Drug addicts treatment motivations : perception of family members

Objective: to identify the reasons and motivations why family members search treatment for the drug addicted. Methods: descriptive qualitative research, developed in 2012 and 2013, in a Drug Addicts Rehabilitation Unit of Parana State, Brazil. A total of 19 semi-structured interviews were conducted with the drug addicts’ family members in treatment. The results were analyzed based on the Transtheoretical Model of Behavior Change and organized in thematic categories according with qualitative data analysis. Results: the search for treatment for drug addicts occurred: in the pre-contemplation stage infl uenced by external factors; in the contemplation stage both for ambivalence and behavioral changes needs; in the action stage by awareness of drug addiction and also professional help needs; and in the maintenance stage because of the non-conservation of behavioral changes. Conclusion: an evaluation of motivational stages in the beginning of treatment is required for expansion of success possibilities in the rehabilitation process.


INTRODUCTION
The increased consumption of psychoactive substances (PS) by the world's population is confirmed by the World Drug Report, stating that, in 2010, approximately 4.6% of the population had used an illicit drug.Of these, on average, 27 million developed dependence for these substance (1) .
Substance dependence is characterized as a chronic, multifactorial disease, responsible for considerable individual, family and social disruptions, favoring family problems and misery of thousands of people (1)(2)(3) .This condition requires treatment with an interdisciplinary approach from psychotherapeutic and social interventions aimed at rehabilitation and social reintegration of drug addicts.However, treatment for drug addiction is seen as a difficult route by the propensity to episodes of relapse and low adherence rates (4) .
The high dropout rate to treatment was confirmed in a study developed with 227 drug addicts in a Psychosocial Care Center for Alcohol and Other Drugs (CAPS AD), in the state of Piaui, which presented 56.8% of non-completion of treatment (4) .This is also confirmed internationally, as a study in the region of Asturias, Spain, showed that among 57 chemical dependents undergoing treatment in a rehabilitation unit, the dropout rate was 52.9% in the period up to six months and 67.8% in a year (5) .
Several factors influence the search for treatment and its adherence.Among them, there is the motivation of the addict as one of the main criteria involving the demand and treatment maintenance.This condition is characterized as a state of readiness or willingness to change the problematic behavior (6)(7) .
The Transtheoretical Model of behavioral change proposed by Prochaska and DiClemente's (7) , developed in the early 1980s, is based on the combination of ideas that recognize the central role of drug addict in the change process.It assumes that the individual goes through five stages of motivation to change behavior: pre-contemplation, contemplation, preparation/determination, action and maintenance, which apply both to the behavior of use and to treatment (6,8) .
In the pre-contemplation stage, the individual has the belief that he/she has more benefits of using the drug than to stay abstinent.This is due to lack of information, lack of insight or denial.Commonly, when seeking treatment, they do it under the influence of family or friends.The individual may remain, for many years, at this stage, since it does not consider the need to change behavior as he/she does not realize the problems of biological, social and occupational spheres resulting from chemical addiction (6)(7)(8) .
In the Contemplation stage, individuals can make associations between their problems and drug abuse, they even cogitate the possibility of change, but there is still no commitment to do so.Therefore, it is characterized by ambivalence.Drug addicts who are in these two first stages represent the lowest level of readiness to change and thus, are more distant from the quest for treatment or abstinence (6)(7)(8) .
In the third stage, Preparation or determination, ambivalence is shaped, the addict is determined and committed to behavioral change, however there is no entrepreneurial action.In the fourth stage, called Action, the drug user engages in actions and situations to achieve behavioral change, such as seeking treatment through their own initiative (6)(7)(8) .
The last stage, called Maintenance, is characterized by the persistence of successful actions in trying to change, reaching the end of the process.At this stage, the need to consume the drug gradually decreases and the challenge is to support abstinence.However, it is common to experience several relapses and return to earlier stages several times, until they reach total maintenance.Thus, the chemical dependent must seek healthy alternative practices to drug use, building a new lifestyle different from his/her old ways of living, developing various skills and strategies for change (6)(7)(8) .
It is emphasized that the role of the family becomes a predictive factor for behavioral change and adherence to treatment by the drug addict in order to favor him/her.This is because the active participation of family provides opportunities to perceive the difficulties faced by the addict in the rehabilitation process, favoring the family insertion in the therapeutic project of the subject (9)(10) .
Given the above, researches on this topic offer opportunity for reflection and guidance of health professionals practice and specific authorities, through the construction and expansion of knowledge about the readiness to change behavior of drug addicts in the search for treatment.In nursing, the expectation is that this knowledge contributes to the qualification in the area of mental health, favoring the performance of a more competent, conscious, responsible and valued professional practice.The objective of this study was to identify the reasons and motivations why family members seek treatment for drug addicts.

