Care actions for family members of users of psychoactive substances : intentions / expectations

Objective: to understand the professionals’ intentions and family members’ expectations about care actions developed to the relatives of users of psychoactive substances. Method: a social phenomenology approach according to Alfred Schütz, performed in a Psychosocial Care Center for Alcohol and Drugs. Interviews were performed with 13 professionals and 12 family members. Results: there is a reciprocity of perspectives between the professionals’ intentions and the relatives’ expectations, described by the effectiveness of the treatment of the user (typical of the action of both). The family members seek for care actions, expecting to improve the user’s treatment. Final considerations: the fi ndings provide refl ections for professionals about the health care actions and the organization of the service for the family’s mental health. Descriptors: Health Personnel; Drug Users; Substance-Related Disorders; Substance Abuse Treatment Centers; Family. RESUMO Objetivo: compreender as intencionalidades dos profi ssionais e as expectativas dos familiares acerca das ações de cuidado desenvolvidas aos familiares de usuários de substâncias psicoativas. Método: abordagem da fenomenologia social segundo Alfred Schütz, realizada em um Centro de Atenção Psicossocial Álcool e Drogas. Realizaram-se entrevistas com 13 profi ssionais e 12 familiares. Resultados: revela-se que há reciprocidade de perspectivas entre as intenções dos profi ssionais e as expectativas dos familiares, descrita pela efetividade no tratamento do usuário (típico da ação de ambos). Os familiares buscam as ações de cuidados com a expectativa de melhorar o tratamento do usuário. Considerações fi nais: as descobertas oportunizam refl exões para os profi ssionais sobre as ações de atenção à saúde e a organização do serviço voltado à saúde mental do familiar. Descritores: Pessoal de Saúde; Usuários de Drogas; Transtornos Relacionados ao Uso de Substâncias; Centros de Tratamento de Abuso de Substâncias; Família. RESUMEN Objetivo: comprender las intencionalidades de los profesionales y las expectativas de los familiares acerca de las acciones de cuidado desarrolladas a los familiares de usuarios de sustancias psicoactivas. Método: enfoque de la fenomenología social según Alfred Schütz, desarrollado en un Centro de Atención Psicosocial Alcohol y Drogas. Se realizaron entrevistas con 13 profesionales y 12 familiares. Resultados: se revela que hay reciprocidad de perspectivas entre las intenciones de los profesionales y las expectativas de los familiares, descritas por la efectividad en el tratamiento del usuario (típico de la acción de ambos). Los familiares buscan las acciones de cuidados con la expectativa de mejorar el tratamiento del usuario. Consideraciones fi nales: Care actions for family members of users of psychoactive substances: intentions/expectations Ações de cuidado aos familiares de usuários de substâncias psicoativas: intencionalidades/expectativas Acciones de cuidado a los familiares de usuarios de sustancias psicoactivas: intencionalidades/expectativas


INTRODUCTION
Psychoactive substances, whether illicit or not, represent a public health problem, due to its disseminator power and because it is present in almost all countries (1) .The prevalence of those substances is increasing worldwide, reaches about 27 million people, which represents 0.6% of the world's population, and has aroused a strong social concern (2) .
The Ministry of Health's Policy of Integral Care for Alcohol and Other Drugs Users establishes the construction of care networks, composed by a substitutive service, Psychosocial Care Center for Alcohol and Drugs (CAPSad -Centro de Atenção Psicossocial Álcool e Drogas), which provides the population with substance related problems, producing therapeutic and preventive activities to the community, seeking, among other strategies, to offer care to family members of the service users (3) .CAPS is responsible for offering support to families, to keep and strengthen emotional ties between users and their families, emphasizing the importance of the family presence in the service (4) .
Scientific productions show come concerns related to the users' families, such as the need to reinforce strategies of family treatment.The researches also indicate some damages to the families due to the use of psychoactive substances and consider the family as a preventive/protective and risk factor (1,(5)(6)(7)(8) .Thus, the family needs to be perceived according to its experienced reality, from participation spaces and construction of actions that allow the integration of family members to the care.
Given this context, Social Phenomenology is based on the individual that lives the experience of a particular phenomenon, considering that only the involved actor can mention what is aimed with the action.Thus, it values the individual, his/her experiences, conscious actions and expectations.The use of this theoretical reference is relevant, as it gives voice to the participants involved in this research, the family members and professionals.Also, it allows them to act and interpret the daily life they live in, describing their lived experiences and the meaning of their actions in the social world (9) .Thus, there is the guiding question: what are the intentions of professionals and the families' expectations about care actions developed to the families of psychoactive substance users?

