Religious therapeutic communities: between salvation by faith and the denial of its principles

The growth of Brazilian therapeutic communities points to a return to the asylum par-adigm, with public funding for hospitalizations based on labor therapy and religious conversion. The relationship between these institutions and government sectors has expanded since 2013 in the state of Espírito Santo, Brazil. Given this sce-nario, we aimed to analyze, through this qualitative research, the role of religious therapeutic communities in the treatment of individuals with problematic drug use, focusing on the impact of the religious methods employed in these places. To this end, we conducted semi-structured interviews with 28 individuals who had been treated in these places. The interviews were held for six months and subsequently transcribed in full. The data were analyzed using the Discourse Analysis. The subjects’ statements widely differed: 13 reported that institutions had an essential role in their treatment and pointed out that religious methods helped them, while 15 argued that institutions were inefficient in their treatment and religious methods were ineffective. The study elucidated the need for inspection of these institutions and stirred a reflection concerning their suitability as publicly funded places to treat the drug user population.


Introduction
The Brazilian mental health care reform process is a global reference and has historically obtained several achievements 1 , among which is the National Mental Health Law (10.216/01), which provided the protection and rights of people with mental disorders, redirecting the network of territorial services 2 .This Law downsized psychiatric beds in the country -from 80,000 in the 1970s to as little as 25,988 in 2014 -and increased spending on psychosocial care -from 24.76% to 79.39% in the same period 3 .
The Psychosocial Care Network (RAPS) implementation in 2011 brings essential changes, such as free treatment in coordination between equipment.However, it also has challenges 4 .In practice, such network equipment can experience integration challenges and focus their practices within the institution, maintaining an asylum-oriented guardianship and dependence rationale 4 .
These hardships are sometimes used as justifications by managers for divestments in RAPS in a contentious setting 5 .Brazil has been undergoing an escalating dismantling of its social policies in recent years, involving historical underfunding, definancing, and setbacks with the implementation of Constitutional Amendment 95/2016 6 .
In this context, we have the approval of Resolution No. 32/2017, which determined the return of the psychiatric hospital to the treatment network with readjustment of daily rates and expansion of vacancies in Therapeutic Communities (TCs) -intended for drug abusers -from 4 thousand to 20 thousand 7 .TCs emerged in England in the mid-twentieth century, when the physician Maxwell Jones started the worldwide Psychiatric Reform movement, developing a TC model that aimed at greater patient participation in their treatment process and opposed the history of enclosure of allegedly socially maladjusted individuals 8 .
However, the expansion of these Brazilian institutions, which have been present since the 1960s, has been accompanied by alleged violations of the most basic human rights 9,10 .Nevertheless, since 2011, TCs have been part of RAPS in the country 11 .Amid the discourse of war against crack consumption, initiated in 2010 by the media and politicians, these institutions emerged and put pressure on the Federal Executive Branch to integrate them into drug user care 8 .
A set of documents are required as a mul-tistep process, among which we highlight: Ordinance No. 131, which established financing for TCs 12 ; Resolution No. 01 of the National Drug Council (CONAD), which regulated TCs within the National System of Public Drug Policies (SISNAD) 13 ; Ordinances N° 834/2016 and 1482/2016, which allowed TCs to request tax exemption through the Certification of Charitable Social Assistance Entities (CEBAS) in the health field 14 and be included in the  15 ; and Decree N° 9.761, which approved the new National Drug Policy, with a provision for additional investment for TCs 16 .
The regulations point to a return to the asylum paradigm, with public funding for prolonged hospitalization and deprived freedom for individuals 17 .There is a return to ethical treatment based on labor therapy and religious philanthropy: 82% of TCs in the national territory are linked to churches, especially those with a Christian matrix 9 .Some TCs impose a strict prayer routine and mandatory participation in religious activities 10 .Even so, the State has supported these religious entities, contrary to their secular character, provided for in the 1988 Federal Constitution 18 .
Another important aspect is that Brazilian TCs are hardly inspected, even when they receive public resources 10 , and their regulations do not have a team of professionals to deal with drug-abusing individuals 13,16 .
From this setting, Brazilian society faces the challenge of knowing how the experiences of individuals in these places have been taking place.This paper analyzes the role of religious TCs in the recovery of drug-abusing individuals, focusing on the impacts of religious methods for subjects who have resided in these institutions in the state of Espírito Santo.Thus, this work is structured as a brief presentation about the TCs in this state, the research's methodological paths, and the results obtained from the analysis.