METHOD
Qualitative descriptive research conducted from February 2012 to November 2013, developed into a rehabilitation unit of comprehensive hospitalization for drug addicts, who were male and aged over 18 years, located in Parana.
A total of 19 family members of drug addicts participated in the study, one for each chemical dependent.The invitations were made on the visiting day or in the family meeting.Both took place once a week.The number of participants was determined by theoretical saturation of data, which comprises the suspension of the insertion of new research subjects when the data reaches redundancy and do not add any further relevant information in research (11) .de cambios de comportamiento.Conclusión: es imprescindible la evaluación de las etapas motivacionales en el inicio del tratamiento para la ampliación de las posibilidades de éxito en el proceso de rehabilitación.Palabras clave: Transtornos Relacionados con Substancias; Salud Mental; Familia; Motivación; Enfermería.
Inclusion criteria were: being aged over 18 years and being a family member of one of the drug addicts in treatment in the rehabilitation unit.
Data were collected through semi-structured interviews with the following statement: "Talk about what you believe made your chemically dependent family member to seek treatment".The interviews were recorded using a digital recorder and performed individually, in a setting provided by the coordination unit, considering the preferred schedules of the subjects.
Data were analyzed according to the proposed Qualitative Data Interpretation (12) involving the stages of sorting, data classification and final analysis.In the data sorting stage, the interviews were transcribed, the reading of the material was made and the reports were organized according to their similarity.The data classification stage, exhaustive reading of the data in search of the key ideas was held, grouping them according to the six stages of behavioral change of Prochaska and DiClemente (6)(7)(8) : Pre-contemplation, Contemplation, Preparation/Determination, Action, Maintenance, except for the third stage, Preparation/ Determination which did not correlate with data from interviews.In the final analysis, articulation was established between the data and the theoretical framework of the research.
This research originated from the research project approved by the Research Ethics Committee of the UFPR Health Sciences Sector, registration number 904.029.10.03;CAAE: 0825.0.000.091-10.The ethical principles were respected, in line with Resolution 196/96 of the Brazilian National Health Council.The participants were identified in this study, by codes (Family member 1... Family member 19), without following a relationship with the order of the interviews.

RESULTS
The results are presented starting with the characterization of the participants (Box 1) relating them to their family members with addiction, followed by the thematic categories exemplified with the family members interviews excerpt from statements according to the stages of change of the drug addicts: In my family, my sister and I always wanted the best for him.So we forced him to perform the treatment, that is why he did not continue.We made him do it and we said we did this and that, but he was the one who had to continue the treatment, it is an exchange, a family pressure.(Family member 2, Grandmother) I talked to him, so he decided to be treated.Soon after, he told me it was only to please me, he did not want to stop using drugs.He did not stay in treatment, he did not get treatment.(Family member 12, Mother) He sought treatment because I was determined to put him out of the house.I was no longer putting up with this.(Family member 18, Mother) The Family member 4 indicates that the patient is not aware of his dependence, since he believes can stop drug use when desired, without the need for professional help: I always asked him to be hospitalized and he would not do it, because he said he would stop it by himself.But he was already sleeping in the street, did not eat anymore, did not shower.His condition was really critical.(Family member 4, Daughter) The search for treatment is also related to court orders or clinical problems arising from the use of drugs such as seizures and physical weakness, and not by individual awareness of their dependence: When he's drinking and money ends, within a day or two without drinking, the seizures begin, so he seeks help and is admitted in an institution of clinic.When he leaves the treatment, he drinks for 15