OBJECTIVE
To understand the professionals' intentions and families' expectations on care actions developed to the family members of psychoactive substance users.

METHOD Ethical aspects
This study met the ethical precepts of research with human beings, according to the Resolution n. 466/2012 of the National Health Council and was approved by the Committee of Ethical Conduct in Research Involving Human Beings.To preserve the anonymity of participants, the professionals were identified by the letter "P" and family members by the letter "F" followed by a number chosen by the order of interviews.

Theoretical-methodological framework
We opted for an approach of Alfred Schütz's Social Phenomenology, based on the person that lives the experience of a particular phenomenon, considering that only the actor involved can refer to what he/she expects from the action.It is understood that the actions directed for the care of the family members of psychoactive substance user at the CAPSad are not only in the individual context of the action, but in a world of relations with others, in which there is an intersubjective meaning, contextualized in the social world.It also allows to know the reciprocity of perspective of care actions developed to the family members of psychoactive substance users in the intentions of professionals and in the expectations of relatives.
The general thesis of reciprocity of perspectives reaffirms the intersubjectivity in the social world.It is the possibility of exchanging points of view and the congruence of impact systems, as the world's objects are accessible to the social actor as well as for his/her equal (9) .In other words, knowing the intentions and expectations of care actions for family members in the perspective of professionals and relatives and those common to the groups.

Type of study
Study with qualitative approach, using Alfred Schütz's Social Phenomenology .

Study scenario
The study was performed in a CAPSad of a municipality in the state of Rio Grande do Sul, Brazil.The CAPSad team was composed of 13 municipal public servers (two doctors, being one psychiatrist and a clinician; two psychologists; one social worker; one nurse; one physiotherapist; two mental health technicians; a nursing technician; a receptionist; and a harm reduction worker).It also counted with seven professionals of the Multidisciplinary Residency in Health (RMS -Residência Multiprofissional em Saúde) (three nurses, two psychologists and two social workers).

Data collection and organization
We interviewed 13 CAPSad professionals and 12 family members of psychoactive substance users that were treated in the service, through phenomenological interviews, from July to November 2016.The interview was individual, like a meeting, so that a face to face relation and a comfortable situation were established, allowing a reciprocal relation between researcher and interviewed (9) .The elected inclusion criteria of participant professionals were: be a professional of the multi-professional team in health with employment relationship or residents of the RMS, active in service during the data collection.And, for the users' families, the criteria were: to accompany the user in CAPSad at the time of admission or appointment, and those participating in a family group offered by the service.The exclusion criteria for participant professionals were: those who are not in service due to health license during the data collection, and those with less than six months in the service.

Data analysis
To analyze the data, the steps mentioned by researchers of Social Phenomenology (10) were used, trying to identify, through data readings, the units of meaning, the relation of the categories with each other, finding, thus, the convergences that allow the construction of concrete categories of actions established between CAPSad professionals and family members.The findings were interpreted in theoretical conceptions of Alfred Schütz's Social Phenomenology (9) .
From the results analysis, three concrete categories emerged: Professionals' intentions regarding actions of care; Family members' expectations regarding care actions; and Reciprocity of perspectives of intentions and expectations.

RESULTS
Of the 13 professionals interviewed, 11 are female and two are male, with ages from 20 to 59 years, with a majority of Catholics (six) and married.As for the interviewed professions, three are nurses, two are doctors, two are social workers, two are mental health technicians, one physiotherapist, one psychologist, one nursing technician and one damage reduction worker.Regarding the time in service, four interviewed have been working for two years in the service, two between 2 and 4 years, five between 5 and 9 years, and two for more than 10 years.
As for the 12 interviewed family members, 10 are female and 2 are male, with ages between 20 and 70 years, half are Catholics (six), and there are four mothers, three wives, three sisters and two are fathers.Regarding the family income, four receive between one and two salaries, two between two to three, and six have an income above three salaries.With regard to schooling, five have incomplete Elementary School and two have higher education.As for the interviewed's children, six have three children, two have two children, two have five and two do not have children.Concerning the occupation/ profession, two are stay-at-home, two are housemaids, one is self-employed, one is a kitchen assistant, one is office attendant, one is a pharmacist and one is a gas station attendant.
From the results, we identified that some care actions for families of users that seek care at CAPS are listening, acceptance, individual care, guidance, referrals, family groups, home visits, care, case management and psychological support.And, after understanding professionals' intentions and relatives' expectations on care actions developed for family members of psychoactive substance users, three categories emerged that will be presented below.

