The social network of individuals under treatment at a psychosocial care center for alcohol and drugs ( caps ad ) : the ecomap as a resource

This study assessed individuals undergoing treatment at a Psychosocial Care Center for Alcohol and Drugs Abuse (CAPS ad) in Southern Brazil. There were 300 hours of participant observation and focal groups, in which the ecomap was used as an instrument to describe social support sources. The study objective was to identify the social network of individuals undergoing treatment due to drug abuse, promoting a reflection about the quality and situation of the bonds established with the people they considered important. The results showed a trajectory of separations and losses. The ecomap permitted to identify points of vulnerability in these subjects’ bonds, and is thus an ethical strategy that allows for a joint identification (between professionals and users) of the needs regarding the social, family, and individual contexts that should be addressed when planning health care, especially concerning mental health.


, Luciane Prado Kantorski 2 ABSTRACT
This study assessed individuals undergoing treatment at a Psychosocial Care Center for Alcohol and Drugs Abuse (CAPS ad) in Southern Brazil. There were 300 hours of participant observation and focal groups, in which the ecomap was used as an instrument to describe social support sources. The study objective was to identify the social network of individuals undergoing treatment due to drug abuse, promoting a reflection about the quality and situation of the bonds established with the people they considered important. The results showed a trajectory of separations and losses. The ecomap permitted to identify points of vulnerability in these subjects' bonds, and is thus an ethical strategy that allows for a joint identification (between professionals and users) of the needs regarding the social, family, and individual contexts that should be addressed when planning health care, especially concerning mental health.

KEY WORDS
Substance-related disorders. Mental health services. Social support.

RESUMEN
Se trata de un estudio desarrollado con individuos bajo tratamiento en un Centro de Atención Psicosocial de alcohol y drogas (CAPS ad) de la región sur de Brasil, a partir de 300 horas de observación participante y de grupos focales en los cuales se utilizó el ecomapa como instrumento para discriminar las fuentes de soporte social. El estudio tuvo como objetivo identificar la red social de los individuos bajo tratamiento por uso abusivo de drogas, promoviendo una reflexión sobre la calidad y la situación de los vínculos establecidos con las personas significativamente importantes para ellos. Los resultados colocaron en evidencia una trayectoria de separaciones y pérdidas; el uso del ecomapa permitió identificar los puntos vulnerables en los vínculos de estos sujetos, configurándose, por lo tanto, en una estrategia ética que posibilita la identificación conjunta (profesional y usuario) de las necesidades de ámbito social, familiar e individual a ser contempladas en la planificación de los cuidados de la salud, sobre todo en salud mental.

