The place of care adolescents using psychoactive substances, according to their perspective

O lugar do cuidado a adolescentes em uso de substâncias psicoativas, segundo sua perspectiva

Abstract

Caring for people using psychoactive substances is historically associated with segregatory practices, even with children and adolescents. This study aims to understand the place of care based on the discourse of adolescents. Participant observation and semi-structured interviews were conducted with six adolescent users of psychoactive substances met at a child and adolescent mental health service. The data were analyzed by thematic analysis and discussed in the light of analytical psychology and of the assumptions of the psychiatric reform. One can conclude that the place of care is not fixed, but depends on how it is carried out, understood, and received, and on how the relational processes are established in the service with the adolescent. From the therapeutic relationships built in the service, it can be understood as temenos, the safe and potentially therapeutic place, where the transformation and development process of the subjects can be supported.

Keywords
Adolescence; Analytical psychology; Mental health; Psychoactive substances

Resumo

O cuidado a pessoas em uso de substâncias psicoativas é historicamente associado a práticas segregatórias, inclusive com o público infanto-juvenil. O objetivo desta pesquisa é compreender o lugar de cuidado a partir das falas de adolescentes. Realizou-se observação participante e entrevistas semiestruturadas com seis adolescentes em uso de substâncias psicoativas, atendidos em um serviço de saúde mental infantojuvenil. Os dados foram analisados mediante análise temática e discutidos à luz da psicologia analítica e dos pressupostos da reforma psiquiátrica. Conclui-se que a existência do lugar de cuidado não é fixa, mas depende de como este é realizado, compreendido e recebido, e de como se dão os processos relacionais estabelecidos no serviço com o adolescente. As partir das relações terapêuticas construídas no serviço, este pode ser compreendido como tememos, o lugar seguro e potencialmente terapêutico, onde o processo de transformação e desenvolvimento dos sujeitos pode ser sustentado.

Palavras-chave
Adolescência; Psicologia analítica; Saúde mental; Substâncias psicoativas

Historically, the association made by society between the use of Psychoactive Substances (PAS) and violence provides the logic of segregation and demonization of subjects with needs arising from the use of “alcohol and other drugs”, hindering care. The discourses based on this logic reiterate psychiatrization and judicialization (Corradi-Webster, 2016), provoking in society a sense of fear by the distorted understanding of the effects of illicit drugs, which hinders the understanding of other contemporary aspects related to the use of PAS (Nunes, Santos, Fischer, & Güntzel, 2010).

The situation is not different when it comes to the juvenile population, with models of exclusion and segregation of adolescents using PAS still persisting. Researches conducted in public health services indicate in general that one imposes to adolescents who uses “drugs” the label of delinquent, which is socially constructed and above all reinforced by institutionalization (Reis, Guareschi, & Carvalho, 2014; Soares, Oliveira, Leite, & Nascimento, 2017). To this day, compulsory hospitalizations, via court order, of children and adolescents to services not aimed at this population are still frequent in Brazil (Paim et al., 2017; Ramaldes, Avellar, & Tristão, 2016). This increase in the process of judicialization of mental health care to addicted children and adolescents meets the maintenance of the normalizing and hospital-centric logic based on the principle of abstinence, which associates relapses to an individual failure in the treatment process (Reis et al., 2014).

The mental health policy for children and adolescents proposes considering the following aspects as guidelines (Ministério da Saúde, 2005): (i) as subjects capable of talking about themselves, children and adolescents must be heard in their demand, as well as the “care” must be conducted considering their particularities; (ii) access to the service must be available to those arriving with the need for mental health; (iii) if there is another service that best meets the needs of subjects, the referral to it must be ensured and monitored, sometimes being necessary to carry out the care along with other services; (iv) the network of services and actions must be in permanent construction to ensure the participation of intersectoral professionals for obtaining an effective response before the problems of alcohol and other drugs for the juvenile population; (v) “the territory is the psychosocial place of the subject; where life happens” (Ministério da Saúde, 2005, p.13); the relationships with social networks and regarding the affection of the subject who is cared for, including school, leisure places, neighbors, and family, must be considered important parts of care; (vi) the demands that arrive must be discussed and organized in a network, by professionals, users, and their families.

In this sense, the Centro de Atenção Psicossocial (CAPS, Psychosocial Care Centers) start to assume a strategic role in the organization of the network, especially from the establishment of the Rede de Atenção Psicossocial (RAPS, Psychosocial Care Network) (Passos, Reinaldo, & Barbosa 2016). Considering that RAPS aims to establish, articulate, and amplify the points of care for people in psychic suffering due to severe and/or persistent mental disorder or use of PAS, the services that integrate RAPS need to also be attentive to the increase in the use of PAS by the juvenile population, and offer a care that meets their particularities (Belloti, Quintanilha, Tristão, Ribeiro-Neto, & Avellar, 2017; Paim et al., 2017).