Professionals' intentions regarding actions of care
The concrete category "Intentions regarding actions of care" describe the intentions common to participants regarding the care developed to family members of psychoactive substance users.The professionals promote actions to family member with the following intentions: effectiveness of treatment; familiar empowerment; to improve the relation between family and user; to minimize suffering/conflict/anxiety; to establish or rescue ties; and to give support.
The professionals develop several care actions to family members, both individual and in groups intended to effectively treat the user.It is believed that those actions can impact in strengthening family members and contribute in users recovery, increasing thus the treatment chances of success.
And that this other family member who is a user, recovers.(P1)

And to increase the chances of success of the dependent's treatment. (P2)
[…] we always hope that the service to the family strengthen the follow-up, and the treatment of the user of the service itself.(P5) The professionals intend the participation of the family as a success and adherence in the user treatment, reflecting in benefits for the whole family.However, they understand that many times the achievement is the user larger time in abstinence or the understanding of the importance of damage reduction.
The intention at first sight is to provide an improvement to the user.But considering that the improvement will do well to the family.(P7)

We always hope for the success of the treatment. That we get at least a larger time in abstinence. Or that they can understand the importance of damage reduction. (P8)
To help the family and consequently helping the treatment of users here.(P12) Family empowerment represents another intention of professionals developing care actions to the families.That other family members can see the empowerment as people included in society.To promote this empowerment, it is relevant to promote the knowledge about substances use and to clarify to the family that this is a disease, that the use can cause clinical, psychological consequences, and even other disorders.That the family members understand the user's treatment process.To do so, they believe it is important to bring the family close to the treatment.relationships are rebuilt, that the actions improve communication and bring harmony and balance back among the family members.

That harmony returns, within normal rage, with balance. Balance is good in moments of sadness and happiness. (P1)
We try to mediate and to facilitate relationships, the relations between parents and children.So they can all have a better harmony.(P3)

To try to facilitate communication among them [user and family]. (P7)
And that family relations can, in a way, be rebuilt.Because they arrive here with ties completely destroyed.(P12) The professionals, through their care actions, expect to harmonize family ties, as well as to cause moments of reflection about their behavior regarding the users, so they can feel supported in their family space.
The professionals perform care actions to family members to minimize suffering/conflict/anxiety of psychoactive substance users.So that family members can understand the process of chemical dependency and, therefore, decrease anxiety, relieve the suffering and avoid conflicts among users and relatives.
But, to say so, the issue of avoiding conflicts is more generalized to everyone.(P1)

I hope that this exchange, that we can alleviate this suffering. (P4)
The professionals believe that from the relatives' understanding about dependency, they will be able to provide care to their loved ones with more knowledge, patience and dedication.To listen to their complaints, concerns and anguishes may lessen their suffering.
Establishing or rescuing ties, and supporting also represent an intention of professionals when they perform care actions to users' families.

Yes, the intention is more or less this, to give support. So they can feel strength […]. That this support is interesting to the family member as an individual. (P5)
The first question is to increase the bond.This issue is the most important tool we have in mental health, the bond between patient and family.(P9) And that we can give, in a way, support.Because this support I'm talking about is most of the time listening.(P10) Sometimes, in that process, family ties are broken, so professionals develop acceptance, listening and support actions to rescue that bond among users and family members.That the family feel strength and become partners in providing care to users.

Family members' expectations regarding care actions
The concrete category "Expectations regarding care actions" describes that family expectations are focused on the effectiveness of the user's treatment.Family members seek care actions so the user can get better.So the users carry out the treatment effectively and that there are no relapses, that is, so they do not make use of substances again.The families state they are afraid that the user might relapse, and that is why they seek support at CAPS.The families mentioned that they feel welcomed at the CAPS and that, if the user is fine, they will also be fine.They report that they feel happy and thankful to the team and to all the care offered to the user.The families claim that their expectations regarding the users are being fulfilled at the CAPS.