INTRODUCTION
The impressive, increasing use of drugs all over the world is contextualized by the characteristics of the post-modern world, with many changes in habits and values in several sectors of everyday life, especially regarding behavior. This phenomenon, with its social, physical, biological and psychological repercussions on the individual and in the family environment, becomes a considerable public health problem (1) .
The use of psychoactive substances often consists in an alternative found by the individual to deal with the stress caused by the family environment. Such stress in the family may be a consequence of dysfunctions in the expression of affection, dysfunctions in the establishment of limits and/ or the assumption of roles (2) . Therefore, the use of drugs as a way of dealing with problem situations is a complex phenomenon, which can be understood by analyzing the family and socio-cultural context and by assessing the risk and protection factors that support effective preventive actions (3) .
Although Brazil has made efforts to incorporate socio-economic and socio-cultural aspects in epidemiological studies, the dimensions related to the social support network still need to be explored (4) .
A social network consists in the structure that provides social support, i.e. it is the group of bonds (and their respective roles) related to the individual, either by family, friendship or acquaintance bonds; it could also mean a particular individual's chart of relationships, or a chart of relationships connecting people in a group (4)(5) .
Actions focused on the socio-cultural domain promote the creation, maintenance and strengthening of social networks. The analysis of the structure of such networks is relevant to lead people in physical suffering towards rehabilitation and treatment. The networks are intervention objects, allowing for the organization of personal and group experiences which, after being studied, will yield new and more adequate ways to intervene in the context (6)(7) . Study networks permit mapping the relationships between individuals or groups, starting with the direct contacts (8) .
Regarding the studies on such a construct, we criticize those using non-standard instruments, with overly global items that make it impossible to determine specific aspects of the individual's social network, such as: density, reciprocity, function or ratio between family and friends' support or lack of support. This lack of standardization, therefore, makes comparison with other findings impossible (5)(6)(7)(8)(9)(10) .
Conversely, in spite of the standardization of the instruments adopted, several measurements that are part of some studies do not consider the complex and multidimensional nature of social support; they examine, for example, a single, circumscribed type of social support, such as the perceived social support or the structural aspects of the support network (5)(6)(7)(8)(9)(10) .
Therefore, some of the prerequisites for the studies about social network constructs are: • Good conceptual development of the social support field; • Good operational definitions: instruments that allow for behavioral references instead of measuring support in a global, non-specific scope; • Good description of the measurement method; • Instruments that contemplate the support received and provided, as well as the structure, utilization and orientation of the social network; • Demographic information of the sample, such as gender, age, education, marital status and religion (5) .
Another issue regarding the social network construct consists in the lack of uniformity of the definition and concept of social support, since the social network theme has a complex, multifunctional nature, implying difficulties to measure it (5)(6)(7)(8)(9)(10) .
Social support consists in the existence or availability of people who can be trusted and who provide care, values and love; it contributes to positive adjustment, to the development of personality and to protection against the effects of stress (10)(11) . These are bonds of affection, consideration and trust, among others. Such bonds connect people who share social life and can influence the behavior and perception of individuals in the social network (12) .
Individuals with healthcare problems or disabilities usually need social support to reinsert themselves in the community. Therefore, the goal of social healthcare goes beyond treating symptoms, focusing on the reintegration of people to social life. Individuals who are integrated into their communities tend to live longer and can count on more resources to deal with and/or recover from physical, mental and social suffering affecting their health. This situation shows the current emphasis of social healthcare in the treatment of patients as social beings who share a complex context (13) .
Naming a social network, materializing it or simply talking about it consists in the first step to access it for therapeutic purposes, as systemic knowledge of this network allows for the planning of interventions that can become effective. In this stage, the individuals under treatment participate, aiming to activate, deactivate or mobilize the networks (6) .
These premises justify the choice of the instrument known as the ecomap for this study, because it details the The use of psychoactive substances often consists in an alternative found by the individual to deal with the stress caused by the family environment.

OBJECTIVE
This study aimed to identify the social networks of five subjects receiving treatment in a Psychosocial Care Center for alcohol and drugs, discriminating the supporting and stressing factors and promoting reflection about the quality of these individuals' relationships.

