimum family health team in the period of data collection were excluded.
As participants of the study, women over 18 years, registered in the selected FHU and with alcoholic companions were selected.Data collection occurred in the period from January to April 2017.During the data collection process, the total quantitative study participants was defined, based on the completeness of the information, as proposed by the sample saturation.thus, the study's final sample consisted of 11 women.
A script containing questions about sociodemographic aspects and women's daily life and care guided the interview.the interview process ran through three stages: the pre-interview (preparation of the meeting), the interview itself (which, regarding OH, is brief and objective) and post-interview (to present the transcription), to build coherent narratives (Meihy 2005).All the interviews were conducted in the family environment in the companion's absence, in a single phase, with an average duration of 45 minutes.
the interviews were fully transcribed and organized systematically receiving alphanumerictype encoding, in which the consonant P refers to participant and the Arabic number determines the order of the interviewees.After this step, the textualization occurred (suppression of questions), in which the text becomes the narrator with the identification of the tone that corresponds to the sentence, which will guide the reader's perception (Meihy 2005).the content was worked in order to synthesize the ideas, but without losing any sense desired by the narrator.
King's theory of Goal Attainment was used as the interpretation guideline.this theory assumes that perceptions (goals, needs and values) of the nurse and client affect the process of interaction.the nurse's role is to inform customers about the aspects of health care, to help them make decisions consciously; clients should receive information about the care and participate in decisions that affect their life, health and community services.The author also recommends respect and consistency between goals of nurses and clients and their right to accept or reject any aspect of health care (King 1997).
the study complied with all ethical standards in researches in accordance with resolution 466/2012 of the National Health Council (CNS), starting the study only after its approval by the Human Research ethics Committee (CeP) of the State University of Mato Grosso (UNeMAt) under CAAe number 64028317.4.0000.5166and opinion number 2,088,653.All the participants of the study signed the Consent Form Free and Informed (tCle).

RESULTS AND DISCUSSION
the participants in the study are between 18 and 45 years old.Most of them self-reported pardas, married, Catholic, with complete high school.they perform remunerated activities autonomously (seamstress or diarist), with family income between R$ 937.00 R$ 1,874.00.Most of them do not consume alcohol or other psychoactive substances, reside with the partner and children, without leisure activities with family.they sleep an average of 4-8 hours per day.these women's histories show predominantly negative and hopeless tones.the narratives were grouped in two main themes for discussion: "Being an alcoholic's wife" and "the couple's everyday life".the narratives focus on the violence when the companion is under the influence of alcohol.Its use affects interpersonal relationships with the companion, generates suffering, feelings of anger, fear and a troubled family background.the frequency of this phenomenon seems to generate changes in family dynamics, due to constant conflicts that exasperate the woman.
Studies (Martins et al. 2012, Mota 2013, Feijó et al. 2016) reveal similar situations, which highlight the life marked by moments of violence, sense of insecurity and fear for unusual behaviors, especially the frequently oscillating temperaments.the power relations in that coexistence and constant charges, incompatible with the existing and oppressive situations, limit the exercise of other roles and generate great sufferings for the woman who becomes increasingly lonely and unhappy.
the narratives show that some of them, although facing situations of violence and infidelities, cannot leave the relationship and end up reinforcing another type of destructive behavior, the sufferaccept.the study of Ávila et al. (2017), consistent with what we have found among alcoholics' companions, shows that, in those relationships, men assess their wives by the "fellowship" degree, understood as tolerance of aggression and respect to orders.Criteria that perhaps lead the woman to accept his lifestyle and behaviors.
Focusing on the interactions of that user's family with social community allows listing the problems in interpersonal relations, essential requirement for constructing or re-evaluating the predetermined therapeutic project for the companion.Based on the theoretical assumption (King 1997), the professional should seek a favorable communication and introduce him/ herself to the family with empathy and solidarity, in order to rescue lost autonomies and dignities.therefore, the professional can assist women by guiding strategies to face situations and not to be so permissive with respect to alcohol consumption by the companion, who has difficulty establishing control mechanisms and limits of use, helping them to develop behaviors that do not reinforce this habit.