therapeutic communities in the state of espírito santo
The state of Espírito Santo covers a total area of 46,074.444km 2 , distributed into 78 municipalities, and a total population estimated at 3,972,388 inhabitants 19 .Compared to other Brazilian states, the state is characterized by a significant presence of Pentecostal evangelicals and currents of mission evangelicals due to the strong influence of colonization of German origin in the region 20 .
TCs from Espírito Santo have always maintained a relationship with the state apparatus 21 .However, as of 2013, through the launch of the "State Program of Integrated Actions on Drugs", the state government provided for partnerships between the third sector, municipalities, the Federal Government, and households 22 23 .
Meanwhile, RAPS has a shortage of Psychosocial Care Centers for Alcohol and Other Drugs (CAPS ad) -strategic devices for the care of patients with alcohol and other drug abuse 24 -, beds in general hospitals and care units in all the administrative regions of the state 23 , characterizing disputes over public funding of treatment of drug users.
In this scenario, the prioritization of TCs reinforces our objective of analyzing their role in the recovery of these individuals, focusing on the impacts of religious methods on subjects who previously stayed in these institutions.

methods
This qualitative research involves semi-structured interviews with individuals with a drug use history and former members of religious TCs.We conducted 28 interviews: 21 of them based on the indication of professionals from CAPS ad in the Metropolitan region (Vitória, Vila Velha, and Serra) -a region with the highest concentration of drug user treatment institutions in the state 23 -and seven through indication of professors and researchers from a research group on the topic of drug use to diversify the sample.
The semi-structured interview roadmap consisted of sociodemographic data (date of birth, schooling level, marital status, and religion (if any)) and open-ended questions to draw the hospitalization period and the post-hospitalization period in the TCs.The roadmap was tested in a pilot interview, which was incorporated into the sample after verifying that it met the research objectives.A preset number of individuals to be interviewed was not established.The sample size was defined by theoretical saturation when data collection is interrupted when no new elements to support the desired theorization were provided 25 .
The interviews were conducted between October 2017 and March 2018, without interruptions and exclusions, with an average time of 40 minutes each.All interviews were recorded by an audio recorder and transcribed in full.The sharing of transcripts with the participants for comments or corrections was not provided for in the research due to the difficulty of scheduling visits with the respondents and the impossibility of doing it remotely because most of them do not have an email address or access to the Internet.
All data were collected by the principal researcher -a doctoral student and higher education professor -in closed rooms at CAPS ad or the university.The researcher had no previous relationship with the participants.No third parties were present during the interviews, and there was no need to repeat any interviews.
Besides the interviews, from the perspective of data triangulation 26 , we searched in the respondents' medical records indicated by the professionals to gather information regarding: 1. Sociodemographic data (name, date of birth, gender, schooling, religion, and access to social benefits); 2. The access route to health services; 3. Registration of admissions in TCs.This information was necessary before the interviews to obtain telephone contact for the indicated subjects; and, after the interviews, to complement the information already obtained or clarify doubts.
The Discourse Analysis was employed 27 to analyze data without any filing.After transcription, we read all the interviews to familiarize ourselves with the several discursive forms used by the subjects and identify meanings and ruptures in the material.Next, we identified analytical devices for accepting and denying TCs and their religious methods.Finally, we apprehended the ideological formations that permeated the re-spondents' discourses -a set of representations that originate the rules outlining discourse production in a context 27 .
The Research Ethics Committee of the Federal University of Espírito Santo (Opinion N° 2.333.891) and the Municipal Health Secretariats of Vitória, Vila Velha, and Serra approved the project.Fictitious names replaced subjects' names, and all agreed to sign the Informed Consent Form (ICF).

Results
Respondents were primarily male (20), aged between 21 and 56 years.Regarding schooling, 12 had incomplete (nine) or complete (three) elementary school, 14 had incomplete (three) or complete (11) high school, and four had incomplete (three) or complete (one) higher education.Most respondents were black.The length of stay and the number of hospitalizations in the TCs varied among the participants, which is not a determining aspect for the proposed analysis.
Their statements differed around the evaluation of their experiences within the TCs.These were organized into two axes: positive and negative evaluation.As it is not just a straight "yes" or "no", part of a group had a varying outcome -the respondents evaluated it positively but criticized it.