METHOD
This is a qualitative study, developed with five users at a CAPS ad (Psychosocial Care Center for alcohol and drugs) in the city of Pelotas, Rio Grande do Sul. The criteria used to select the subjects were: having attended the service for over three months; not having serious cognitive deficits; and accepting to participate in the study voluntarily, after receiving clarifications and signing the term of consent.
The study was performed with data collected from participative observations, medical records and a focus group, held in three meetings, whose discussions focused on the bonds these individuals share and their respective social networks. The instrument used to identify the social networks of the subjects was the ecomap.
In the participative observation, the observer places himself in the position and at the level of the subjects, and should become a part of the group as if he were one of them. As such, he will be better able to comprehend the habits, attitudes, interests, personal relationships and functional characteristics of the group (14) .
A total of 300 hours of participative observation were performed, where the observations were part of the day-today service, following both internal and external activities, registering the interactions, behaviors and attitudes of the users in the field journal, as well as the attitudes adopted by the professionals, the conflicts and other details.
The focus group consisted of 5 to 15 people, whose opinions and experiences are requested simultaneously. This technique has the advantage of yielding lots of dialogue, despite the disadvantage that some people do not feel comfortable in speaking to a group (15) . This technique is performed during group sessions, where several aspects of a specific topic are discussed. Such sessions should be guided by a moderator, who should encourage the participants to express their opinions and feelings about the issues and keep the discussion focused. The script with questions should be prepared according to the study goals and previously tested. An observer should also be present, in charge of registering non-verbal information expressed by the participants (16) .
Three sessions were held with the study participants. In the first meeting, the group members were introduced and some of the main concepts were explained. The discussions, in this session, were focused on the themes bonding/social networks.
The ecomap was used in the second meeting. The social networks were sketched by the subjects themselves, after being oriented about the meaning and goals of the instrument and receiving elaboration instructions. Next, subjects were invited to talk about their ecomap, providing a moment of self-reflection about their bonds and changes in their social networks during the process of addiction. The data were registered by an observer, and the group coordinator registered her observations, perceptions and feelings in the field journal after the sessions were over.
The ecomap, with the objective of representing the relationships of the individual and/or family with the other systems, is characterized primarily by its visual impact. To draw it, the family genogram is placed in a central circle, and other circles are drawn around it, representing people or institutions that contextualize the individuals and their families. Next, lines are drawn between the individuals and/ or family and the other circles in order to indicate the type of affective bonds that exist (17) . Therefore, the ecomap is configured as a pertinent instrument to analyze the social network of patients in rehabilitation individually. It shows a diagram of the family and the individual, associated to the systems that are part of the family life, allowing for an ecological-systemic visualization of the characteristics of the interactions and intensity of the bonds; it also shows the family support system, the sources of stress and fusion and the sources of care, outlining the relationships of the individuals in their situations of life (18) .
Then, the third meeting started with a synthesis of the previous meetings for the sake of data validation, and the contributions of the focus group were evaluated collectively.
The project was submitted to and approved by the Review Board of Faculdade de Medicina at Federal University of Pelotas (Protocol # 035/05).

DISCUSSION OF THE RESULTS
Regarding social networks, the Care Policy of Care for Drug and Alcohol Users requires the adoption of an enlarged healthcare perspective, prioritizing care in the community, healthcare education, involvement of community resources (community, family and users), bonds with other sectors, support for research and creation of human resources organized according to the Damage Reduction logic. Damage Reduction is a clinical-political approach, emphasizing behavioral changes through interventions focused on the construction of social support networks working in the territory (places where the individual usually goes to). It also aims at advancing the users' and relatives' autonomy

Souza J, Kantorski LP
through non-repressive resources, contemplating the defense of life. As such, it needs healthcare teams that are open-minded, flexible and able to work with other services (education, work and social promotion) (17) .
CAPS ad is a psychosocial healthcare service with a community and territorial focus, intent on helping patients with disorders resulting from the use of and addiction to psychoactive substances according to the damage reduction logic. As stated by the Ministry of Health (17) , CAPS ad offers daily care to patients who abuse alcohol and other drugs, allowing for therapeutic planning within an individualized perspective of continuous evolution. This service should be supported by psychiatric beds in general hospitals and other community healthcare practices (home care, community insertion and others). It offers three modalities of treatment: a) intensive -focused on patients who need daily monitoring due to their current clinical condition; b) semi-intensive -designed for patients who need frequent monitoring, as stated in their therapeutic plan, but who do not have to be present at the CAPS every day; c) non-intensive -care that can be delivered less frequently due to the clinical condition of the patient.
CAPS ad is open from 8 AM to 6 PM, from Monday to Friday, with a technical professional on duty on those days to provide service. The activities developed in these services range from individual service (drug-based therapy, psychotherapy and/or orientation) to group-based care, with therapeutic workshops and home visits. They should offer conditions for rest and outpatient disintoxication for those who need this type of care and do not require hospital-based attention. First, we propose a reflection about parts of the subjects' lives and an analysis of the ecomap representation, which yields basic information about the most deteriorated bonds throughout the history of alcohol and drug abuse. The ecomap also allows us to visualize the social network these individuals wove.

