Adolescent users of psychoactive substances: experiences and challenges during psychiatric hospitalization

Abstract

Introduction

The scope of care and adherence to treatment of adolescent users of psychoactive substances (PAS) is a challenge for professionals and researchers. Understanding the situational contexts and itineraries taken by adolescents can assist in searching for solutions to this problem.

Objective

Identify the experiences and challenges during psychiatric hospitalization from the perception of adolescent users of PSA.

Method

This is an exploratory, qualitative study conducted with four adolescents with a history of psychiatric hospitalization, linked to two Psychosocial Care Centers - alcohol and other drugs (CAPSad) in different cities in the interior of the state of São Paulo, Brazil. Data were collected through semi-structured interviews on substance use, life paths and context, therapeutic itinerary, and experiences during hospitalization. The responses were fully transcribed and analyzed using Bardin’s Content Analysis method.

Results

The results showed an early start of PAS use, experiences of PAS abuse, vulnerability in the socio-family context, and a history of involuntary hospitalizations. The main challenges experienced and reported by these adolescents during hospitalization were: confinement associated with the long seclusion period, distance from family, lack of safety, and lack of therapeutic approaches.

Conclusion

It has become evident that there is a significant challenge in integrating adolescent users of PAS into the Psychosocial Care Network devices within municipalities, as well as into the processes of coordination and accountability of proper care. There is a discrepancy between what is recommended and indicated in public policies and the premises of psychosocial care versus the actual reality of adolescents in psychiatric hospitals.

Keywords:
Adolescent; Drug Users; Substance Use Disorders; Involuntary Treatment; Psychiatric; Occupational Therapy

Resumo

Introdução

O alcance do cuidado e a adesão ao tratamento de adolescentes usuários de substâncias psicoativas (SPA) é um desafio para profissionais e pesquisadores. Compreender os contextos situacionais e os itinerários percorridos por adolescentes pode auxiliar a busca de soluções para essa problemática.

Objetivo

Identificar as experiências e desafios durante a internação psiquiátrica a partir da percepção de adolescentes usuários de SPA.

Método

Estudo exploratório, qualitativo com a participação de quatro adolescentes com histórico de internação psiquiátrica, vinculados a dois Centros de Atenção Psicossocial - álcool e outras drogas (CAPSad) em diferentes cidades do interior do Estado de São Paulo, Brasil. Os dados foram coletados por meio de entrevistas semiestruturadas abordando uso de SPA, percursos e contexto de vida, itinerário terapêutico e vivências durante a internação. As respostas foram transcritas na íntegra e analisadas pelo método de Análise de Conteúdo de Bardin.

Resultados

Os resultados evidenciaram início precoce do uso de SPA, experiências de uso abusivo de SPA, vulnerabilidade no contexto sociofamiliar e histórico de internações involuntárias. Os principais desafios vivenciados e retratados por esses adolescentes durante a internação foram: confinamento associado ao longo período de reclusão, distanciamento familiar, falta de segurança e carência de abordagens terapêuticas.

Conclusão

Evidenciou-se dificuldade de inserção dos adolescentes usuários de SPA nos dispositivos da Rede de Atenção Psicossocial dos municípios, assim como nos processos de articulação e responsabilização do cuidado. Há uma discrepância entre o que está preconizado e indicado nas políticas públicas e nas premissas da atenção psicossocial em comparação com a realidade de adolescentes internados em hospitais psiquiátricos.

Palavras-chave:
Adolescente; Usuários de Drogas; Transtornos Relacionados ao Uso de Substâncias; Tratamento Psiquiátrico Involuntário; Terapia Ocupacional

Introduction

The use of psychoactive substances (PAS) was identified by the United Nations Office on Drugs and Crime (UNODC) as a serious and growing public health problem. This assertion was based on findings from the World Drug Report for the year 2021, which indicated that 284 million people aged between 15 and 64 had used some PAS, and a significant portion of them had developed some kind of related disorder. The report also showed a significant increase in the use of these substances among young people, as well as a rise of 9 million in the number of marijuana (cannabis) users in one year (United Nations Office on Drugs and Crime, 2022).

In the Brazilian scenario, the situation is no different. According to statistical data from the III National Survey on Drug Use by the Brazilian Population, conducted by the Oswaldo Cruz Foundation in 2017, 15 million Brazilians had used some illicit substance in their lifetime - the median age of first use was 16 years. These adolescents reported greater ease of access and acquisition of substances such as cocaine, crack cocaine, and steroids compared with those over 18 years old (Bastos et al., 2017). Some authors have stated that these disorders are multicausal and multifactorial, therefore, of high complexity and challenging treatment (Miranda et al., 2018; Silva et al., 2021).

Frequently, young people tend to glorify drugs, so their use can be appreciated, recognized, and validated by the group, increasing their chances of starting using them based on a sense of belonging (Duan et al., 2009).

This aspect is reinforced by the UNODC, which points out that adolescence (12 to 17 years old) is the critical risk period for the initiation of PAS use (United Nations Office on Drugs and Crime, 2019).

The abusive and uncontrolled use of PAS by adolescents is concerning due to the physical, psychological, social, and occupational damages caused. It is also generally associated with the development and worsening of mental disorders, involvement in criminality, and dropping out of school, among other issues (Raposo et al., 2017).