Category 2 -Contemplation
When they start treatment, some addicts express ambivalent feelings about the need for behavioral change.One of the patients consented to carry out the treatment as long as he could use drugs again, and another believing that was restored after a period of treatment: He wanted to be hospitalized and at the same time did not.By the time we got here he went out with the taxi driver and said he would only stay after doing something.Then he went and I stayed here with the papers while he used drugs.Soon after, he returned to start the treatment.(Family member 2, Grandmother) [...]He was seven times in a psychiatric hospital X and here is the second time he spends 15 days hospitalized and he always asks to leave because he thinks he is clean.He says he is now well and will not drink any more.When he leaves, he has plenty of family support, [...] suddenly he disappears and goes to the bar.(Family member 5, Brother) Category 3 -Action There are drug addicts who are aware of their addiction and need professional help, therefore, they decide, by themselves, to complete the treatment and demonstrate suggestive attitudes that they will change their lifestyle: I believe now he adhered to the treatment, so much that in the ten minutes I talked to him, I saw fully the modification in these days he was here.[...].This time, I think he saw that something had to change in his life.He came and is here being treated, tomorrow will be a month he's here.[...] At no point said he wanted to give up.(Family member 7, Aunt) The first time I took him, I almost dragged to the hospital, we almost had to call the police, it was against his will.The failure to maintain behavioral changes prompted the need for a new hospitalization and many relapse to drug use progressively underestimating dependence.Family members point to the difficulty of changing lifestyle habits and avoiding staying in places they used to go, as decisive factors to relapse and return to treatment:

Subjects
They offered him a drink.He did not want, but they said, "just a sip will not hurt".In such a sip, he was starting to drink again and told us "If I know how to drink I will not get addicted anymore".From sip to sip he was back drinking again.(Family member 4, Daughter) [...]He thinks he is good and can drink.He begins having a beer today, tomorrow two, after tomorrow three and then he loses control.We think that's what happens.(Family member 5, Brother)

DISCUSSION
The research data show that, in seeking treatment, drug addicts are in different stages of behavior change.According to the Transtheoretical Model of Behavior Change (6)(7)(8) , these stages follow a temporal dimension that varies according to each individual since changes occur over time, and are configured at specific levels which permeate the personality and psychological states of each one of them.
The chemical dependence makes the individual helpless faced the possibility to control drug use, and this becomes a priority over other activities.Further exploring this scenario, some dependents have difficulty to accept his/her condition and now has a false sense of control over the use, which promotes several episodes of relapse (8,13) .This is consistent with the narratives of the subjects in the pre-contemplation stage, when they verbalize that their family members did not believe them to be drug addicts and therefore did not admit to having problems arising from the use of drugs, having no need to start a treatment.
Still in the pre-contemplation stage, the interviewed claimed that some drug addicts have not sought treatment voluntarily, but by external influences such as family pressure, lawsuits and clinical problems.It is understood that the treatment of drug addicts started by coercive measures has limitations because it is believed that the lack of motivation and initiative, commonly, result in poor adherence to treatment (6)(7)(8) .
According to the Transtheoretical Model of Behavior Change (6)(7)(8) , for effective behavioral change with a view to rehabilitating, the addict needs first to have a cognitive development regarding the need for treatment and then a behavioral condition.Thus, the previous treatment of social coercion

This time he came to me, said he was on drugs, which had started again, he needed help and asked to be hospitalized in the next day. He came on his own, I didn't have to force it, insist or anything, he said, 'I want, because alone I can't. (Family member 10, Father)
He came because he wanted to, he was not forced, there was no kind of pressure, neither psychological.We just told him, you are seeing the situation, you're losing everyone, let's change, we are here to help you, you should want to, I cannot live your life, I cannot decide for you.So he decided to be treated.(Family member 17, Sister)   Issues related to clinical and family problems were also cited as essential to the development of the chemical dependent insight regarding their need for treatment and behavior change: He spent a week in the street, without eating, without bathing, I think he could not handle the weakness and ended up in my aunt's house.He saw the need, the need was stronger than the stubbornness, then, he sought help alone and was hospitalized.(Family member1, Daughter) He did not accept treatment, but was not holding up, he felt very bad and had convulsions.After that, he realized he could no longer drink and asked to be hospitalized.He said he wanted to live life more, wanted to see their grandchildren grow.(Family member 3, Daughter) He asked me to be re-hospitalised.[...] This was because he was staying in house to house, no one wanted him, until he realized that it was not possible and asked to be treated, then I brought him here.(Family member 4, Daughter) He spent four days without eating, without sleeping, just using drugs.He came home feeling bad and saying that the only way out was to be hospitalized.He was willing to be treated.(Family member 15, Wife)