Although the mental health policy for children and adolescents considers that, as subjects capable of talking about themselves, adolescents must be heard in their demand, these subjects are little approached directly by researchers, and their histories and demands are usually mediated by parents or guardians, professionals or medical records. Thus, starting from a reference that recognizes children and adolescents as subjects of their own history, this research is justified by enabling a space where these subjects can be heard to construct a perspective of care that actually gives voice to their demands, conceptions, needs, and difficulties. Thus, this study aims to understand this place of care based on the discourse of adolescent users of PAS met in a Centro de Atenção Psicossocial Infantojuvenil (CAPSij, Psychosocial Care Centers Children and Adolescents).

Method

This is a qualitative study, which carried out participant observation in a CAPSij of a southeastern Brazilian city and semi-structured interviews with six adolescents met by the service. The CAPSij in question is the result of a recent merger between two services directed to the juvenile population, a CAPSij with eight years of operation, which met the demand “disorder,” and a CAPS adi, newly created, which met the addiction demand. After one year of operation, the CAPS adi was closed and its users and part of the professionals were reallocated to the CAPSij, which started to meet the two demands.

Data collection started by participant observation, and was also performed during the interview period, having a dual function: constructing a basis of trust, respect, and acceptance of the research participants; and apprehending the life and relationships conducted day to day, symbolized and interpreted by the social actors (Minayo, 2004). The observations were recorded in a field diary and, for the presentation of results, the term “observation” was used to identify them.

Before the beginning of the interviews, a total of 100 hours of observations were performed. The semi-structured interviews were conducted with six adolescent users of PAS met by CAPSij – five boys and one girl. The guardians signed the informed consent form and the adolescents signed the assent form. The interviews took place between May 20, 2016 and October 4, 2016 and lasted between 16 and 65 minutes.

The interviews were guided by a script with questions about care practices directed to adolescent users of PAS, aiming to understand the place of adolescents in the mental health care for children and adolescents. The interviews were recorded and performed at a previously scheduled date and time with the participants and their guardians and were subsequently transcribed.

At the end of the interview, the researcher invited the respondent to choose a name to be used in the research. Kramer (2002) points out that this proposal, while guaranteeing the anonymity of the subject, proposes an alternative for these adolescents, often expropriated from their place of subjectivity, to maintain an identity in the research. This is pertinent in our study, since we consider hearing their voices essential, and, thus, we try to guarantee a “place” of authorship for these subjects. Therefore, the interviewed adolescents will be identified by the chosen name.

The data obtained were organized and analyzed based on content analysis, in the modality of thematic analysis (Minayo, 2004). This procedure was performed having as criterion the frequency with which the themes appeared, considering aspects pertinent to the research objectives, and the conduction of cutouts, such as phrases and keywords, enabling the categorization of the data. Subsequently, the raw data were transformed into content, with the classification of the data. Then, the interpretation of the obtained data was performed, and the discussion was guided by Analytical Psychology and the assumptions of the Psychiatric Reform. The results will be exposed alongside the analysis.

The research was previously authorized by the Municipal Health Secretariat of the municipality and approved by the Research Ethics Committee of the Federal University of Espírito Santo (Number of Opinion: 1.379.899).

Results and Discussion

The following categories were obtained from the analysis: (1) place in CAPSij; (2) place of care in CAPSij; (3) place in the city; and (4) search for a place.

Place in the CAPSij

The category “place in CAPSij” includes results related to “place for crazy people,” “place together with or separate from the disorder demand,” and “place of treatment.” We observed in some moments that the CAPSij would be seen by the adolescents as a “place for crazy people.” This statement was made by the adolescents, and they reported having heard this elsewhere: “Like today, I went to ask for information and the person asked, “Why? Are you crazy?” then I looked at the person’s face and said, “Of course not!,” then I went and said, “No, I’m just going over there to deliver something to a colleague of mine” (Luluzinha da Alta).

Therefore, one can see that the social construction of the CAPSij space is still permeated by the stigmatizing view of madness, a “place for crazy people,” the madhouse. This is also reflected in the discourses and perspective of the adolescent users of PAS met in CAPSij, “I’m not going there because it’s a place for crazy people” (Iago). This aspect can generate a difficulty in the process of linking adolescents using PAS to CAPSij, since the construction of a cultural view about madness is based on the feeling of rejection and exclusion.

In this sense, the adolescents point to the fact that the care in the CAPSij is “together with or separated” from the disorder demand. This was verified both in interviews and reports and in several experiences of the groups in CAPSij, as we can verify in the observation report “By passing through a place where one can see a hill... They make some comments, like not wanting to be seen near the other boys (those who have disorder issues); they speak a little about that place – trafficking environment” (Observation).