In Brazil, the Unified Health System (SUS) offers drug users treatment in services/devices from the Psychosocial Care Network (RAPS). RAPS was established through ordinance No. 3.088/2011 and is configured as an arrangement of services and territorial strategies aimed at comprehensive and continued care, encompassing different levels of technological density and complexity. RAPS is present in Primary Health Care, Specialized Care, Emergency and Urgency Care, Transitional Residential Care, Hospital Care, and Deinstitutionalization and Rehabilitation strategies. This proposal arises in opposition to isolated curative actions and the fragmentation of programs and clinical practices (Brasil, 2011).

Specifically for PAS users, treatment should preferably occur in the Psychosocial Care Centers - alcohol and other drugs (CAPSad). This device belongs to the specialized and strategic care of RAPS. Regarding CAPS, it should be mentioned that they are open-door services, where teams, users, and families come together to construct a personalized therapeutic project (PTP). In this sense, the PTP is established as an essential tool in care, as it incorporates a set of combined therapeutic proposals resulting from discussion/agreements between the multidisciplinary team, the individual, and their family (Brasil, 2011).

Nevertheless, it is worth highlighting that, in recent years, especially during the Jair Bolsonaro administration (2019-2022), the divestment in contributions to public mental health policies evidenced strategies to dismantle the sector, clearly regressing towards care practices that have been demonstrably outdated and ineffective. Such regressive actions and the absence of guaranteed rights are illustrated in ordinance No. 3.588, dated December 21, 2017, which includes psychiatric hospitals in RAPS (Brasil, 2017).

Psychiatric hospitals are characterized as closed-environment institutions that serve PAS users and people with mental disorders in three modalities: voluntary, in which the user is aware of the need for treatment; involuntary, where admission is usually requested by the family and/or legal guardian and is carried out against the user’s will; compulsory, in which admission is mandated by the court based on a medical report, claiming protection for the user and society.

Beyond these characteristics, these setbacks point to the return of the “Madness Industry”, where treatment expenses are directed to hospital bed funding and, to a lesser extent, to community devices (Pitta & Guljor, 2019).

Some authors have suggested that these setbacks not only imply the reversal of public health spending but also the abandonment of successful strategies, such as harm reduction and open-environment care (Pitta & Guljor, 2019; Lussi et al., 2019).

It is well known that harm reduction does not focus solely on reducing drug use, but also involves preventing and reducing harm to SPA users’ health, which is a strategy employed in dozens of countries (Beg et al., 2015). However, offering a treatment based on harm reduction is only possible through a network of structured services and devices that ensures users a therapeutic itinerary considering the continuity of their care post-discharge.

Given the aforementioned points, which encompass the multifactorial nature and complexity involved in treating chemical dependency, as well as the various social actors involved in the care process (user, family, professionals, and services), it is evident the relevance of continuing investigative studies on aspects associated with PAS use and possible deficiencies that treatments have demonstrated from this population’s perspective.

Associated with this factor is the scarcity of studies considering the subjects’ opinions on the received treatment; typically, research reports the viewpoint of professionals and managers (Messias et al., 2020). This finding underscores the lack of studies that value the user’s experience in mental health services.

Considering the perspective of adolescents about their treatment is an essential tool in adapting services so that they meet their choices and needs.

In this context, this study aimed to identify the experiences and challenges during psychiatric hospitalization from the perspective of adolescent users of PAS.

Method

This is a qualitative exploratory study. This type of research aims to develop, clarify, and modify concepts and assumptions and subsequently formulate objective questions that support future studies. Thus, it aims to provide a general overview of a certain fact (Gil, 2008).

It is worth noting that this article is part of a master’s thesis that aimed to identify the experiences of adolescent PAS users during their psychiatric hospitalization at CAPSad.

The study was submitted for analysis to the Ethics and Research Committee of the Federal University of São Carlos (UFSCar)—Certificate of Presentation for Ethical Consideration (CAAE) 39624920.8.0000.5504—and approved under opinion No. 4.477.341. All ethical aspects that ensure voluntary participation, confidentiality, and anonymity were met. It should be emphasized that the contents of the Informed Consent Form (ICF) and/or Assent Form (AF) were explained to the participants, who signed the document and received a copy also signed by the researchers containing their respective contacts.

The study sample was composed of four adolescents aged 17 to 18 years, with a history of psychiatric hospitalization for chemical dependency treatment, and being attended to at CAPSad. The following inclusion criteria were adopted: being between 12 and 21 years old, being linked to a CAPSad at the time of data collection, having a history of PAS use, and having one or more hospitalizations for PAS use treatment. Exclusion criteria were as follows: being under the effect of PAS at the time of data collection and presenting cognitive impairment diagnosed by service professionals.

The study was conducted in two CAPSad belonging to RAPS in different municipalities in the interior of the state of São Paulo, both regularly registered in the National Registry of Health Establishments (CNES). The selection of the municipalities was due to the circulation difficulties imposed in the first year of the COVID-19 pandemic and, therefore, for convenience.

One of the CAPSad was located in a medium-sized municipality, with approximately 240,000 inhabitants, which had a Regional Health Department (DRS), responsible for formulating and evaluating the Municipal Mental Health Program in conjunction with the Management Group of the Municipal Health Department, a specialized Mental Health outpatient clinic, a CAPS II, a CAPSad II, a CAPS II - children and adolescents, a psychiatric ward with 18 beds in a general hospital, and a psychiatric hospital. However, care for adolescent PAS users was only provided by the CAPSad II. In this study, this municipality will be called A. The other CAPSad was located in a small municipality, part of the same DRS as municipality A, with approximately 44,000 inhabitants, which had 12 Family Health Units, a psychiatric hospital as a reference for psychiatric admissions, a CAPS I, and a CAPSad I. This municipality will be called B.