I think his expectations, and consequently ours, is well attended […]. He even makes the appointments and he has a professional return. (F4)
The families wish that the users keep attending the services and actively participating in the proposed therapeutic activities.

It is because of this boy that we live, and with this I have more experience. So he keeps doing the treatment. (F6)
That each meeting he attends only adds.An that he can realize that the dependency should be left aside.(F8) What I expect is for my brother.That he gets even better.And that he goes, that he accepts and wants to go there [CAPS]  when he has to go.To make the treatment right.(F12)

Reciprocity of perspective of intentions and expectations
To understand the reciprocity of perspectives in the light of Alfred Schütz (9) , a schematic synthesis will be presented on the approximations between the typical action of interviewed participants, concomitantly with the intentions (CAPS professionals) and expectations (family members).
Thus, Figure 1 shows the concrete categories of the typical action of CAPS professionals and family members, translated by the intentions when the professionals perform care actions to family members of psychoactive substance users, and the expectations of those families regarding the care actions offered by the service.
Figure 1 shows that the CAPS professionals' intentions and families' expectations described by the typical action-in other words, the ones common to the group-refer to the effective treatment of the user.It also shows that, specifically, the professionals' intentions regarding care actions are based on family empowerment, improving the relation family/user, minimizing suffering/conflict/ anxiety, establishing or rescuing bonds, and giving support.
Care actions for family members of users of psychoactive substances: intentions/expectations Siqueira DF, Terra MG, Vieira LB, Mello AL, Moreschi C, Soccol KLS. more satisfactory results in users' treatment and empower the families.Therefore, it is essential that the professional hold a good dialogue relation with the family (13)(14) .
Thus, the family needs to understand the user's treatment process and be prepared to deal with situations resulting from substance use.From their life history, the family is capable of building their own knowledge and empower themselves to think about more appropriate alternatives to cope with each experienced situation (15)(16) .
The professionals develop care actions to family members to improve the relation between family and user.Participation and support to family members, when supportive to the treatment, demonstrates greater confidence in the user during the exposure of their problems and contributes to understanding the situation.Especially in situations where the user is at "rock bottom", it is a motivating and triggering factor to treatment permanence (11)(12)(13)(14)(15)(16)(17) .
Given this context, it is up to the professionals that work this problem to guide and stimulate the family, strengthening ties and facilitating the process that involved the treatment of the user.It is necessary that the services assess the family dynamics needs, as well as the impact of substance use to the family or social context, considering that each family member can be influences (12) .
In addition, it is up to the multidisciplinary team in mental health to demonstrate how relevant is the family presence in the service, and reinforce the importance they have as partners and co-responsible for the user treatment.Also, to inform them that, through their participation, it is possible to achieve the user's adherence to the treatment from the bond and mutual responsibility, approaching the ideal family insertion in the treatment.
A person, after being born, experiences a world as a set of social relations, of systems of signs and symbols, as a private network of meaning and social organization.Those elements of the social world are assumed as natural.The social world's natural aspects, to those who live in it, constitute the group's internal customs, which are socially accepted and naturalized, as they were tested over time and socially approved.In this line of thought, the daily life of families with relatives that are substance users can influence other family members to use those substance as well.
In the world of life, people relate to each other, becoming part of the personal history of the other.What the person is, how he/she is and what he/she will become is determined by the participation in relationships "of us" that remain in the family group (9) .In this perspective, people who experience the use of psychoactive substances in the familiar context, being intimately connected to the user, constituting relationships "of us", have this problem of use as a part of their daily world.The influences, interactions and frequent disorders among family members mark their biographical situations, so that they can motivate what they are now and what they will be in the future.
It is understood that the family has a leading role on the process of treatment, because, being inserted in the everyday life of the health service, they are able to understand the context of drugs and their particularities, therefore, they notice the user needs.It allows to extend the point of view in face of the difficulties experienced by the user, seeking a better way to deal with the context (18) .
When analyzing the convergence between professionals' intentions and families' expectations described by both typical actions, there is a convergence between participants' intentions and expectations, as both professionals' intentions and families' expectations are based in the effective treatment to the user.
However, it should be highlighted that professionals' intentions overcome the expectations of families, as such actions, besides seeking effectiveness in the user's treatment, they seek to empower family members, to improve the relation family/ user, minimize suffering/conflict/anxiety, as well as to establish or rescue bonds, and give support to family members of psychoactive substance users.