There is thus a difficulty in approaching “disorder” adolescents. This aspect can relate to a perception that the other, located in the “place for crazy people,” cannot be present in the group of addicted adolescents, so that the latter will also not be categorized as crazy. These aspects can be understood from the concept of cultural complexes. These are dynamic energy fields that promote a distortion of the world to one’s consciousness, generating automatic responses to the other. This makes the reality of the other invisible, even if such attitude is unconscious to ourselves (Novaes, 2016). Cultural complexes are shared by individuals within a specified group or collective context. This can be understood from the idea that cultural complexes are based on repeated historical experiences that have their roots in the collective psyche of the group and of each member of this group (Novaes, 2016; Oliveira, 2018).

It is understood that the cultural complexes that circumscribe the group to which the adolescents are inserted (Kimbles, 2003) may favor the affective approximation of the individual with the cultural patterns of the group they belong, or to which they would like to belong. This aspect is pertinent to the construction of the bonding of the addicted adolescent to the service, by the group of experiences, since they organize a sense of belonging. However, this same idea of belonging can act as a negative function of the cultural complex, in the construction of prejudices and an attitude that looks at the other from a devaluation (Kimbles, 2003). Thus, driving others away, devaluing them, could be understood as an attempt to affirm an identity as a group.

One can verify that, at certain moments, some adolescents seem to be inhibited with the presence of the “disorder” adolescents, and vice versa. However, as one works with the two demands together, such inhibition can be overcome. It is necessary to reflect on the positive aspects of having the two demands together, such as learning to deal with differences, having patience, sharing similar difficulties, even though the main demands are different, such as a socioeconomic and impaired context.

Caring in this context allows one to work in the sphere of the dynamism of alterity, where the ego can recognize itself as a subject from the recognition of the other, not only in its identifying aspect, but recognizing the function of the “other” in its development. This aspect would be of great importance, because its

“Great virtue is the maintenance of its identity and coherence and letting things happen, at the same time it opens democratically to the others to whom it basically respects, because it knows that it needs them to be complemented and not lose its experience of totality”

(Byington, 1983, p.24).

The learning of relating in harmony with what is different favors the development of an attitude of understanding and relationship with the other at the micro level (CAPSij), to subsequently be able to be expanded to the macro level (city).

Another pertinent question pointed out by the adolescents and observed during the research is how the adolescents use “CAPSij”, especially the relationship between the place of treatment and a place for the use of “drugs” or for performing the same activities related to the trafficking environment. In an interview, an adolescent report a situation she experienced: “... The boys smoked here, and then the guys were all in here. Then they smoked without even... . I was afraid someone would come and see. I was ashamed too. ... Because we are coming here to be treated and we come and smoke here, I think... . I don’t know, it’s teasing. I just took a couple of puffs and then they put it away” (Luluzinha da Alta).

In one of the groups observed, the adolescents take advantage to talk about these situations, some question about the use of drugs in that space and about why they go to CAPSij: “A professional asks what is CAPSij for. One adolescent says it’s to stop doing drugs. Another one says he is forced to go there” (Observation).

There is a fine line between the perception of a place of “treatment” and a place where they could maintain the use of drugs and other attitudes corresponding to their daily lives. One can think about the “place of treatment” as a space between the surrounding of the drug and between a health institution and, thus, it may have characteristics of both for the adolescents. This is important because it allows the feeling of belonging and association with the service in the adolescents. Understanding that the construction of a group idea for these adolescents may be related to the cultural complex (Kimbles, 2003), it is possible to argue that the nucleus of this group has a relationship with the surrounding of the drug. Therefore, their attitudes express the repetitive behaviors related to the cultural complex, since they are rooted in what is considered essential, being difficult to reflect or resist it.

According to Singer (2003), when the collective, as the nucleus of a group, is nourished healthily, the collective spirit supports and guides from the collective to the individual level. But when the spirit of the group is wounded, the archetypal defenses of the group are activated, easily assuming a fierceness and energy of those who fight something, to protect the sacred value of the group and avoid its extinction. It is understood that this group, to which the adolescents belong, is “wounded,” either by the conditions of structural violence or by the demonization of the drug and the user, both inside and outside CAPSij. This attitude of transgression could be a defense to the possibility of dissolving or weakening of the group. Thus, one needs to symbolically understand this transgression. What is it for? If the service projects the collective shadow on the group of adolescents, the attitude to be taken will repeat that of society, that is, exclusion. It is understood that this shadow refers to specific aspects (individual or collective) that cannot be seen or accepted, and which is projected on the other (usually, characteristics considered negative) (Jung, 2014). Thus, the collective shadow projected on the adolescent user of PAS reflects the social misery, the ruin (failure), which, projected on the other, exempt us from dealing with what is also “ours”: “our” failure in creating a therapeutic relationship that we believe to be “healthy” or “accepted.”