Data were collected using two instruments: a form to characterize the socioeconomic profile of the users and their families, and a semi-structured interview.

The interview script was divided into two sections addressing different themes. In the first section, PAS use was addressed, allowing the identification of the start of use, types of substances previously used, characterization of use, its historical context, and impacts. The second section addressed the trajectory in health services, psychiatric hospitalization (type, institutional dynamics and routine, care professionals, hospitalization limitations, service evaluation), and experiences during hospitalization.

The contact with the participating institutions began in October 2020, aimed at gathering information about procedures for the research development request. After authorization from the Assistance Director, Health Education Management, and Superintendence, data collection procedures commenced. Due to the social distancing period and the adoption of restrictive measures, the researcher could not remain on-site in the services. However, contact was maintained with some professionals from each location to identify potential participants.

Upon arrival at the services, alongside a professional from both CAPSads, the adolescents and their families were invited to participate in the study. They were provided with information about the research objectives, its stages, duration of the interviews, and confidentiality assurances. After agreement, clarification of all doubts, and signing of the consent forms by the adolescents and their families, the adolescents were led to a room provided by the service to conduct the interviews. All COVID-19 safety protocols were strictly followed. The interviews were conducted between February and May 2021, individually, without the presence of family members, and lasted 30 minutes on average. A mobile phone and a portable recorder were used to collect the participants’ statements.

The responses were analyzed using the Content Analysis technique proposed by Bardin (2016). The content of the interviews was transcribed in full and then meticulously read to understand the meanings and identify the core ideas. After identification, the contents were grouped into two thematic categories: “Trajectory followed until the current care” and “Experiences and challenges faced during hospitalization”.

Results and Discussion

Initially, we will provide an overview of the participants, followed by an exploration of the two thematic categories.

Participants’ profile and history of PSA use and treatment

The study participants were given pseudonyms: Luiz, João, Ana, and Vitor. All began using PAS at an early age, between 12 and 16 years old. All reported the use of multiple substances, mostly illicit, with a prevalence of marijuana and synthetic drugs, followed by cocaine. There was a context of socioeconomic vulnerability among their families. The details of each participant are described below.

Luiz: An 18-year-old who completed high school. He lived in municipality A with his mother and three younger siblings. His family’s socioeconomic situation was challenging, living in a rented house, receiving government emergency aid, with his mother being the sole income earner. He began using PAS at 14 as a coping mechanism for family conflicts. He used marijuana, synthetic drugs (Ecstasy, LSD, PCP, and ketamine), and cocaine. He had legal issues due to theft. He first received care at CAPSad, which requested a court order for psychiatric hospitalization.

João: A 17-year-old high-school freshman. He lived in municipality A with his father and stepmother and has a one-year-old child. His family lived in a rented house, and every family member, including João (who collected used oil), worked. He began using PAS at 14, driven by curiosity. He used marijuana and synthetic drugs (Ecstasy, LSD, and ether spray). He voluntarily underwent psychiatric hospitalization three times and never had legal issues.

Ana: A 17-year-old high-school senior. She lived in municipality A with her mother and stepfather. The family lived in a rented house, with both her mother and stepfather being retirees. She began substance use at 12, having used marijuana, synthetic drugs (LSD and ether spray), and cocaine. Peer influence and curiosity led her to start. She had been involuntarily hospitalized in a psychiatric hospital three times, which was her first form of treatment. She never had any legal issues.

Vitor: An 18-year-old undergraduate living in municipality B with his mother and grandfather. They owned their house, with only his mother working. He began using PAS at 16, wanting to fit in with his peer group. He used marijuana, synthetic drugs (LSD), cocaine, and alcohol. He received treatment for PAS usage, referring to CAPSad as the starting point for his hospitalization process. He was involuntarily admitted to a general psychiatric ward once and had a history of legal issues due to bullying.

Despite the small number of participants in this study, the data collected here are similar to those of other studies, showing that the predominant age range in the analysis of the adolescent population assisted at CAPSad is from 15 to 19 years old (Gonçalves et al., 2019; Araujo et al., 2012; Mendes, 2020). Likewise, the participants’ reports about their living, working, and family conditions show that these young people are socially and economically vulnerable and experience complex family realities. This relates to aspects highlighted by studies that focus on risk and protective factors associated with PAS use. They point out that socioeconomic conditions, family experiences, and situations, among others, are risk factors for PSA use (Pratta & Santos, 2006; Paiva & Ronzani, 2009; Cid-Monckton & Pedrão, 2011).

Regarding the educational situation, unlike other research (Galhardi & Matsukura, 2018; Oliveira et al., 2022), the results of this study indicate that the participating adolescents have completed their studies or still maintain a school link. However, it is worth noting that all four participants reported several school changes throughout their journey; but despite this, they either graduated or continued in school. While it is not possible to specify the reasons that led to these repeated school changes, the literature indicates that problems related to the school environment, such as failures, expulsions, and low academic performance for their age, seem to occur regularly among adolescents who use PAS. This suggests that this situation demands urgent preventive actions (Andretta et al., 2014; Araujo et al., 2012; Oliveira et al., 2022).