DISCUSSION
The professionals develop several care actions to family members to have a more effective treatment, empower families, improve the relation family/user, minimize suffering/conflict/ anxiety, establish or rescue bonds, and give support.
It is noted that those actions can impact on strengthening family members and contribute to the success and effectiveness in the treatment.The family members involved in the user's treatment, participating regularly in activities offered by the service, improve their expectations regarding the users' treatment, and learn to deal better with the issue of using psychoactive substances.Those activities often consist of guidance and family awareness to improve mainly the quality of relations among their members to collaborate with the user recovery (11)(12) .
The family, when contemplated by the health service interventions, changes their comprehension about the user and, consequently, the way of dealing with the problem and to understand the treatment.So, they start to contribute to a healthier family relation and, especially, offer support to the user adherence to the treatment.It should be noted that the information transmitted to family members, as well as their involvement in the service through participation in available activities, ensure  So, when the family is involved in the care provided to the CAPS user, offering support to face difficulties of daily life, the emotional charge, as well as the family and user communication is moderate, increasing the level of interaction, harmony and empathy among them.Besides, the service provides and extend life possibilities, mediating social relations within the family (18)(19) .
The professionals perform care actions with the intention of minimizing their suffering/conflict/anxiety and those of psychoactive substance users.By providing care, they can help them relieve feelings of loneliness and social isolation, allowing reflection and exchange of experiences.In addition, they offer information, guidance, as well as emotional support, which allow the family to have a perception of the actual situation they are living, helping them to face it (20)(21) .
Establishing or rescuing ties, and supporting also represent an intention of professionals when they perform care actions to users' families.At CAPS, professionals have skills to support the family, help them to understand and deal with the daily life that involves taking care of the psychoactive substance user.In this sense, the families that attend the service learn to deal with the user, getting stronger and finding instruments to assist in his/her care.Also, they feel relieved, renovated and strengthened, as they can share their concerns and anxieties with the professionals (21) .
It is up to CAPS to offer support to family members to strengthen emotional bonds with users, and it should reinforce and demonstrate the relevance of their presence in the service, informing them that they are partners and co-responsible for the treatment.In the meantime, their participation is vital to a good adherence to the treatment, from the bond and mutual responsibility (4) .
The families seek care actions so the user can get better.The guidance and support they receive in health services are fundamental, as they favor the comprehension of the situation experienced and contribute to the user's adherence to the treatment.Following this logic, the family members seek attendance to get support to themselves and to the user.Their intention is to have their own demands answered and, especially, the user's demand (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22) .
The integration of family members on health service reflects, at the same time, the interest in taking care of their own health and to promote effectiveness in care to the user.Those expectations are related to those family members biographical situation (9) , characterized, sometimes, by the fear that the user can relapse and stop attending CAPS.Given this context, the family members are essential elements, as they establish bonds with the service through participation in therapeutic activities, becoming collaborators and multipliers of lived experiences.
Besides, they can cooperate with strengthening the humanized care and in accordance with the purposes of the psychiatric reform, especially as regards practices geared to user needs (23) .The therapeutic activities contribute to the improvement of social and family coexistence, in damage reduction related to the use of psychoactive substances, in stability and in crises reduction.Also, they represent important elements of re-socialization and psychosocial rehabilitation, collaborating to the autonomy exercise in their daily life (23)(24) .
The reciprocity of perspectives reveals that there is a convergence between participants' intentions and expectations, as both the professionals' intentions and the family's expectations are based in effectiveness in the treatment of the user.Thus, the reciprocity of perspective implies that the experiences of elements of thought of the social world by the person and his/ her equal have different peculiarities for each until a given moment, because of the typified edifications of the social world's objects (intersubjective) (9) .
In a social relationship between contemporaries, each person perceives the other by typification, with reciprocal knowledge of this perception, and each expects that the other's interpretation is congruent to his/hers.From this idea, and according to the general thesis of reciprocity of perspectives, it is relevant to highlight the concept of idealization of the reciprocity of motives.Such concept refers to motives attributed to the other and that are typically their own or their equals in typically similar circumstances (9) .
In other words, by typifying the action of individuals, several motives were attributed to them, which guide their actions, supposedly immutable.Based on this perception, it is possible to say that the action of a person will induce his/her anonymous equal to perform typical actions according to typical motives, to achieve the state of things designed by him/her.Also, one can argue that people have a typified conception of themselves, based on motives that are typical and supposedly invariant, and presupposes their self-typification, since they must project their actions in a typical way in which the other expects them to act.
Thus is revealed the interweaving between the reasons between the motives for and the motives because in a social interaction between a person and an equal (9) .This relation is relevant in the context of CAPS, as it is expected that people's expectations (family members), and their motives for when to seek care, are the motives of the professionals that perform care actions to family members.Thus, there should be a convergence between expectations and intentions of the people involved in that social relation.
Therefore, this study revealed the typical action of each group of people (professionals and families) through analysis of motives for care actions for the families of psychoactive substance users.The concept of reciprocity of perspectives allows to perform an analysis between the groups' typical actions, finding where there is convergence in the entanglement between intentions (professionals) and expectations (family members).