Thus, one must understand that the models of care for subjects using psychoactive substances transpose the comprehension that identifies the drug as an enemy to be overcome and the user as a depositary of what is culturally undesirable (Silveira, 1994), to the symbolic understanding of the disease and of the symptoms/symbols presented by the subject who is cared for. Therefore, it is important to talk about these symbols also expressed in the attitudes of the adolescents, such as transgression, among the members of the group itself, since the measure of “talking about” among equals opens the opportunity to, from the collective, integrate the unknown or poorly developed aspects of the subject, and consequently build a “place of care.” We do not propose that transgressions should be allowed without limits being presented, but that, on the contrary, they are essential. However, they need to be worked out from the establishment of a bonding relationship.

Place of care in the CAPSij

The understanding of the place of care in the CAPSij from the perspective of the adolescents was built from the results that include “how they feel in the CAPSij,” the “place of desire versus place of obligation,” “place of care,” and “place of discrimination.”

Some adolescents point out they do not feel good in the CAPSij, either because the treatment has changed and they have not adapted to the new proposals or because they have no interest in the treatment or in the relationship with people. It can be seen that, during the interviews, when the adolescents do not respond vaguely that things are fine, the answers are negative and have as common point the relationships established with the professionals of CAPSij. “Everything that is obliged people don’t like. But can I do, I have to come here, right.” /Researcher: “Do you like the people here?” Iago: “No. They’re just pawns... idiots” (Iago).

There is a difference in the attitude of professionals that is perceived by adolescents, which seems to reflect on the way they receive and respond to care, as one can see in the aforementioned statements and in the following report: “One of the boys complains that she [the professional] was screaming and the others were not saying anything. They go out in group to another hidden place” (Observation). Thus, the feeling of having a place in the service seems to oscillate for them as they feel treated well or poorly.

When adolescents perceive they are not heard or that there is no interest directed to them, they understand they are not cared for, even if they remain in “treatment.” Therefore, the understanding of care for the adolescents is different from “treatment”; while treatment seems to be related to techniques and procedures performed for them, and not with them, care involves Eros, which, according to Jacoby (2008), is the capacity to place oneself in relationship with the other; that is, it involves affection, continence, attention. Thus, one can conclude that, when there is a relationship in which the adolescent is understood and listened to, there is a place of care. The Logos, on the other hand, is about the individuals’ capacity to perceive the separation with the world that surrounds them, transforming it into an object, enabling its recognition and the reflection about it (Jacoby, 2008). When the attitude is based only on Logos, that is, a relationship oriented by the logic of classification and discrimination, typical of the absence of Eros, there is only treatment. We believe that creating a care supported by the principles of both Eros and Logos is desirable and possible.

In this direction, some forms of this “treatment” evoke the feeling of “place of discrimination”, even in groups with the presence of professionals who work more with the addiction issue: “They keep preserving the other girls as if they were holy... . Yes, kind of watching them. As if I were a bad influence” (Luluzinha da Alta).

Discriminating means classifying, isolating, establishing differences. These characteristics have positive aspects if we consider that adolescents using PAS require specific mental health care, and, for this, they need to be known, and the differences with the public in issues related to severe and/or persistent mental disorders need to be understood. The problem is created if the attitude directed to them is based solely on these assumptions and sticks to the characteristics evaluated as “negative” attributed to addicted adolescents. In this sense, the establishment of differences serves only to separate them from what is considered a standard or desirable for an adolescent, thus establishing a stereotype. Thus, the interviewees perceive that, in some situations, the service does not look at the adolescents as subjects, but classifies them as objects only. It is necessary to clarify that this is not a generalized attitude, but, on the contrary, by the speeches of the adolescents, the service seems to be one of the few places where they feel listened to, even regarding their desire.

About the “desire” to be in the CAPSij, the speeches vary around wishing to be there and not knowing why they continue to attend, although they do not feel obliged, as in the following report: “Were you forced to come here? No, my mother only said, next Friday you go there” (João); and that they go only by court order. Although referred to CAPSij by court order, an adolescent points out that he likes the service: “Because it has the stuff of justice and it is also good right” (Jay Woldsu).

Although the referral to serve the socio-educational measure in CAPSij is something recurrent, it is perceived during the observation that the user often does not meet this order and starts to not attend the service. It is understood that, despite the court order, adolescents can “choose” not to attend the service and bear the consequences of this, a situation that happens with many of them, who often do not come to CAPSij in person, not even to the initial care. This involves a desire to be in the service, and both the interviews and the observation indicate that the choice for going to CAPSij is attributed to the relationship established with the professionals and other adolescents present there. “An adolescent sits next to me and says ‘you guys bring boring things for us to do, but we like it’; I ask why he comes and he mentions the court order, then I say, ‘but you said you like it’... he says ‘I come here because of you, of the nurse... to meet new people’” (Observation).