I feel very embarrassed, I do not like when he drinks, I like only when he drinks one beer. When he drinks, he gets so boring and quarrelsome. There is nothing you can do. Sometimes, I feel I am responsible for him [...] (P1)
We drink together, but he always overdrinks and embarrasses me a lot [...]

. (P8)
the narratives show the expression of a common behavior among women, who deny the harmful effects of abusive consumption in interpersonal relationship, beyond the guilt and embarrassment for realizing they cannot control the situation.the study by Souza et al. (2012) confirms the appearance of guilt and shame in the woman with the intensification of the episodes of mood disorder and her helplessness to deal with her husband.
Health professionals' intervention is of the utmost importance to manage these situations, and they shall be able to identify needs, establish and achieve goals, so that their interventions alleviate family stress levels and reduce the internal or external triggering sources (Araújo et al. 2017).
the family also needs to modify harmful habits that add damage to the environment, through a mutual complicity in the care and recovery process.the partner's involvement in this process is crucial, because staying away from alcohol and alcoholic consumption will stimulate her partner to keep selfcontrol (Belotti et al. 2017).
Despite permissiveness in relation to the use, they recognize that alcohol use interfered in the companion's work performance and, in their perception, it contributed even more to harm the family interaction, stressed the discouragement and put at risk the couple's finances and the emotional and intellectual performance of children.Some researchers (Seixas and Pereira 2014) also highlighted the close relationship between absenteeism at work and abusive alcohol consumption, such as the increase in unexcused absences, decrease in the worker's production capacity; damages that went beyond work environment and reached directly family relationships as a whole.

[...] Especially
In relation to children, several authors (Mangueira and lopes 2014, Cyrino et al. 2016, Bessa and Catella 2017) agree with the presented narratives, indicating that tumultuous paternal coexistence, sense of abandonment and lack of paternal support are factors that contribute to the family imbalance.exposure to episodes of aggression and unresolved conflicts make children vulnerable, affecting subsequent stages, or influencing them in the interest or approximation of psychoactive substances, and reproducing behaviors similar to the father's behaviors.
Corroborating King's theory of Goal Attainment, nursing care, focused on the user and his/her family, should involve care technologies enough for effective interventions based on his/ her demands, ensuring the sharing of decisions between professionals and clients (Nascimento et al. 2017).
the nurse must inform the companion that therapeutic adherence of users of psychoactive substances is one of the main obstacles for interventions to succeed in the FHU context, due to the complexity of the health-disease-care process inherent in every individual.thus, the therapeutic project, considered as key device to reach effectively the identified problems (Peixoto et al. 2017), should be adjusted whenever necessary, in addition to incorporating demands of the companion and other significant people in order to be effective.
Managing a rowdy coexistence is exhausting and generates anxiety in women, especially due to expectations regarding the future of their companion and children.Circumstances that might lead them to the need for using medicines.the studies consulted show indirectly (Avila et al. 2017, Souza et al. 2012) or directly the woman as the primary caregiver of their partners (lopes 2015).this caregiver's experience, generally without support or specific care for herself, represents an evolutionary process of illness, including gradual accession to medicines, initial step for a new dependency in the family environment.
Assuming an illness resulting from a family background that arose from a companion's habit, which brought losses to all, and in which she is involved, is not a perception that comes easily, it can be late and hard for the woman to accept.She often needs professional help to reflect and acquire such level of perception.these women's resources may be scarce and the intervention of support services, non-existent.therefore, the professional, based on respect, starting point of the interaction, should not only support the client even when sad and/or reluctant, but also help her rethink the losses, seek alternatives and chart a new path (King 1997).the professional's support, as well as emotional comfort, allows realizing the actual situation experienced by them and the damages caused by dependency.Women's participation in the companion's therapeutic project can stimulate An Acad Bras Cienc (2019) 91(1) e20180008 7 | 13 self-care strategies and promoting their mental health (Constantinidis 2017).Otherwise, non-realistic expectations will predominate; women will hold up in a type of hope for their companion's recovery supported by an idealized perspective based on the "wellbeing", at the expense of faith and tolerance, in the hope of rebuilding a harmonious coexistence in the family, not always achieved.
I miss support, my mother did not support me, even nowadays she does not!My mother was afraid I would divorce and become a single mother with three children; [...] she did not want me to be unmarried.(P8) [...] Faith that he will abandon alcohol and drugs and be that loving and happy man he used to be.But being alone is very complicated, sad, I do not know where to start! (P9)