salvation by faith
Part of the respondents (13 respondents) pointed that the TC experience was positive, as follows: It was a perfect place, a place where I learned a lot.[...] They don't give medicines there, right?You are treated through the word of God: preaching and worship.It's for God's sake.No medicine, nothing.So, it was good for me to have stayed there.(Davi) We get better after we get in there, got it?The pastor will guide you, telling you that now it will be a new life, that you will change, that you are already someone else after you crossed the gate.You are no longer that person you used to live there looking out for drugs.(Alexandre) In these cases, the positive experiences were associated with accepting the religious methods they endured since, according to their statements, a new connection to God and a valued contact with His word in the worshipping moments could be observed within these locations.Resorting to God to stop using drugs appeared as the only alternative for some.In this sense, what appeared after their religious conversion was their dependence on God in many areas of their lives.The conversion was expressed as a process where one is "born again", a discourse very present in the statement of these respondents, which materialized through substantial changes in their lives from communicating with God: And change happened from the moment I accepted Jesus.I did some soul searching: it's not easy.You really want to use them (drugs), but you try to find other ways, and the only way I found it was to cling to Jesus.[ Accepting Jesus is the repeated mantra that points to conversion, understood as the highest point in assimilating the teachings accessed within the TCs.For evangelicals, the conversion consists of rebirth, from evident changes that usually occur when people are repentant and seek a solution to a disruptive situation, convinced that God would help them 28 .Respondents also started to associate drug use with the influence of the devil and other evil forces, through the invitation to use made by the devil disguised as a man: Look how the adversary disturbs us.At that time, I was not an evangelical.[...] from that door out, there will be many trays; trays are the friends who will see you.They will say 'where were you, man?', [...] Then they will introduce you to drugs and cachaça.'Oh, don't worry.One sip won't make a difference'.That's where you fall [...] So, I said in my mind, 'Satan is rebuked, in the name of Jesus! (Silvia) Blaming the "foe" for the use of drugs, the respondent's distancing from the understanding of the phenomenon of drugs in society was perceived, a distancing from the millenary history of drug use and capitalism's empowerment of these substances as goods 29 .With this process of moving away, what was left was to rebuke and watch over the evil force, moving away from ways of life that did not resemble the God's Word.
The act of entrusting to deities and religions the solution to problems or the responsibility for what happens to them can be understood as a strategy of human beings who live in a situation that exploits and oppresses them.Once inserted in such reality, they need illusions to survive 30 .In this sense, men dream of a fantasy world and project their essences onto a superior being, perhaps because they are unable to see, in the real-life of society, the conditions for developing their humanity 31 .
Such movement denoted a self-distancing of these respondents as social beings, a movement of inhumanity, which was socially constructed in their daily lives 32 .In a social and political dimension, as an expression of man's alienation from his real world, this process can be understood as alienation that sometimes contributes to the perpetuation of a given society 33 .We can observe this self-distancing in the reports mentioned above.However, sometimes, even defending TCs as beneficial in their treatments, some (four) individuals criticized the institutions.

I have my caveats against this salvation process
Part of these 13 respondents criticized the TCs.The main complaints were the food served, staff 's authoritarianism, the lack of inspections, and residents' exploitation in exhaustive and compulsory work.Regarding the last aspect, the most mentioned by these participants, the criticisms referred to the work for the internal maintenance of institutions, such as cleaning, weeding, food preparation, and work carried out outside the TCs, such as the sale of products in collective vehicles.Such activities are called "labor therapies" and are one of the main working methods of these institutions and are justified as they promote discipline and change the habits of residents 34 .
Labor therapy is used in more than 90% of Brazilian TCs 9 .It is far from care-based methodologies because, among other aspects, it is not formulated on a technical, theoretical, or scientific basis.It is also not part of the singularities of each individual since, in most institutions, there is a lack of a singular therapeutic project 10 .Also, TCs are prohibited from submitting those receiving shelter to forced or exhaustive activities, subjecting them to degrading conditions 13 .
Furthermore, when they were activities that generated money for the institutions, individuals felt exploited, as they did not consider that the profit obtained from sales was used for the benefit of the residents, but only for the benefit of the managers.Such annoyance was enhanced when the residents were aware that the TC received different types of resources to operate: How did I feel?Pay to work for others?I'm really telling the truth, right?[...] I worked in the fields, a farm there that I had to clear, take the scythe and pull it out, understand?I paid two minimum wages and a staple food basket, besides the government that contributed.(Reinaldo) According to a report by the Institute for Applied Economic Research (IPEA) (2017) 9 , 25% of the existing TCs in the country receive public funds.Furthermore, we have that 75.4% of the places receive donations from people who support the cause, 66.6% receive voluntary contributions from the residents' relatives, and 63.5% receive church donations 9 .Even in the face of funding, 46% of national TCs charge a monthly fee to the sheltered ones, and, despite this, they keep the place's maintenance activities under the responsibility of residents 9 .
It is important to emphasize that such criticisms did not lead them to evaluate the general experience lived within the institutions negatively.Thus, these 13 respondents assessed TCs as institutions that helped them in their drug abuse treatment, and all of them showed great acceptance of the religious methods accessed during admissions.