Three of the four adolescents who participated in this study were men, corroborating recent research that points to a predominantly male pattern of young PAS users at CAPSad (Mendes, 2020; Oliveira et al., 2022). Researchers in the field have indicated a lack of studies involving the female population and PAS use (Galhardi & Matsukura, 2018; Menezes & Pereira, 2019). Therefore, it is essential to highlight the need for investigations that can also delve deeper into experiences and specificities concerning gender diversity and access to healthcare in situations of abusive PAS use.

It should be emphasized that adolescents began using multiple substances very early, with marijuana being the most prevalent among them, followed by LSD, cocaine, and both ether spray and ecstasy equally. The results support studies conducted with adolescents in CAPSad, which report that marijuana is the most prevalent illicit substance among this population (Araujo et al., 2012; Mancilha, 2015; Silva et al., 2014; Vasters & Pillon, 2011).

Next, we present the results derived from the analysis of interviews with adolescents based on the two identified categories.

Trajectory followed until the current care

Involuntary hospitalization was a common aspect for three (Luiz, Ana, and Vitor) of the four participants, occurring as a result of family demands, judicial orders, or even at the request of CAPSad; thus, these adolescents were prevented from freely exercising their right to choose - only João chose voluntary hospitalization:

Look... at first, I went against my will. It was ordered… (Luiz).

It was my family… (Ana).

Well, it was actually CAPSad that decided. Because I was really freaking out here, right. So, they decided that I was going to be hospitalized (Vitor).

When was the first time? I had the first hospitalization last year. I wanted to. I decided to get the treatment (João).

Paradoxically, we noticed that the adolescent’s admission to the hospitalization system also came through CAPSad. This information highlights the absence of territorial services in these adolescents’ circuits, culminating in their hospitalization. The study by Ribeiro et al. (2019b), which aimed to analyze the trajectory of adolescent crack cocaine users until they arrived at CAPSad, corroborates the findings of this research. They identified that the services most frequently used by adolescents present a culture of asylum treatment. Additionally, public community health and protection services are rarely utilized.

This study found that the adolescents had already gone through CAPSad before the hospitalizations, and despite these visits, two of the participants underwent several hospitalizations (3) still as adolescents.

The reasons related to the demand for hospitalization were another aspect highlighted by the adolescents:

Before the hospitalization, I was already coming to CAPS. They [CAPS] even went to the judge, asking for a judicial order and everything. [...] I was already addicted; I didn’t want help (Luiz).

Well, because my family’s situation was going downhill... nobody trusted me anymore, nobody wanted to trust me... believe in what I was saying, so I decided to ask for help... (João).

I wasn’t able to communicate very well because I was having a crisis, and she (the doctor) was trying to find out what was wrong with me. Then my sister said... that I had used marijuana, and I had been without it for a while, that’s why I was freaking out. Then, after... after a lot of fighting here and moving around, they ended up hospitalizing me (Vitor).

Araujo’s (2018) study aimed to understand how the meanings of involuntary or compulsory hospitalization of PAS users were constructed with their families. Among the results, it was found that involuntary hospitalization was sought by families as a tool to educate users since they would remain abstinent to avoid another hospitalization. Due to the progressive context of abusive PAS use, involuntary admissions were seen as a way to achieve immediate abstinence. For families, hospitalization was also seen as a way to care for users, aiming to eliminate characteristics that lead to their greater stigmatization, such as lack of hygiene and association with people living on the streets. Similarly, hospitalizations were viewed as a relief for families, offering users a period without PAS use, since family members were overwhelmed by conflict situations with them. The hospitalization time also allowed the family to reorganize minimally.

As if the issue of hospitalizations was not challenging enough, the situation is further complicated by judicial intervention. According to Guareschi et al. (2016), after the “treatment” is completed, the adolescents return to the same vulnerable contexts, receiving only medication and having only therapeutic communities and mental health services as future paths and life projects. The procedure of compulsory hospitalization, together with the diagnostic class that legitimizes it, is imposed on adolescents and begins to govern their everyday lives when they are recognized as individuals who require specialized care to move freely because of a supposed “illness” present in their bodies (Guareschi et al., 2016).

Hospitalization seems to be a punctual treatment alternative, where a reductionist and moralistic view predominates, neglecting the uniqueness of individuals and infringing on their rights to freedom, dignity, culture, and family and community life as provided for in the Statute of the Child and Adolescent (ECA) (Brasil, 1990). Furthermore, there is no construction of a Therapeutic Service Plan (TSP) focused on post-discharge care in RAPS, complicating the therapeutic itinerary that the adolescents should follow. In short, this circuit ends up directing adolescents towards certain life paths governed according to economic needs and supported by the argument of care.

As often observed, when hospitalization does not occur through judicial means, it happens at the family’s request. Reflecting on the family’s need regarding the practice of hospitalization—a phenomenon that persists to this day—leads us, among other aspects, to the role of the family as the first institution of discipline, responsible for correcting certain behaviors and which, when faced with unsustainable situations, turns to a higher authority, like medical power and hospitalization (Foucault, 1987).

On the other hand, involuntary and/or compulsory hospitalizations are sought by families because they do not believe it is possible to control drug consumption within their homes. Thus, hospitalizations are seen as a form of protection, as they remove the drug user from a risky context (Araujo, 2018; Paula et al., 2017).

However, working with families in the mental health scenario remains a challenge in these services, raising difficulties in family relationships, which may encompass the interdiction and/or invisibility of the rights and autonomy of users (Assad & Pedrão, 2011; Ferreira et al., 2022).