Category 4 -Maintenance
The interviewed believe that some patients seek treatment due to non-continuity of treatment in non-hospital settings, after the previous hospitalizations because they believed they were recovered.The highlighted the need for continuous treatment for maintaining abstinence: Drug addicts think they are well, they spend a year well and say they will not drink any more, but that's not what happens.I think that anyone who is an alcoholic a lifetime have to have a treatment because they may relapse at anytime.He did not do it, he took care only for a while.So I think it's a lack of treatment.(Family member 1, Daughter) [...]He thinks he is good, he no longer needs treatment outside the hospital, but it is mistaken, because as the professional said now he has to get out and look for a CAPS, a treatment, must continue, You can never stop.(Family member 5, Brother) He was discharged from the other hospital, but did not continue treatment in CAPS AD.It was our fault I assume [...] presents a challenge to health professionals, since the changes require an internal commitment of the individual and not external (6,8) .
The fact is evidenced in a study (13) held in Rio Grande do Sul with 103 drug addicts, in which 69.3% of the subjects dropped out of treatment for not believing they had drug-related problems.The treatment was not sought on their own initiative, but family pressure and involvement with the justice system.The difficulty of maintaining abstinence and treatment seems to be related to the pre-contemplation stage (13) .
In contrast, the treatment of pre-contemplative addicts enable the pursuit of self-knowledge and the awareness about the behavior problem increases the probability of an individual to accept his illness, powerlessness over addiction and remain in treatment (4,6) .
In the contemplation stage, the results show that the search for treatment was also related to ambivalence between change or stay in the behavior (8,(14)(15) .To seek treatment at this stage, the individual evaluates the advantages and disadvantages to rehabilitate, think about the implications of drug use and brings to him/he and others, as well as efforts and losses demanded by the rehabilitation process (15) .
In the treatment, this motivational stage has limitations because the contemplative addicts cannot opt for behavioral change and relapse, but can also move forward in the process of change and progress to the action stage (8,15) .Concomitant to this, professionals should be trained to help them minimize and deal with ambivalence, favoring the passage of contemplation stage for the preparation and action (16)(17) .
In the results of this research, there is no relationship between the search for treatment and the stage of Preparation/Determination, possibly due to the difficulty of defining this stage, which is characterized as a process of transition between stages of contemplation and action (6)(7)(8) , making the delimitation of boundaries between them incomprehensible.
According to the participants' statements, the action stage includes a certain time that addict realizes the need for specialized help, so seeking treatment willingly.The specialized treatment is included as support for coping with difficulties arising from substance abuse, aid for the pursuit of self-knowledge and recognition of other sources of pleasure (4,10) .However, behavioral change for permanent withdrawal involves not only the efforts of health professionals, but also requires the direct participation of the individual and family member (10) .
In the action stage, the motivation to cease the use of psychoactive substances is an important self-determinant, because it causes the individual to move towards a specific goal, generating positive behavior change.This determinant is analyzed as a process because it is based on the assumption that it is a condition of readiness or willingness to change, which can range from one situation to another, from time to time (4,16) .In addition to the behavior change, this period is marked by constant change of reasoning, emotions and thoughts (10) .
According to the subjects, the notion of losses arising from lived experiences was essential for the development of awareness regarding the need for treatment.Many researches (16,18) with addicts state that the motivation for treatment comes from clinical problems, loss of material goods, labor problems, helplessness, self-destructive situations and need for revitalization of affective and family ties, which corroborates some narratives from this research.It is from these experiences that awareness of failure arises, the confrontation between what we crave and what does not wish to live, which seems to emerge an understanding of a possible rehabilitation and a viable life-changing project (18) .
In the maintenance stage, the subjects showed that some patients were readmitted due to the non-continuity of extrahospital treatment.Corroborating this finding, a research (19) held in a rehabilitation unit for substance abuse in the metropolitan region of Curitiba, with 350 drug addicts, showed that the high number of readmissions are possibly related to low adherence to outpatient services, as only 29.9% of patients attended these services.
After hospital discharge, some addicts have difficulties to keep the behavioral changes when faced with problems coming from social life and therefore, return to the consumption of drugs (19)(20)(21) .The continuity of treatment in outpatient services proves to be essential for the rehabilitation and social reintegration, as the addict combines treatment with life in society without having to move away completely from their daily occupations (19) .
In addition, some addicts do not give sequence to treatment and behavioral changes after hospitalization by the false belief of healing, a fact mentioned by the subjects of this research.As a result of abstinence, commonly, the individual has the illusory idea that he/she is healed and can make sporadic drug use (21) .However, in situations of risk, he cannot control his acts and reacts compulsively.As a consequence, they return to consume drugs (18)(19) .
A research (18) held in Caxias do Sul (RS) with thirteen addicts found that the greatest difficulty is not to achieve abstinence, but to continue the behavioral change process.The authors mention that the experience of abstinence favors the coming instability of lifestyle change and also the negative emotional states, which serves as a stimulus for the recurrence of drug use (18) , it is this consumption that addicts find ways to cope or escape problems (18)(19) .
Therefore, for the remission of conditions to occur satisfactorily, the adoption of substitute behaviors that can compete with the addictive behavior should be considered, and the willingness of the dependent person to compulsory supervision during certain time, engagement in new personal objectives and recovery self-esteem (18) .
During the rehabilitation process, the addict must be prepared to make changes of life and behavior associated with drug use in the course of a lifetime (6) .In addition, he/she will need to support the effort made to change as well as using cognitive, affective and behavioral skills needed for the desired changes (6,8) .
The family´s presence positively promotes the drug addict rehabilitation process, in aid of affective, cognitive and behavioral changes (10,18,22) .A study (23) conducted in a CAPS AD of Campo Grande (MS) has found that the participation of two or more families directly impact the consolidation of patient adherence to treatment, favoring the commitment to modify the living habits and ways of living, in which drugs are not present.