A swamp in the search for help
Unlike these participants, other 15 respondents in the survey expressed that the passage through the TCs did not play a positive role in their recovery processes and TCs were not efficient institutions for the treatment of drug abuse: I am going say it straight out.I didn't learn anything there.I used even more drugs.It didn't do me any good.I just went to make my family know I was there just as make-believe...just to cheer them up, understand?(Reinaldo) So, it was nothing.After I left there, the time I was there didn't add anything to me.(Débora) These respondents criticized and rejected the institutions' religious methods such as prayers, cults, and biblical exercises.They stated that prayers were not adequate for the treatment and criticized reading and interpreting the Bible, not generally agreeing with the understanding given to them by the leaders.They opposed the path of religious salvation, to the idea that God supplies everything and, thus, a relationship of dependence with Him in all areas of life: There is no such thing as the devil, demon, and the like.Don't spiritualize everything, no.'You're using it because it's the devil; you're possessed, it '

s the demon that put an arrow in you'. It has nothing to do with it. I want to do this [...], so I have to work with this desire of mine and this desire to deny what I feel. It is elementary for me to transfer my guilt to others, which is much simpler. (Bruno)
The respondent fought against a view among neo-Pentecostalism adherents: that everything that happens on the earthly plane derives from what happens on the spiritual plane 35 .This belief alleviates our guilt, our responsibility, and our autonomy in the face of the world 35 .For the participant, it is necessary to leave the scope of "it's God's will" or "because the devil wished so".However, when stating, "I want to do this", he mentions a single dimension of drug use and leaves out the social and economic dimensions.In other words, polarization masks the multiple dimensions in the drug-human relationship.
These participants also opposed the rules of the institutions, reporting, above all, discomfort with the control to which they were submitted, with the deprivation of freedom and with the authoritarianism of employees in the institutions: So, I lived this terror.Obliged to have to do..

. you have to get up. You have to do your work. You have to be at the table. You have to do this. You have to do that right away: an obligation, you know? They don't let us think about anything or stop and think... even that, even that they keep watch, God is more! [...]. I couldn't talk on the phone. I couldn't contact my family. It looks like you're defeating yourself there. (Rita)
Look, a violation is that constant of you not being able to leave, right.I never liked being stuck, not having access to the street.(Adriano) Such reports meet the characteristics of most Brazilian TCs: 35% of them allow family visits from the onset of treatment; the others establish temporal rules and, sometimes, participation in preparatory activities 9 .Only 5% of locations allow visits at any time 9 .Some also prevent contact with friends (17%) and boyfriends/girlfriends (11%) 10 .In this research, participants reported that visits took place on specific dates and were monitored.
Concerning the means of communication, 91% of the TCs do not allow the residents to use a cell phone, and 86% do not allow internet access.Some also prohibit access to television (7%), books, magazines, and newspapers (39%) 9 .This research obtained reports that the programming that could be accessed on television was only religious, previously selected by the leaders of the institutions.Access to books was restricted to the Bible.
Regarding discipline, we can note that TCs have a series of obligations, which consist of compulsory participation in therapeutic activities, including courses (60%), religious ceremonies (53%), and labor therapy tasks (73%) 9 .
Contrary to the Psychiatric Reform, TCs are similar to total institutions, defined by Goffman 36 as places of residence and work where a large number of individuals, separated from society, lead a closed and formally managed life.Thus, TCs resemble total institutions in several aspects, especially in social isolation and discipline, as they lead to a loss of individuality and subjectivity of subjects who start to be controlled at all times 37 .
All these characteristics violate what is provided for in CONAD Resolution N° 01/2015, according to which TCs must ensure the participation of the family or person indicated by the patient in the reception process and social reintegration actions 14 .Furthermore, they violate the 1988 Federal Constitution of 1988, which includes under its principles human dignity 19 ; and the Bill of Rights of Health Users, which advocates that every citizen has the right to adequate, respectful, humanized, and effective treatment, free from any discrimination 38 .
These participants also criticized labor therapy, mentioning that they felt exploited.Other criticisms of the institutions were identified: reports on the directors' appropriation of money and belongings of patients received; mention of drug use within one of the TCs by employees, coordinators, and residents; and physical violence perpetrated against the patients.These reports lead us to question the fundamental objectives of some of these institutions since promoting drug use is something that opposes the objective to which the TCs are publicly committed: the spiritual rebirth of individuals, traversing abstinence as an essential condition for that goal.
In a punitive and moral approach, the use of violence and punishment towards residents is based on the understanding that the drug user is an offender, a violator of limits, or even a sinner in need of harsh and merciless correction 37 .
It is important to emphasize that, while these respondents denied TCs and their religious methods as a treatment option, four of them recognized that religion could play an essential role for those who seek to abandon or reduce drug use, but not within TCs' compulsory schemes.
These participants recognized the religious spaces of society as a source of social support.According to Valla et al. 39 , these places offer support groups and create motivations for individuals, especially in poverty, to face their problems in a society that daily denies them opportunities.Evangelical churches stand out in this type of support because they represent the working classes, promote a sense of group belonging, and disseminate an optimistic perspective of life 39 .Notwithstanding this, these respondents considered the religious spaces a complement to treatment, as they include drug abuse as a health issue.They reported that they only improved with the monitoring of professionals in this field, and the most mentioned equipment was the CAPS ad, as it provided free treatment for individuals.
In a nutshell, these 15 individuals did not recognize that TCs and their methods were efficient for drug use treatment.On the other hand, they advocated the understanding of drug use as a health issue, which should be monitored professionally, with respect, and without the need for deprivation of liberty.