Thus, if when there is relationship there is care, and when there is no relationship there is only treatment, the place for the child and adolescent using PAS is relational and is transient, because it depends on how and when they relate to them and when and how they allow themselves to relate to the service, and on what they understands about it. The relational place can be understood as therapeutic setting. It is, for several times, mistaken for the physical space of the office or of an institution; however, according to Tristão and Avellar (2014), the setting could be defined as the potentially therapeutic place, and it is not necessarily physical, but related to the space where the therapeutic/care relationship is established. From Analytical Psychology, one can create a relationship between the therapeutic setting and the “temenos”. The term is used as a metaphor for psychological application, especially to describe an analytical (transferential) place. One can also amplify the idea of temenos as an alchemical term whose understanding would be “sealed airtight container” within which the transformation of opposites takes place (Jung, 2012). Analogically, the therapeutic process would be the analytical continent, where consciousness and unconsciousness relate and where transformations are possible. Thus, the CAPSij can be seen as temenos, the safe relational place, where transformations necessary to one’s development process can happen.

Place in the city

To compose the category “place in the city,” we used the results regarding the “marginalized place” (outside CAPSij), “place on the streets,” and “place in trafficking”.

Concerning the feelings of marginalization reported by adolescents in the interviews or in the groups, most reports discuss situations outside the health spaces. In one of the interviews, they state that people cannot understand the use of drugs and that they often associate it with the risk of theft: “Well, when you use it, it’s not like everyone will turn their face on you. But there are some people who can’t understand... that it’s like a problem and it can be solved, you know. Then sometimes they treat you bad, sometimes they curse you. They think we’re going to rob them, you know?” (Aleff).

It is worth highlighting that all adolescents who took part in the observed activities are black and poor. One can therefore wonder whether the experiences of marginalization are due only to the use of drugs or to how ethnicity and social class are perceived by society. One can also ask why only the boys with these characteristics “arrive” to CAPSij, since it is currently a reference place to serve the juvenile population regarding the issue of alcohol and other drugs, and the use of PAS permeates all classes.

It is important to point out that a significant number of adolescents are referred to CAPSij because of involvement with trafficking or offenses, not necessarily having a clinical demand related to dependence or harmful use of PAS. Thus, despite the anti-asylum struggle, one can ask whether other asylum strategies have been produced for the black population. Among them, there are compulsory hospitalizations, driven by the judicial system, taking place mostly with black people (Azevedo & Souza, 2017). Such situations point to an institutional racism, which is still quite present in the network of services that should take care of children and adolescents using PAS in an integral way, but that fits them, especially those black and poor, in the profile of “delinquent” and socially dangerous, which need “care” under socio-educational measures (Passos & Lima, 2013).

Not only in the services, but in the city as a whole, the demonization of the user of PAS and the view of them as depositary of social misery, provoke an objectification of the subject, which is seen only as stereotype, which has no other possibility of existence. The city projects on the users of PAS, especially those black and poor, the collective shadow, because they cannot, or want to, see their own miseries, the misery of society as a whole. The attribution of stereotyped characteristics of the user to these adolescents builds a symbolic place, marked by the prejudiced looks of the city.

This same “street” sometimes appears as a place where adolescents meet. CAPSij receives, in several moments, adolescents in street situation; they receive basic care (referral to bath, rest, and food) and often return to the street, as reported in the interview: “That time I was getting on the street with him, it was hard for ‘we’ to go on the CAPS there... that time there was hard... . Before I used to have a little place to sleep there, but... there on the guy’s slum. ...It was a house, but the house was empty, there was only one mattress on the ground, it had no light, nothing” (Paulinho).

In the case of adolescent girls, there is also the issue of sexual violence. We have found that all adolescent girls we contacted during the research, either by the interview or the observations, were victims of some type of sexual violence. Some were referred to the CAPSij after the occurrence of such situation. The permanence in the street situation, in these cases, is worsened by the exposure to situations of violence, as can be seen in the following observation report: “I ask where did they sleep tonight [two adolescent girls]. They answer that on the street, in the square. But they said they did not sleep well... . ‘you have to sleep with one eye open and the other closed’... that there’s many wicked people, and when they perceive someone coming close, they soon get worried” (Observation).

It is worth asking why, with the possibility of being housed in a care institution, some adolescents prefer to stay in the street, which is a place of danger/risk, rather than staying in the shelter. By their statements, one can understand that they do not feel put in the place of subjects in both sites. However, it seems that the rules, considered strict, from the care institutions are more troublesome than the “rules” of the streets, although the latter involves potentially high risks. However, why remain in this place if they know it is dangerous? Why keep this drug use this way? According to Silveira (1994), the question to be asked should be ‘why using drugs has become a privileged means of taking risks?’ Why does this way of living encompass a risk of death as an implicit necessity?

The risk of death on the street, argues Silveira (1994, p.30), is not equivalent to the suicidal impulse, but an effort to “establish a different relationship with a higher body that can guarantee the right to exist, as we observe in initiation rituals of various cultures”. That is, it is an attempt to exist in another way than the previous one. To exist as a member of some group.