Another hypothesis regarding this admission to the health system through hospital care instead of primary care is pointed out in the study by Araujo, 2018, which aimed to understand how the meanings of involuntary and/or compulsory hospitalization of alcohol and other drug users are constructed with their families. She shows that forced hospitalizations were seen as a way to achieve abstinence, given that this type of intervention was valued, for years, as the only and best way to care for SPA users. However, this conception ended up contributing to blaming the user for the problem.

Teixeira et al. (2021) analyzed the first hospitalization experience from the perspective of families. Psychiatric hospitalization is indicated when the behaviors of users endanger their integrity (moral and/or physical) or that of others (Braga & Pegoraro, 2020). The narratives of the families showed that there is no differentiation in the care provided for the user in acute or crisis situations, the chronic patient, or those in their first hospitalization. The dynamics of the work process remain the same, without any exceptions or prioritization of first-time hospitalization cases and the impacts of this hospitalization in a closed-environment and disciplinary institution (Teixeira et al., 2021).

The establishment of a comprehensive service network acting in crises still requires investments. The failure of communication between services, the difficulty in selecting and directing cases, the low number of CAPS III, and the deficit of teams, among other issues, have contributed to making the hospital still appear to be a viable alternative for solving these challenges (Roquette, 2019).

Experiences and challenges experienced during hospitalization

A recurring theme identified among adolescents when discussing their hospitalization experience was the strict routine and the lack of meaningful and diverse activities during their stay. The monotony of the daily routine during hospitalizations was particularly highlighted concerning meal times, medication schedules, and occasional professional care sessions. The adolescents’ accounts underscored a lack of enjoyable activities tailored for their age group, as well as a failure to grasp the significance and purpose of the treatment, as illustrated by the comments by Ana and Vitor:

We would wake up and... breakfast was at eight. After that, in this last hospitalization, there was an occupational therapy session, then lunch at eleven, afternoon tea at three, dinner at five, and supper at eight in the evening. There was... there was the physical educator, and... Gosh... Occupational therapy, physical education, sessions with the psychologist, meetings with the social worker (Ana).

I used to wake up in the morning, make my bed, brush my teeth, and then take my medication. Then I would read until lunchtime, take a shower after lunch. In the afternoon, I used to have tea, and take medication in the evening. Then there was supper, and then sleep... There was... there was a small group, sometimes for chatting, sometimes for making a recipe, drawing, painting... they always had an activity for us (Vitor).

A concerning revelation was made by Luiz, who stated that he used drugs during his hospitalization:

Because there were drugs, you know. So... just because I was inside a psychiatric hospital doesn’t mean there won’t be drugs... there were! The place, the people, the nurses... regarding the nurses, they were quite nice... but, not all the nurses thought the same way. Some even smuggled drugs for us inside... I don’t think it would be relevant to mention which nurse did this, but... it usually happened (Luiz).

It is alarming to think that drugs can be accessed in an institution that supposedly aims for complete abstinence through isolation. Luiz’s account suggests that cases of negligence and lack of safety are commonplace during hospitalizations and are even more concerning when linked to the conduct of professionals responsible for care. Luiz’s testimony exposes practices that are, at the very least, abusive, underscoring the urgent need to address behaviors that resemble those of total institutions, diametrically opposed to the principles of Brazilian psychiatric reform and psychosocial care. A hardship commonly cited by all these adolescents during hospitalization was the separation from their families.

Ah, the longing. Longing for the family [...] (Luiz).

Of my family... And the drugs, of course... (Ana).

My family... My son... (João).

Another frequently cited challenge was the feeling of confinement, as well as incidents related to security concerns and aggressive behaviors from other patients:

[...] In the adult ward... that’s where the visits took place. So it was a pleasant atmosphere, I got to leave my area a bit, which was ward 2, so like... because we’d just move from the room to the dining area and back, it was... complicated (Luiz).

The mere fact of being there. Ah, because you’re deprived of your freedom [...] (João).

Ambivalent feelings during hospitalization were evident in the adolescents’ accounts.

There was discomfort due to feelings of imprisonment and lack of freedom. However, for Luiz, his confinement was permeated by ambivalent feelings, particularly when he spoke of the fleeting relief of leaving his ward, even if it did not mean leaving the hospital premises. This mirrors the findings from Ely et al. (2014, 2017). In these studies, patients recounted mixed feelings such as sadness and happiness, imprisonment and freedom, when discussing their psychiatric hospitalizations.

Similar sentiments were noted in studies by Ely et al. (2017) and Cruz (2019), which aimed to understand the perceptions of patients hospitalized in the psychiatric ward of a general hospital concerning their treatment. These studies showed that feelings of pain, distress, persecution, imprisonment, and anxiety were often experienced by the patients during their hospitalization. The restrictive environment, reminiscent of a prison, was also noted as a negative aspect.

These observations are diametrically opposed to the tenets of psychosocial care. Therefore, there is an urgent need to move away from traditional treatment approaches based on isolation and segregation. For genuine care to occur, it is imperative to recognize and honor the individual’s freedom, dignity, and uniqueness. As emphasized by Ferreira et al. (2017), the primary goals of care are to advocate for life, promote citizenship, and ensure community participation and belonging - dimensions that cannot be addressed in a treatment rooted in confinement.