[...] I feel sad, people judge me, but I love my companion, I believe he will change. But there comes a time when you keep trying, without support and without any progress, then I feel sad. (P10)
The narratives suggest the difficulty to think and accept a new life without the partner, whether for fear of being effectively alone, or because they still refer affection for him.The desire is to change, but they realize that their efforts alone do not have the expected effect, and thus, they feel sad and disbelievers.they do not have support for their needs and their companion's needs, which would benefit them, because they believe in the possibility of recovery, although they do not know the paths for effective care.
the feeling of compassion is present, and even with the difficult experiences and full of sorrows, some women cannot let go of the responsibility they feel to have with their sick companion, accepting a risky and undignified way of living (Souza et al. 2012).
The specific support for the user's companion is necessary, because the feeling of abandonment contributes to eliminate the prospect of a new life, for fear of not finding another mate and for perpetuating the belief that only the current companion is able to protect her from the world, which leads to renounce dreams and desires (Visentin et al. 2015).
Nurses and other health professionals should be alert and able to act in the interests of family support, from the initial reception without judgment, from a care network design, in which health services (specialized and basic attention) do not act in isolation and focus only on the user (teixeira 2015).
Without family support in the therapeutic project, interventions will be more difficult.The family is part of the rehabilitation process and tends to contribute to the user's adherence to the treatment, to withdrawal or reduce alcohol consumption.treatment should include everyone, based on the collective construction of goals and responsibilities, when disseminated among all family nucleus, reverting in understanding and conscious changes (Carvalho and Menandro 2012).
the nurse, as part of the professional group, provides means for achieving goals in common with the health team, according to roles and actions, including the quality of the interactions to establish (King 1997).Effective nurse-client interaction can determine the level of adherence to the therapeutic project (Araújo et al. 2017).
the process of rehabilitation of the user and his/her family has no passive relations.those involved are active beings that are able to act and react to nurses' interventions; thus training that professional to work with this set (user-partnerchildren) is important.the family is a child safety link, responsible for his/her process of socialization from birth; it is the environment where he/she acquires behaviors, skills and values advocated by the culture.the father acquires a central role in this process; if he is absent, the maternal role is overloaded.
An alcoholic father adds more responsibilities a woman with few fortresses (Antoni and Batista 2014).With this paternal omission, women become the only family's supporters and seek to minimize the losses in the children's intellectual and emotional education, but feel demotivated and unassisted (Borges et al. 2017).
Nurses' intervention must be friendly and centered in the pursuit of the conception they have of themselves, of their expectations and desires and the way they think their life situation could change in a perspective of reality, which might not be the ideal, but possible.together (professional and client), they may be able to design and plan the goals to achieve the most effective therapeutic project (King 1997).
the narratives also show that current life conditions generate numerous needs, from those related to financial aspects to those relating to freedom, affection and companionship, basic requirements for maintaining family links; Money, that is all.Sometimes, we lack things.(P1)

Oh! I miss having a loving companion, with the same ideas I have, who does what I do, who does not drink [...]. (P5)
The things I miss the most is talking more to him..., the fellowship.He is so rude, we have to be polite, [...]