Conversations about trafficking are very common among the adolescents in the groups observed. It is common for them to point out who they know and what they do or did, indicating an attitude of bragging about having a place in trafficking, according to the observation: “they say one cannot go in certain places, because they already feel the evil looks. They talk about involvement with trafficking and who they know on the “slum” (Observation).

Thus, being a member of the “slum” or “trafficking” group grants them a place, even if it is forbidden and dangerous. Therefore, this situation presents a meaning in the life of the adolescent, for whom a “self-imposition of evidences” acts as a ritual where “succeeding” would imply a right to existence (Silveira, 1994). When trying to be recognized as members in the trafficking group, these adolescents are looking for a place both in this social group and in life.

In several moments, some adolescents report their involvement with trafficking, mentioning having handled guns and witnessed deaths. One of the adolescents reported that he first became involved in trafficking and only after started using the drug, and that he sought it because of the intense family conflicts he experienced, such as beating and family neglect: “before I did not do drugs, I did nothing, then my mom started hitting me, and my stepfather, and then I got a little mad with life, you know? ... then I revolted, I started to see the kids from the street there, they started to leave guns and drugs in my hand for me to sell, they came and said: “This is yours, this here you sell that it’s for us” (Paulinho).

For Analytical Psychology, the dependence of PAS is characterized by a model of use where a dual individual-drug relationship takes prominence, especially before an unbearable reality (both subjectively and objectively), which the user cannot handle or modify (Silveira, 2002). Thus, drugs and even trafficking often enter the lives of these surveyed adolescents because of the unsustainability in dealing with aspects of structural violence and subjective aspects. The drug assumes the function of making life bearable and enabling their existence in the world, as one can understand from the speech of one of the adolescents during the interview: “how can you get by without drugs lady? Life is too bad... there’s no way” (Iago). It is worth investigating with each subject, therefore, what is the meaning of the relationship they establish with the drug (Silveira, 2002) and how this related to their existence in the world.

In several situations, problems with trafficking are more intense than the use of PAS itself. The adolescents themselves point out that they do not use a lot of drugs, but that they are involved in trafficking situations and they have no desire to leave: “I can attend the church every day, but I will not get out of trafficking... I think about getting a job; but in one night, in two hours, I earn 80 reals” (Iago).

If on the one hand belonging to the group, based on an understanding of the cultural complex, can have positive aspects, in the sense that the individual is supported in the collective realm, on the other it presents negative aspects, among which the need to strengthen this group to the detriment of others. In this sense, Singer (2003) points out the so-called archetypal defenses, especially before the fear of annihilation of the spirit of the group. However, these same archetypal defenses can become aggressions to anything that seems to threaten the “spirit” of the group, such as the social transgressions committed by the adolescents, especially those involved in trafficking. Society is perceived as the external that does not produce opportunities for the adolescents, but, on the contrary, that tries to undermine their existence, via structural violence. In this direction, there is no perception of another viable possibility other than the involvement with trafficking. Thus, one must think about strategies to create other places of existence for adolescents to broaden their life perspectives.

Search for a Place

Although most of the demand for the care of adolescents using PAS comes from the family or from justice, one can observe that this adolescent also seeks a place of care, either because of the use of drugs or to search a momentary welcoming place. “... it was I who dug and ended up falling into a hole, in the rock bottom, but now I’m trying to get up” (Paulinho). It is perceived in some cases that even if initially the adolescents are “forced,” they admit they attend a place of care by desire, when there is something to be sought in this place, as identified in the interview: “I was referred to a lot of psychologists, they called my house, and it was all set for me to go, but I didn’t go. ... I just came here because... at first, I just came because I was forced to. Now I come because I like it, I like it here. I like to come here, to talk to you, you know?” (Luluzinha da Alta).

We have found that the attendance in the service is mostly not systematic, even if it is scheduled for the adolescents to be present, they often do not come. Thus, care is performed largely when there is a spontaneous demand by the adolescent, that is, when they seek this place, either initially by basic care, when they flee the care institution or are in a street situation, or in situations in which something more serious has happened and they want to talk or need help. “Oh, I’m not okay. I’ll go there: ... I was robbed and then I came on Thursday here” (Luluzinha da Alta).

Before the impossibility of altering or dodging an unbearable reality (objective or subjective), the involvement with the drug assumes an alternative place. The crisis is installed when at the same time one cannot live without and with the drug, and and a different element that supports the adolescents to maintain their existence or even survival has to be included (Silveira, 2002).

The crisis is, therefore, the propitious moment for inserting the therapeutic element in the relationship established between the adolescent and the drug. The therapeutic agent cannot compete with the seduction and pleasure provided instantaneously by the drug experience. Thus, one must take advantage of the gaps offered by teenagers, in their search for a place, to try to insert possibilities of other relationships that can be accepted and built with them.