And... in there, if... there were rules, If you didn’t follow them, you’d get ‘salved’. What’s ‘salved’? Typically, someone would keep watch at the door, and 2 or 3 would be in the bathroom, usually the ‘Jet’ - the person responsible for maintaining order, and the enforcers, ‘first voice’, ‘second voice’, all that nonsense... You’d stand in the bathroom with your hands behind your back, if you moved them in front, it’d be worse, and once... they told me to help them climb the wall because they wanted to get some weed and inhalants, and like... I fell, fell hard, kind of blacked out, but that wasn’t reason enough for me to be punched a hundred times in the chest. It was a hundred. They counted, that’s how I know. Because it’s... like, 10 punches from each person... and... they keep going until they reach one hundred. It happened more than once, twice actually... I... was threatened [...] they wanted to establish dominance, to feel the power, you know... and these guys... if you went against what they preached, you’d... simply get beaten up [...] seriously... it was like... in prison they say it’s the ‘dog’s law’, it was similar during hospitalization (Luiz).

Furthermore, from Luiz’s account of his hospitalization, there is a clear reference to practices, terminologies (salved, enforcer, Jet), and principles derived from the drug-trafficking world, underpinned by specific discipline and violence (Biondi, 2018).

The violent experiences lived by Luiz resemble the code of conduct of the First Command of the Capital (PCC). Similar terms were found in the research by Ribeiro et al. (2019a), which described prison sociability in the penitentiary system. That study shows that “brothers” and “partners” relate in the PCC pavilions based on the imposition of strict disciplinary rules set by the faction, making immediate punishment inevitable for any misconduct.

The “Jets” and the “disciplines” are entities responsible for maintaining internal organization and order. The role of the “disciplines” is to teach the norms of the PCC’s statute and to oversee and monitor the prisoners’ behavior. In this context, Ribeiro et al. (2019c, p. 228) state:

When instances of misconduct (exchanges between inmates, drug debts, fights, arguments, etc.) arise or are detected in daily interactions, the members of the discipline group summon those involved, request the drafting of reports on each side’s case (accusation and defense), and finally, send the reports to the “Jets” for analysis and to call in the parties for “judgment” depending on the severity of the event.

As observed, although this study does not deal with the prison system, but with a psychiatric hospitalization unit, it is understood that the terminologies related to the world of drug trafficking were present during the hospitalization of at least one of the adolescents. Even more crucially, it should be highlighted that these adolescents should have been under the protection of a health institution, but as seen, it did not guarantee them safety and protection, with no accountability from the institution for these situations of violence and neglect.

Next, in another dimension, Luiz reflects, kind of self-critically, on his behaviors during his stay. However, in these accounts, it seems as if the criticism is directed only at himself and the other adolescents involved, and there is no institutional accountability for these events.

I’ve made mistakes... there was a time when I teamed up with the guys, M., but it wasn’t M. P., it was Japa and Pedrinha... no, it was... no, it was... his nickname was Ugly, D., so we decided, and G. took us to the field, right, and they went, jumped over the wall, went to the drug spot, and got two packets of marijuana, we brought them into the institution, and there we smoked them [...] We also took HAF, which is basically haldol, fenergan, and promethazine, that stuff knocks you out, you sleep for 2 days, only wake up to have lunch, dinner... you know... deserved, for what I did, it could’ve been worse, right, it could’ve been worse. Also, my penalty, sort of penalty... it got extended, you know... I was supposed to be released earlier, but I didn’t because of that, it was recorded in my file, and I stayed longer (Luiz).

The study conducted by Ely et al. (2014) sought to understand the meaning of psychiatric hospitalization for patients under CAPS care. According to the researchers’ report, the domination of bodies as an object in the power relation often established by professionals and the institution becomes evident in the hospital routine. Constant surveillance and the abuse of actions deemed as “care”, such as restraints and medicalization, resemble Luiz’s account. Even though he was not restrained, he was medicated to sleep after an impulsive act. The extension of the hospitalization period further emphasizes the notion of punishment for behaviors considered “inappropriate”.

In this regard, Guareschi et al. (2016) made important findings, highlighting the need to break away from established discourses on the criminalization of drug use and surveillance over adolescents (especially the poor and street-dwellers), traditional family configurations, and hygiene standards, behaviors, and values, presenting opportunities for alternative care methods to be considered.

As previously mentioned, Resolution No. 8 of August 14, 2019 (Brasil, 2019a) stands against Law No. 13.840 of June 5, 2019 (Brasil, 2019b), which regresses decades by prescribing involuntary hospitalizations as a central strategy in drug users’ care. This is reminiscent of other backward measures, undermining successful experiences and technical-scientific advancements, mischaracterizing regulatory agents, diminishing public participation, and reducing resources/strategies aimed at social inclusion, work, and income generation.

According to this resolution (Brasil, 2019a), mental health care and its mechanisms must ensure access to care without any form of human rights violation, eliminating cruel and degrading treatments, maltreatment, physical and chemical restraints, loss of civil rights, or practices that encourage discrimination, prejudice, and stigma. However, contrary to what this benchmark proposes, such practices during hospitalizations are still observed in the system’s everyday operations, as mentioned by Luiz.

Ana viewed her stay in the institution negatively:

I think the time we spend there. I think it is too long, isn’t it? (Ana).