.]. (P4)
The lack of affection, lack of companionship and insecurity are punctuated in the solitary experience.the narratives also reveal how the affective ties begin to weaken by prolonged exposure to suffering, little dialogue, unattended needs and annulment of themselves.Peaceful and affectionate interpersonal relationships are hard to have, being replaced by privations, dissatisfaction and concern for social and financial instability.Feelings and emotions generated from uncontrolled use of a psychoactive substance destroys the affective links with the partner and lead women to think over their current condition.
The family's vulnerable financial conditions make women dependent on the others' solidarity (Soccol et al. 2014) and the constant disappointments with the time alter women's self-esteem, limiting their own freedom (lopes 2015, Colossi and Falcke 2013).they commonly experience feelings of failure and weakening, which culminate with the lack of future prospects (Ribeiro and Silva 2014).
the predatory character of dependence on a psychoactive substance stands out, as the dependent, in addition to burdening physically and emotionally, reaches the family financially, depleting the available resources (Cyrino et al. 2016), which can be employed to obtain the psychoactive substance or to ensure his and/or the family's subsistence, due to unemployment (Souza et al. 2012).this can continue even when the couple separates.
[...] especially now that he is living with another woman, I have heard that he is suffering a lot because of his addiction [...] he keeps coming to my house to ask for money, he is a bastard.(P9) Getting closer to women allows the professional to establish and enable dialogue and listening, facilitating notifying the possible occurrences of violence, in order to identify the conflicts arising out of the partner's lifestyle.This approach subsidizes knowing the family's fragility and inclusion in the health care network and other social support services.
It is essential to consider the family's economic and socio-cultural aspects, since they are part of the completeness of the care, workshops of income generation being an important resource to be included in the therapeutic projects.
Attempts to limit the use of alcohol imply changes in family routine, with restriction of group activities, recreational and leisure moments.
We usually do something different to try to go out with our children not to drink beer, to drink something alcohol-free; these are the activities we try for us not to drink [...] the restricted and exhausting life discourages the woman to take care of the alcoholic and herself.
No activity at all!I do not feel like taking care of him nor of me.We do not do anything together.(P7) I do not take care of myself.He would rather go out with his friends to the bar than going out with us.(P10) the few social activities in family result in lack of interest in going out, indicative of the emotional blunting, helplessness and saturation.the discouragement leads to confine social relations to the family coexistence (Dahmer et al. 2012).
the continuous wear resulting from the relationship with the partner contributes to this condition, and it can make her give up the companion's rehabilitation and adopt a codependency (teixeira 2015) and prostration situation regarding the events of family life (Ambiel et al. 2015).
the incentive to start over seems to result from the break up with the partner, feeling relieved and liberated to reconstruct her own existence.
I am divorced!Today, I feel pleasure to work, to stay at home, enjoy my family, my children, go out for dancing, something I could not do in the past!(P11) Nevertheless, women that keep these relationships seem to want to keep the image of a socially respectable family and preserve the partner's physical safety and the children's emotional safety.the narratives show these women's concern to seek protection and support mechanisms for their family, minimizing the exposure of their problems to the social environment, which apparently does not modify the damage of alcoholism.
the fear of exposure can relate to the family marginalization, either by the pressure of the social medium to display a "perfect" group as by the fear of breakup of relations with friends and other relatives, if they revealed their marital intimacies and family particularities (Andrade et al. 2017).
thinking over the participants' stories in this study indicated tolerance as the main care for the partner, by the fear to be alone, accommodation (dependency), fear of judgment of the social environment, hope that they will change, or affection.In all situations, this care is full of discouragement, without conviction, fueled by lack of knowledge about what is the dependency on psychoactive substances.
Some perceive the effectiveness of attempts of protection from the external environment, when avoiding his contact with alcohol, but this practice, without the user's commitment, guidance of reasons and reflection of the family set, can be a mere restrictive procedure that affects all members, and where he can leave at any time.
Paying the debts in order to ensure the user's integrity also seems to be a way of the woman's care, which may result from the difficulty to feel less responsible for the partner.Another care-like prerogative is asking neighbors for help, for being more positive than trying to hide the problem, because it shows that she tries to expand her support network.Unfortunately, they did not report seeking support in the health service, which should be the main support of the user, or dependent on psychoactive substances and his partner.the omission of reports about the support received and who provides it suggests the failure of health services/professionals/nurses' communication with this clientele to promote the quality of life and health care management.therefore, professional intervention becomes urgent.
In the restricted context of health services, implementing effective therapeutic care requires professional host and link to configure as fundamental elements, as well as aligning assistance practices to the needs presented by users and their families.this will enable greater interaction and shared responsibility for the therapeutic plan, besides allowing evaluating its effectiveness, with the necessary adjustments.
In accordance with the reference (King 1997), the wear observed by the narratives occur in human interactions when the person feels overwhelmed and faces difficulties regarding the user's care and the ability to make decisions.the nurse is responsible for working goals and realistic perspectives.
Other nurse's actions are encouraging the client to search for new ways and being a reference for supporting users of health services in the process of recovery and social reintegration (Borges et al. 2017).
the limitations of this study were the participants' non-continuous follow-up in different moments, which may have prevented identifying elements that would determine other forms of family care.