Subject 1
Started drinking at age 18, lives alone and his parents are dead. Had been divorced for 6 years, and a restraining order prevented him from seeing his children (alimony lawsuit). Upon being admitted at CAPS ad, he would not eat, would speak gibberish and would sometimes be found unconscious on the streets with amnesiac episodes.

Subject 2
At admission, he mentioned having used intravenously-injected cocaine and crack. At the time he was using cocaine through inhalation, marijuana, and sometimes alcohol. Mentioned aggressive behavior after drinking. Was hospitalized in a psychiatric ward at age 16 for using amphetamines and alcohol.

Subject 3
Upon admittance, was a chronic alcohol abuser, to the point of drinking pure ethylic alcohol. Was hospitalized three times in psychiatric wards. At age 39, he had a broken arm, and desperation due to not being able to work led him to drinking. Did not marry. Had a child in his youth, but did not assume the paternity. Currently, lives with his 84-year old mother.

Subject 4
Started drinking at age 19. Was hospitalized six times in psychiatric wards. Had been divorced for 17 years. His wife left home to buy rice and potatoes and never came back, leaving him to care for their two daughters. Sometimes he feels very depressed, sad and lonely. Currently he lives alone in a motel room paid for by his brother.

Subject 5
Started abusing alcohol after his first wife committed suicide. Pressures during his second marriage and the loss of his job increased his ingestion of alcohol. At the time of admittance, he was having an affair with another woman, but his wife decided to support him during the treatment.

Chart 2 -Subject history -Pelotas, RS -2005
It is worth noting that the choice for having the subjects draw the ecomaps themselves arose from the certainty that, even if a representation that did not correspond to reality were found, it could also be a way to communicate

Souza J, Kantorski LP
something subjectively -the desire to re-forge bonds, memories of a certain period in their lives or even the omission of a very difficult aspect of reality. However, such divergences, when detected, were noted in this study.
As seen in Figure 1, the ecomap provides a general overview of the significant relationships of the nuclear family with other people, institutions and agencies, yielding a perspective of the nature of such relationships (bonds that are ei-ther strong, superficial, stressing or supporting) and the flow of resources and energy in the relationships (as shown by the arrows). It is, therefore, a qualitative instrument of assessment, which can be used in many situations to assess the bonds connecting the individuals to significant people, as well as their opportunities to interact in order to obtain social support. It allows for the exploration of the role of social support in the healthcare process with selected populations, aiming to increase the care strategies (5) .
Has been divorced for six years. Has two children (one aged 7 and the other aged 10 years), whom he has not seen in seven months due to an alimony lawsuit. Reported that alcoholism caused the separation from his wife and children. Showed no bonds with 5 of his siblings; however, showed an ambiguous bond with a sister (a moderate and stressful bond at the same time). Said that she is very good to him when he is not drunk.

Family
The user meets his friends at weekends, when they decide on what they are going to do. He stressed the difference between acquaintances and friends. According to him, the latter are present in good and bad times, and few are like that. His circle of friends is restricted to the bar, predominantly.

Friends
Unemployed. The patient is exempt from having to pay the alimony while he is in treatment at CAPS. He felt very insecure about his discharge. Work

Mentioned fishing and soccer matches with his friends. Leisure
Goes home at weekdays after leaving the CAPS facilities, mentioning that he avoids going to the bar as much as he can. Watches TV and rests. At weekends, if he can afford it, goes to a dancing hall or goes out for walks.