As observed, nearly two decades after discussions about the lack of care and the absence of effective public policies for children and adolescents, the historical process of social control, and the prevalence of a punitive and protective mindset carried out at the National Forum on Child and Adolescent Mental Health, the lack of care scenario remains unchanged. All the experiences during the psychiatric hospitalization of the adolescents in this study point to the inefficacy of “care” actions, still rooted in segregating logic and marked by punitive and coercive practices in which conduct imposition prevails. These situations highlight an inhumane, institutional, fragile, and irresolute care, dominated by the lack of guarantee of rights present in the National Declaration of Human Rights and ECA.

In this context, it is important to emphasize, based on the VIII Extraordinary Meeting of the National Forum on Child and Adolescent Mental Health (Brasil, 2014), the recommendation that the hospitalization period should not exceed 45 days. Typically, this was not followed for the adolescents in this study. The latest hospitalizations for Luiz, João, and Ana lasted 4, 2, and 3 months, respectively. Vitor was the only one hospitalized in a general hospital with a psychiatric bed for 1 month, and it is worth noting that it was not the first hospitalization for two of the participants.

As for the benefits of hospitalizations, the adolescents reported that the hospital environment was perceived as a means to serve time, achieve detoxification, recognize the need for help, and become aware of the harms associated with PAS.

Ah, it helped me realize that I shouldn’t go back there because, well, I learned a lot there; it was an education, it was something that... I did wrong, and I had to pay for it, so today I’m clean [...] (Luiz).

It helped me understand that I need... I need help. That I won’t make it on my own... (Ana).

Uh... it helped me... stop using, not using drugs. Well, in a good way, because I arrived there, um... totally... like... under the effect of... these substances. Completely dominated by them. So I... I underwent that treatment to see if I’d stop. Thank God I managed to quit (João).

It helped me center my thoughts... because I was very confused. It also made things click for me because... even after freaking out, I still missed the drug. It helped me realize it wasn’t good for me (Vitor).

The perspective of hospitalization understood as learning through punishment, as discussed by Araujo (2018), seems to be present in Luiz’s statement when he associates his hospitalization with paying for all his transgressions, implying he would not need to be hospitalized again.

When discussing their views on what was not good about the hospitalizations, Luiz and Ana offered suggestions:

“They could care more. Care more for... especially given what the teenagers are doing there among themselves. Because they did many wrong things [...] some nurses turn a blind eye. They’d say, ‘that kid’s a screw-up’, I’ve seen, I’ve witnessed, ‘go get him, I’ll keep watch’. [...] The nurses should be more vigilant, more attentive, you know... because there are drugs there, I’m sure of it, there are people being beaten up, people suffering, people wanting to kill themselves” (Luiz).

I needed more... emotional... support. I lacked someone to lean on, someone who had gone through what I did. It felt like nobody there was depressed, only me (Luiz).

I think there could be more activities during the week (Ana).

The moral discourse turns the person who harmfully uses drugs into an object of disciplinary control during hospitalization (Araujo, 2018). For instance, situations of negligence and violence carried out by those responsible for care are observed mainly in psychiatric hospitals and other closed-environment institutions. In this context, and supporting Luiz’s statement, the literature reveals abusive and inhumane situations by professionals towards those in their care. Some interviewees denounced acts/conducts of ridicule and suppression/control/silencing of patients by professionals, the use of medication, restraints, and even physical assaults against those in care (Araujo, 2018; Messias et al., 2020; Rocha et al., 2018).

Thus, it is essential to reassess the guardianship over young people so that it does not simply become total control over their minds, actions, and desires. We must differentiate necessary care from guardianship that nullifies individuals. There is a fine line between care and control, and it can lead to dangerous implications (Couto, 2001).

When asked about other forms of help that could be offered during psychiatric hospitalization, three of the adolescents believed that all the assistance received during their stay was sufficient at that time. Even though at other times they mentioned aspects that could be improved, it seems there is no understanding or critical analysis of the real effectiveness and appropriateness of the hospitalizations in the adolescents’ accounts.

Ah, I think none because they helped in every way... (Ana).

Ah, for me... everything there was enough because I’m clean now, so... (João).

Ah... everything was fine. I got all kinds of help. There was always someone to talk to. Because I had the nurses, if needed, the psychologists, I stayed the whole day... the entire afternoon there. In the morning, there were doctors... I always had someone to talk to... it even got tiring [laughs]. So, there was nothing I needed (Vitor).

Analyzing the suggestions of Luiz and Ana together, three of the adolescents agreed on the proposals to improve assistance during hospitalizations and reinforced the talks about the need for meaningful activities and improved infrastructure. The most frequently mentioned aspects were the need for entertainment and improvements in the physical space, as described in these accounts:

You know... and if the space were bigger, you know, if there were more activities because there... we had activities..., but most of them didn’t really appeal to everyone. Bring new activities, new things, you know... (Luiz).

I do. Ah, they could change the facilities more, the way... the treatment, it could have more things for... distraction. You know... more things to... forget about the drugs (João).

Ah, more entertainment... would be good... because there was only a little television that people... watched soap operas at night. More games would be nice too because there were only 3 games there, more board games would also be nice... more entertainment in general... ‘cause... staying there all day is kind of boring (Vitor).

Similar data were found in the study by Camargo & Oliveira (2009), which examined inpatients’ perceptions of the treatment they received. The reports show that the lack of activities, idleness, scarcity of space in the facility, presence of window bars, and strict sleep schedules were viewed negatively. Suggestions for improving the premises, physical activities, outings, walks, crafts, and more entertainment in general were also made by the patients to help improve the care provided. Similarly, Cruz’s (2019) research aimed to analyze the experience of young adults during their first psychiatric hospitalization and found that the absence of activities and material resources increased the PAS users’ feelings of uselessness and distress.