Study limitations
The completion of this research presents a few limitations, such as being limited to the CAPSad scenario.Thus, there is no wish to generalize studies, however, its contribution is in the deepening of the studied theme and in the understanding of care actions for the family members of psychoactive substance users, which reveals the importance of this research and of the analysis used.
Contributions to the fields of nursing, health, or public policies The practice of professional nursing along with family members of psychoactive substance users needs to look at the world those people live.On that basis, to establish care actions to constitute a face-to-face relationship, from their intersubjectivity.Thus, the contribution of Alfred Schütz to the nursing and health field refers to understand the other intensely (family member that seeks the service) in his/her human and social dimension in the world and in life, allowing to think and design care actions according to the needs, demands and context of each person.
Care actions for family members of users of psychoactive substances: intentions/expectations Siqueira DF, Terra MG, Vieira LB, Mello AL, Moreschi C, Soccol KLS.
We highlight the relevance of the findings in this research to be contemplated during the training of nurses.It is important that the nursing education is based in a learning process that allows thinking and discussion about care actions for family members of psychoactive substance users.We highlight, thus, that nursing professionals, along with the other health professionals, can develop extension projects in social spaces through educational activities focused on this theme.

FINAL CONSIDERATIONS
The findings in this research unfolded the reciprocity of perspectives between professionals' intentions and families' expectations.By analyzing the convergence between intentions and expectations described by the typical actions of both, it was revealed that there is convergence between intentions and expectations of the interviewed, as both intentions and expectations were based on the effectiveness of the user's treatment.
The expectations of family members regarding care actions are focused on effectiveness of treatment.Also, the family members feel welcomed, happy and thankful with the CAPS team, noting that the operative access to the service contributes to the user's treatment.And, if the user is fine, the family members also are.
It is believed that the findings of this research are opportune for reflections for the CAPS professionals on the health care actions, as well as the organization of the service aimed at the mental health of the relative, allowing thus the expansion of these findings in the consolidation of care in the scenario studied or in a similar one.It is also expected that the families' expectations exposed in this research become tools that can subsidize reflection, discussion, articulation and implementation of strategies of care to be developed by the professionals of the service, focusing in attending their demands and needs.
Their improvement, their [family] empowerment as individuals, as people, within the society.(P1)You have to understand how the use of the substance works, know that it is not shamelessness.It is a disease[…].We hope the family come to the service.(P3) Still, the professionals develop care actions to family members to improve the relation between family and user.That family Care actions for family members of users of psychoactive substances: intentions/expectations Siqueira DF, Terra MG, Vieira LB, Mello AL, Moreschi C, Soccol KLS.
So he[husband] can get better each day […].To see him well, and us too.(F1) So he [husband] keep on with the right treatment.That he does not relapse.Because we are too afraid of this, that he starts drinking again […] Coming to CAPS.(F2)

Figure 1 -
Figure 1 -Approximation between the intentions of Psychosocial Care Center for Alcohol and Drugs professionals and the expectations of family members of psychoactive substance users on the care actions for those families.