Everyday Actvities
Believes in God, but has no specific religious bond. Religion According to the data, the issue of the children is a vulnerable spot in the situation of this subject. Even though he felt comfortable with the court decision regarding the alimony, he suffered a lot for not being allowed to see his children. He said that he felt unworthy of seeing them. As a disturbing factor, he also pointed out the fear of becoming frustrated when looking for a job. His self-esteem was very low, which could be seen in his conditions of hygiene and self-care.

Souza J, Kantorski LP
The importance of incorporating the social network construct in the nursing assessment is noteworthy, as it is essential to obtain data that are relevant for the current and potential support available to the family. Also, it would also aid in the development of realistic nursing interventions for certain needs. The interventions could be focused on social support deficiencies as well as personal/network deficiencies (5) .

LEGEND
The family bonds were represented as strong bonds, although not supporting. The patient mentioned being a child of his mother's first marriage, and his relationship with his mother and brother is rather rough. Separation from his wife happened due to his involvement with drug dealing. In spite of it, he has a good relationship with his ex-wife and his son, who lives with her. Has a strong bond with his sister, but she lives in another state.
Mentioned not having friends, only acquaintances in the places where he lived. His son is the only person he considers a friend.

Unemployed.
Fishing, sports and listening to music.
On weekdays, after leaving CAPS, takes a walk to see what is going on and goes home. At weekends, watches soccer matches in the field across his house and goes to the main avenue, where he can always find an acquaintance.
Believes in God, is a catholic, but does not attend church.
Identified the CAPS bonds as supporting, although moderate. The strongest point of Bill's social network is his son. About four months ago, the subject asked to leave the CAPS for one week to see to family problems. According to him, his son had had a judicial problem and was admitted into the Youth Welfare Foundation -Fundação de Bem-Estar do Menor (FEBEM). In the same month, the patient attempted to commit suicide due to financial and family problems. At the time, he was receiving benefits from the government's social security fund.
Everything considered, it is noted that a careful assessment of the situation allows for the definition of the real bases of the problem and, from there, creative solutions can be developed through direct contact with potential sources of support, mobilizing the sources that are appropriate to each situation. Therefore, it is important to consider the community and family context of the patient carefully when planning nursing actions, as well as the empowerment of individuals and groups, the development of interactions between individuals, families and other systems, the joint elaboration of plans about how the individual can help himself (becoming responsible) or be helped by other people. In addition, the possible changes in the capacity of the social networks to provide support should be taken into account, due to the transitions of life, fatigue, disease, accumulated stress and other factors (5) .

Souza J, Kantorski LP
Mentioned having a good relationship with his family. While he was drawing the ecomap, he would draw and erase it several times, uncertain about how to represent his nuclear family. He decided to represent the relationship he had and the divorce. He was uncertain about how to represent his son, who he does not know. He drew it as a lone circle, without bonds, and then he erased it, with his failed relationship remaining in the ecomap.
Has little contact with his friends, saying that he preferred it this way since all of them abuse alcohol.
Works in the income-generating workshops as a craftsman.
Reading. Before starting treatment at CAPS, he and his friends had barbecues together every weekend.
Is under intensive treatment at the CAPS on weekdays, attending swimming lessons once a week. After the CAPS activities, goes straight home and spends the weekends there with his mother, reading or working on handicraft activities.
Was an Adventist until 12 years of age. Nowadays, attends the Spiritist center, where he meets the same people on a regular basis, but has no closer relationships with any of them.
Identified CAPS, his neighbors and his family as supporting bonds. As observed, the subject lives with his 84-year old mother. He is single, has no girlfriend and does not relate with his friends. Prefers individual activities, both at CAPS and in his everyday routine. The patient drew no stressful bonds in his ecomap; we believe that his source of stress is related to his own loneliness.
Such a fact highlights the need to plan actions that help in the socialization of this subject, as well as nursing interventions focused on increasing the quality of social support, since the negative effects of stress are reduced in the lives of individuals with strong social support systems (5) .