CONCLUSIONS
the women in the study express difficulty maintaining their family relationships, especially by the companion's sick and indifferent behavior, whether in the care with the children or in the family support and development.Some women take some time to recognize the damage of alcoholism and, when this occurs, they do not have enough resources to face it.Nonetheless, they show some forms of care to the partner and concern for keeping images to neutralize the possible negative repercussions in society for their family group.
Few women cares are focused on the recovery of the partner and more on the impact of alcoholism on family dynamics.Strategies and practices are difficult to implement and/or continue since they do not have support and assistance from health services and professionals.
This finding indicates the need for including forms of therapeutic approach covering the health care of partners of the dependent users of psychoactive substances.In particular, to include these demands and people among the priorities of the family health teams in the establishment of PtS, since this health device has a greater bond with families.
this work can intervene decisively in the quality of life of these women, since they tend to abandon their life projects, with the feeling of living in vain and increasingly distant from the idealized, by demands generated in the coexistence with a companion who are perceived as their responsibilities.they feel tired, sad and unmotivated, so they demand care.
King's theory can be a viable philosophicalpractice basis for professional approach, because it allows establishing interactions.Similarly, the methodological referential allowed knowing the life stories of these women, which is an essential precondition for constructing effective therapeutic projects and in line with the reality of families.
Further studies are necessary to understand that the phenomenon of using psychoactive substances is not static and has elements related to family constitution, which need assessment.
[...] I have taken controlled drug since I was 22.I started taking it because I got sick.Nervous, I could not sleep when he got home drunk, screaming, swearing [...].(P7) Today, I am like this, sick, because of his problems with alcohol, I got mind sick {...} I need to take medicine even to fall asleep.(P8) today, I want to live my life, travel, I do not know!(P7) I feel so alone and useless facing the situation [...] I miss the affection, love.(P9) I miss a companion that asks how I am, that loves me, who shares my joys and sorrows [...] all the enchantment was over when he got involved with alcohol [...].(P10) [...] I miss a companion, having a friendly person that is always with me and thinks about the future!I miss [...] today I live as I was about to fall into a hole.Will he ever give up family?Will he leave?Will he find someone else?Will he leave the children and me?I feel An Acad Bras Cienc (2019) 91(1) e20180008 9 | 13 like I am in a roller coaster.I have no love stability [..
What I miss the most is the freedom; I feel like a prisoner, I have no freedom.(P2) I gave up my life, my studies.I have no selfesteem, I think he does not like me, or it is simply feeling of ownership, because he never wants to do anything with me!I miss going out [...], but he does not like it.(P8) [...] we could have our home, maybe a car [...].I keep thinking, I cannot even think about the future.(P6) [...] I miss having my own house, he had never been interested, in evolving, that is why we lacked many things.(P11)

I
try to do my best so that the neighbors do not hear our fights [...].(P8) [...] I paid for his addictions for him not to get killed!(P9) [...] my children saw his violent and drinking scenes, when I could, I put them away from it [...] (P11) Daily life of women with alcoholic companions and the provided care" involved a team of six researchers, both with technical and scientific experience in the thematic area of the study.the lead author, Vagner F. do Nascimento led and was responsible for all stages of the study, design and conception of the project, research development, writing and review of the article, in a direct partnership with coauthor Cláudia A. S. lima. the coauthors thalise Y. Hattori, Ana Cláudia P. terças, Alisséia G. lemes and Margarita A.V. luis participated in the writing and revision of the final version of the article.All the team that integrated the study maintained harmony and commitment in all the activities that gave rise to this scientific article.