Final Considerations

Despite the possibility of understanding a place, we have found that the place of CAPSij, in the eyes of adolescents, is often rejected because it is associated with the “place for crazy people,” pointing to a stigmatizing view that is also socially reproduced. As a place for crazy people, the adolescent does not want to “identify with this space.” On the other hand, by the adolescent’s view, the approach is often not well received, because of the fear of being put in the “place for crazy people.” Thus, according to this view, the adolescent with “disorder” demand could not be present in the group of addicted adolescents, so that the latter is not also categorized as crazy. We understand that cultural complexes, which may favor an affective approximation between the self-identified group, may, on the other hand, create labels and prejudices regarding the groups considered external, and consequently, driving others away is an attempt to assert an identity as a group.

Another place understood as an attempt to search by the adolescent is the street and the trafficking. Despite the difficulties that living in the street or being involved with trafficking create, this search for this place is an attempt to exist as a member of some group. Thus, when seeking to be recognized as a member in the trafficking group, this adolescent is looking for a place both in this social group and in life.

Belonging to this group, understood from the cultural complex, also has negative aspects, among which the need to strengthen this group to the detriment of others. As external, society is perceived as a group that tries to undermine their existence via structural violence. In this direction, it is essential to create other forms of being in the world other than trafficking. To do so, it is imperative to think about strategies to create other places of existence so that adolescents can broaden their life perspectives.

As a subject whose suffering is permeated, and often produced, by serious social issues, the care must include dealing with this environment, being guided by psychosocial care, which is the fundamental principle of the Psychiatric Reform, which in turn is currently seriously threatened, as we have previously mentioned. Therefore, the “care in freedom,” in the territory where life is performed, is fundamental. If, on the contrary, the imaginary about these adolescents has no space to be elaborated, then they will be stigmatized and this will interfere in the place of care, either within CAPSij or in the other points of the Psychosocial Care Network, thus reproducing asylum and moralizing postures.

Como citar este artigo/How to cite this article

• Tristão, K. G., & Avellar, L. Z. (2019). The place of care adolescents using psychoactive substances, according to their perspective.Estudos de Psicologia (Campinas), 36, e180162. http://dx.doi.org/10.1590/1982-0275201936e180162

• Support: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes).
• Article based on the thesis of K.G. TRISTÃO, entitled “O CAPSIJ como lugar de cuidado para crianças e adolescentes em uso de substâncias psicoativas”. Universidade Federal do Espírito Santo, 2018.