LEGEND
Did not talk much about his family. Mentioned having a good relationship with his sisters and a stronger bond with his brother, who brought him to the CAPS. After his divorce, he stayed with his daughters, but he does not live with them nowadays, seeing them every 15 days. Hardly ever sees his daughter from the second marriage, when she is going to school, but without her knowledge.
Mentioned having friends everywhere. Particularly, mentioned a friend at CAPS (who also took part in the study, but did not mention this subject as a friend), with whom he talks a lot. He also has good relationships with his neighbors.
Participates in the income-generating workshops, where he is taking a course on herbal medicine.
Used to go to the beach with his girlfriend. However, he broke up with her for fear of becoming more involved. Mentioned that the leisure activity is deeply associated with the financial situation.
In addition to being at CAPS everyday, he attends the Spiritist religious center on Mondays, Wednesdays and Fridays, and goes to the Cathedral twice a week. In addition, he attends the Alcoholics Anonymous (AA) sessions from 8 to 10 PM. Mentioned feeling very depressed and lonely at weekends.
Often goes to the Spiritist center and goes to the cathedral, but he has a very superficial bond with the people there.
Identified CAPS, the AA group and his family as supporting bonds. The user identified no stressful bonds. He represented the family bonds as strong and supportive, which seems to be coherent with his attitude, intent on showing that everything is fine. Looking at his ecomap, it is possible to see an ideal family outline, in spite of the separation. However, looking at the representation, which is probably idealized, it is clearly not coherent with his state of isolation and loneliness. This state is made evident when the patient speaks about the weekends and his everyday activities.
On the other hand, we believe that such an idealization may be a resource to heal the losses that occur in the indi-vidual imaginary, language and the space where our reality is built (6) .
This factor shows that, although the ecomap is a tool to explore the social network, a more effective access to the need for support of both the individual and the family may be made easier with a deeper comprehension about the many components of the social network, through the implementation of informal techniques and the use of formal questionnaires to obtain information (18) .

LEGEND
Has a good relationship with his family, an especially strong bond with his father, one of his brothers and his daughter. Did not mention the bond with his wife: this indicates a vulnerable bond due to the situation with the current partner, who was not drawn on the map either. He mentioned that the relationship with his wife has improved significantly, but that they had been apart for one year and he noticed that this conflict affected his daughter deeply. After starting treatment at the CAPS, he noticed that he became closer to Except for those people with whom he has contact at the CAPS, he spends most of his time with his relatives. Until some time ago, he had a few friends with whom he used to talk and go dancing. Later, each of them went their separate ways. Nowadays he only considers his relatives as friends.
Participates in the income-generating workshops, where he is taking a course on recycling.
Reading, doing crosswords and spending time with his daughter.
Practiced umbanda for several years. Angry after the suicide of his first wife, he blamed the religion and said having lost his faith. After some time, started following Spiritism.
Identified CAPS and his family as supporting bonds.  The subject presented considerable family support; his wife always stands by him, both when he goes to the CAPS and when he goes back home, and she is also a member of the Group of Relatives. This factor is very important for the treatment, as the patient is being prepared to be discharged from the intensive modality. It is worth noting that, within the group, this user is the only one who has a family member monitoring the treatment. Curiously, he is also the only one who is not definitely separated from his wife.
According to these data, it is observed that the healthcare service could indeed become a formal source of support, providing direct emotional support and assistance to the families to assess their specific support needs and promote the use of their own natural support systems (5) .

Final assessment of the focus group
At the end of the focus group, the subjects were invited to evaluate their feelings regarding the construction of the ecomap and the contributions extracted from the meetings. The fact of having the ecomaps built during the focus group was curious. Even though some information was omitted, the subjects compared the conditions of the others to their own by looking at their ecomaps, looking at the quantity of bonds, support and separations.
Some of them were in such grief when they had to draw their current supporting bonds, as this would have them reflect on their severed bonds directly, that they idealized a social network that was marginally bearable. Such a situ-