Other aspects explored by the adolescents regarding what could assist them post-hospitalization include the mandatory requirement of psychological and familial support, self-awareness of harm related to PAS use, and the establishment of a new routine.

Look, attention from family members and psychologists. Even if it was mandatory, you know? On the family’s part, to oversee their children’s mental health. Mental health and everything else, because many people leave there worse off, you understand? People go there under compulsion... it’s not the institution’s fault, it’s the individual’s fault for not wanting to change. I was a case, I’m a living example of that... (Luiz).

Um... I think therapy with a psychologist... It’s emotional support, right? (Ana).

Ah, I do... To help people, you know... so that they realize that this isn’t good, that it only ruins our lives. It’s also good for individuals to understand that it won’t lead to anything good (João).

Ah... find a routine, you know, maintain a routine because they create one for you there, so continuing that routine would be interesting, right? Because it helps you to not go crazy (Vitor).

Even without knowledge about PTP and psychosocial care, the adolescents point out the need for continuity of care involving all actors. They emphasize aspects they consider vital care tools, notably absent from their treatment: active listening, welcoming environments, meaningful activities, presence/accompaniment of family members, autonomy in their choice-making capabilities, spaces for social exchanges where one can express individuality, and feel a sense of belonging to collective spaces. In short, being the lead actor.

In line with Luiz’s observation, Messias et al. (2020) highlight the need for families to take co-responsible roles in care and promoting the health of their members, alongside health services. The families carry their experiences and ways of conceiving life, influencing how they deal with the suffering of their members.

One factor that might explain the lack of this support is the possibility that, post-discharge, families presumably believe the adolescents are “cured” and hence, do not consider the need to pay them attention and follow up. Thus, the relevance, in the routine of services, of developing actions that include not only the adolescents but also their family members, is highlighted.

Considering the recommendations from all editions of the National Forum on Child and Adolescent Mental Health and the evident failure of care models with asylum-like characteristics based on social and family exclusion, we are still taken aback by numerous cases of rights violations - evident in the trajectories of the four participants of this study. Herein persists the absence of networked care; the continuity of psychosocial care services operating from a total abstinence perspective without technical and scientific backing; and the predominance of hospitalizations as an exclusive, punitive resource that disregards autonomy, individuality, and the subjects’ interests. Starting with the hospitalization indication, considered the last resort for adolescents, to be employed only after all other extramural resources have been exhausted (Brasil, 2001).

The participants of this study indicate that hospitalization was primarily adopted, without even discussing other possible intervention methods to handle their needs. Despite the ambiguous nature of hospitalizations, even if they are prescribed by law, it is underscored that they should preferably occur in psychiatric beds of general hospitals. This is inconsistent with the reality observed in this study, where three out of four participants were admitted to psychiatric hospitals.

Considering the surveillance character of psychiatric hospitalizations, which is commonly one of the main justifications for treating PAS users by managing to distance individuals from an imminent risk context, it is crucial to consider the capacity of other devices to perform this function. This starts with CAPS-ad III and, given the population addressed in this study, Child and Adolescent Psychosocial Care Centers (CAPS-ij). These are facilities that allow monitoring of children, adolescents, and adult PAS users 24 hours a day, including on holidays, for a period of 14 to 30 days, aiming to offer detoxification, diagnosis, and treatment (Brasil, 2011).

Final Considerations

The results have shown that adolescents are seldom heard concerning their own care. It is important to note that all expectations regarding “successful treatment” fall upon these adolescents, placing them in a position of intense pressure. At the same time, their needs and choice possibilities are missing. The conception that treatment outcomes depend solely on the adolescent poses a significant obstacle, revealing cracks in the current care model. This shows that care is not happening as psychosocial care policies advocate: emphasizing shared care with the responsibility of the individual, the healthcare team, and family members.

In this context, there is a highlighted need for greater investment in community services to ensure that policies for the care of PAS abusers are effectively implemented. There is also a suggestion for initiatives in education and continued education on adolescent care as strategic tools for a better understanding of the complexity of this life stage.

The limited number of participants and municipalities involved, as well as the ongoing pandemic, are identified as the main limitations of this study. Nevertheless, the data indicate that adolescents are not fully integrated into the service or welcomed and assisted by the network as a whole, potentially contributing to the continued reliance on hospitalization as the primary treatment for this population.

It is worth noting that even though all the adolescents were attended at CAPS-ad, one municipality had a CAPS-ij. It is recommended that CAPS-ij also be responsible for attending to children and adolescents who are PAS users.

Future studies are suggested to investigate the reality of technicians in the services and the challenges to implementing networked care aimed at children and adolescents who present problematic use of PAS.

• How to cite: Pereira, N. A., Silva, M. L., & Matsukura, T. S. (2023). Adolescent users of psychoactive substances: experiences and challenges during psychiatric hospitalization. Cadernos Brasileiros de Terapia Ocupacional, 31, e3412. https://doi.org/10.1590/2526-8910.ctoAO261434122

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Edited by

Section editor

Profa. Dra. Daniela Tavares Gontijo

Publication Dates

• Publication in this collection
  27 Nov 2023
• Date of issue
  2023

History

• Received
  02 Sept 2022
• Reviewed
  15 Feb 2023
• Reviewed
  10 Apr 2023
• Accepted
  18 July 2023