References

• Azevedo, A., & Souza, T. P. (2017). Internação compulsória de pessoas em uso de drogas e a contrarreforma psiquiátrica brasileira. Physis: Revista de Saúde Coletiva, 27(3), 491-510. http://dx.doi.org/10.1590/s0103-73312017000300007
  » https://doi.org/10.1590/s0103-73312017000300007
• Berloti, M., Quintanilha, B., Tristão, K. G., Ribeiro-Neto, P., & Avellar, L. Z. (2017). Perceptions of the process of work in a psychosocial care center for children and youth. Temas em Psicologia, 25(4), 1547-1557. http://dx.doi.org/10.9788/TP 2017.4-04Pt
  » https://doi.org/10.9788/TP2017.4-04Pt
• Byington, C. A. (1983). O desenvolvimento simbólico da personalidade. Revista da Sociedade Brasileira de Psicologia Analítica, 1(1). Sociedade Brasileira de Psicologia Analítica.
• Corradi-Webster, C. M. (2016). The prohibitionist discourse and practices in the field of alcohol and other drugs. SMAD, Revista eletrônica saúde mental álcool e drogas, 12(1), 1-2. http://dx.doi.org/10.11606/issn.1806-6976.v12i1
  » https://doi.org/10.11606/issn.1806-6976.v12i1
• Jacoby, M. (2008). O encontro Analítico: transferência e relacionamento humano São Paulo: Cultrix.
• Jung, C. G. (2012). Psicologia e alquimia (6a ed.). Petrópolis: Vozes.
• Jung, C. G. (2014). Os arquétipos e o inconsciente coletivo (11a ed.). Petrópolis: Vozes.
• Kimbles, S. L. (2003). Cultural complexes and collective shadow process. In J. Beebe (Org.), Terror, violence and the impulse to destroy: Perspectives from analytical psychology (pp. 211-234). Madrid: Daimon.
• Kramer, S. (2002). Autoria e autorização: questões éticas na pesquisa com crianças. Cadernos de Pesquisa, (116), 41-59. Recuperado em julho 30, 2015, de http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-15742002000200003&lng=en&tlng=pt
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-15742002000200003&lng=en&tlng=pt
• Minayo, M. C. S. (2004). O desafio do conhecimento: pesquisa qualitativa em saúde São Paulo: Hucitec.
• Ministério da Saúde (Brasil), Secretaria de Atenção à Saúde, Departamento de Ações Programáticas Estratégicas. (2005). Caminhos para uma política de saúde mental infanto-juvenil Brasília: Editora do Ministério da Saúde. Recuperado em setembro 30, 2019, de http://bvsms.saude.gov.br/bvs/publicacoes/05_0887_M.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/05_0887_M.pdf
• Novaes, C. S. (2016). Corrupção no Brasil: uma visão da psicologia analítica. Junguiana, 34(2), 5-17. Recuperado em janeiro 23, 2018, de http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S0103-08252016000200002&lng=pt&tlng=pt
  » http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S0103-08252016000200002&lng=pt&tlng=pt
• Nunes, D. C., Santos, L. M. B., Fischer, M. F. B., & Güntzel, P. (2010). “...outras palavras sobre o cuidado de pessoas que usam drogas...”. In L. M. B. Santos (Org.), Outras palavras sobre o cuidado de pessoas que usam drogas (pp.15-26). Alegre: Conselho Regional de Psicologia do Rio Grande do Sul.
• Oliveira, H. (2018). Complexo cultural, consciência e alma brasileira. Cadernos Junguianos, 14(14), 114-125.
• Paim, B. R., Porta, D. D., Sarzi, D. M., Cardinal, M. F., Siqueira, D. F., Mello, A. L., & Terra, M. G. (2017). Atendimento ao adolescente usuário de substâncias psicoativas: papel do centro de atenção psicossocial. Cogitare Enfermagem, 22(1), e48011. Recuperado em dezembro 2, 2017, de http://revistas.ufpr.br/cogitare/article/view/48011
  » http://revistas.ufpr.br/cogitare/article/view/48011
• Passos, I. F., & Lima, I. C. B. F. (2013). Drug policy: What impact does it have on children and youth? Psicologia & Sociedade, 25(Special issue), 111-121. http://dx.doi.org/10.1590/S0102-71822013000500013
  » https://doi.org/10.1590/S0102-71822013000500013
• Passos, I. C. F., Reinaldo, A. M. S., & Barbosa, M. A. G. (2016). A rede de proteção e cuidado a crianças e adolescentes do município de Betim/MG e os desafios do enfrentamento ao uso abusivo de crack, álcool e outras drogas. Pesquisas e Práticas Psicossociais, 11(3), 583-601. Retrieved December. 21, 2018, from http://pepsic.bvsalud.org/scielo.php? script=sci_arttext&pid=S1809-89082016000300005&lng=pt&tlng=pt
  » http://pepsic.bvsalud.org/scielo.php? script=sci_arttext&pid=S1809-89082016000300005&lng=pt&tlng=pt
• Ramaldes, H. Q., Avellar, L. Z., & Tristão, K. G. (2016). Características de crianças usuárias de substâncias psicoativas descritas pela própria criança. Psicologia: Teoria e Pesquisa, 32(4), e324220. http://dx.doi.org/10.1590/0102.3772e324220
  » https://doi.org/10.1590/0102.3772e324220
• Reis, C., Guareschi, N. M. F., & Carvalho, S. (2014). Sobre jovens drogaditos: as histórias de ninguém. Psicologia & Sociedade, 26(Número Especial), 68-78. Recuperado em janeiro. 9, 2018, de http://www.scielo.br/pdf/psoc/v26nspe/08.pdf
  » http://www.scielo.br/pdf/psoc/v26nspe/08.pdf
• Silveira, D. X. (1994). Drogas, vícios: conceitos e preconceitos. Revista Junguiana, 12(01), p.26-33.
• Silveira, D. X. (2002). Drogas: uma compreensão psicodinâmica das farmacodependências São Paulo: Casa do Psicólogo.
• Singer, T. (2003). Cultural complexes and archetypal defenses of the group spirit. In J. Beebe (Org.), Terror, violence and the impulse to destroy: Perspectives from analytical psychology (pp.191-211). Canadá: Daimon.
• Soares, R. H., Oliveira, A. A. F., Leite, K. C., & Nascimento, G. C. G. (2017). Medidas judiciais atinentes à atenção em saúde mental de adolescentes em conflito com a lei. Interface, 21(60), 23-31. http://dx.doi.org/10.1590/1807-57622015.0636
  » https://doi.org/10.1590/1807-57622015.0636
• Tristão, K. G., & Avellar, L. Z. (2014). Acompanhantes terapêuticos na grande Vitória, Espírito Santo, Brasil: quem são e o que fazem? Interface Comunicação, Saúde, Educação, 18(50), 533-544. Recuperado em janeiro 9, 2018, de http://www.scielo.br/pdf/icse/v18n50/1807-5762-icse-1807-576220130759.pdf
  » http://www.scielo.br/pdf/icse/v18n50/1807-5762-icse-1807-576220130759.pdf

Publication Dates

• Publication in this collection
  28 Oct 2019
• Date of issue
  2019

History

• Received
  09 Jan 2019
• Reviewed
  25 June 2019
• Accepted
  23 Sept 2019