FINAL CONSIDERATIONS
The results from the Transtheoretical Model of Behavior Change, identified that the search for treatment was related to all the motivational stages except the stage of preparation/ determination.
We concluded that, in the pre-contemplation stage, the search for treatment occurred by coercive measures, such as family pressure, court orders and clinical problems, while the Contemplation stage was defined by ambivalence about the need for treatment and behavioral change.In the fourth stage, called Action, drug addicts are motivated to seek treatment on their own realizing the need for expert help.Finally, in the maintenance stage, some addicts have returned to treatment due to the discontinuance of the previous treatments, as well as behavioral changes.
The results showed that in seeking treatment drug addicts are at different motivational stages.Thus health professionals must assess these stages at the beginning of treatment because, when planning care according to the patient's idiosyncrasies, they will expand the possibilities of success in rehabilitation.
It is hoped that the issues raised in this research be deepened in further investigations, since the expansion of this knowledge favors the exploitation of health professionals and family members about the understanding of the rehabilitation process and encourages the development of new strategies for prevention of relapses and treatment adherence.

Box 1 -
Characteristics of study subjects.Parana, 2012 Some drug addicts are not committed to cease drug use, they initiate treatment only due to family pressure and effort to get a hospitalization spot, however they do not complete treatment:We always looked for treatment for him, he does not adhere.(Familymember 1, Daughter)I am always the one who look for treatment for him [...].
ContinuesCategory 1 -Pre-contemplation or 20 days, he doesn't eat, become weak, has seizures and seek help again.(Family member 5, Brother) I had to ask for help in counselling tutoring, which went to the Public Affairs.(Family member 8, Grandmother) He was hospitalized only by convulsion, it was one after another.I convinced him to accept treatment for his health.I said, 'You will be hospitalized because you are going to die anytime'.Every time he has seizures he becomes more ill.(Family member 9, Ex-wife)