Conclusion
The research evidenced discourses regarding the role of religious TCs: 13 respondents reported that institutions played an essential role in their treatment processes, and 15 respondents argued that the institutions were inefficient in their treatment.Regarding the impacts of the religious methods accessed inside the places, we could apprehend that the same 13 participants mentioned advocated that the moments of prayer and reading of the Bible helped them, whereas the other 15 participants reported that these methods were ineffective.
Thus, on the one hand, these subjects indicated a relationship between acceptance of religious methods and positive evaluations of admissions and the denial of religious methods and negative evaluations of admissions, on the other.Such associations do not seem random since one of the pillars of Brazilian TCs is the moral-spiritual-religious restoration of individuals.When this principle is denied, it is as if, in general, the institution was being denied as a possibility of treatment.
We emphasize that the respondents who incorporated the religious ideology started to attribute the events of their lives to the spiritual plane, a "spiritual war" waged between good and evil, whose leading figures are not human beings, but God and the devil/demons.These ideas denote alienation: the distancing of the social being and the detachment from social life with its historical relations of power, class struggle, and economic structure.
To morally transform subjects, TCs focus on conversion.They impose an understanding of drug use as an individual issue, associated with sin and the interference of malignant forces, on an alienating trajectory of such a complex phenomenon.Under the devil's guise, the man-drug relationship takes on explanatory particularities and specific prescriptions for overcoming it.
In turn, in its social and political dimension, religion acts as an expression of man's alienation from his real-world and social conformation with this world, perpetuating a given society as an anesthetic that paralyzes individuals in the service of capitalism 34 .
Although this alienation observed in religious TCs caused the respondents to distance themselves from themselves, it also caused, for some, an approximation of explanations that could provide emotional comfort, social support, and hope for a better life.Thus, we understand that we cannot reduce religiosity to mere alienation in its negative sense 40 .
We could also observe that both respondents who rated the TCs positively and negatively criticized the institutions, especially about food, staff 's authoritarianism, the routine of activities to which they were submitted, and the lack of inspection of the spaces.Besides these criticisms, other complaints about violence and drug use within the TC were also made, but only by those who denied these institutions as a place of care and treatment.They advocated the treatment in freedom, in health facilities, with access to qualified professionals, and medication use, commonly citing the CAPS ad as an example.The participants' criticisms and the fact that these institutions are increasingly accessing public funding point to the urgent need to be properly inspected by the government.Also, we highlight the importance of research dedicated to an in-depth understanding of the functioning of Brazilian TCs, especially those that do not use forced labor or other impositions, since some individuals claimed to have benefited from the treatment accessed.The limits of this work were found within the experiences reported by the former residents, not covering a study of the institutions themselves, which can be better exposed to avoid generalizations.
We also emphasize the importance of studies that assess the effectiveness of TCs concerning the abstinence of drug abusers since the data pointed to a trend that, in most cases, abstinence was not maintained when the users left the institutions.
Finally, given the objectives and working methods of the religious TCs, there remains a debate about their relevance as publicly funded places for the treatment of the drug user popu-lation.The reports here express the need not to naturalize moralistic, standardizing, and authoritarian practices and theories found in our society.

Collaborations
G Bardi worked on conducting the research, and writing, reviewing and formatting the article.MLT Garcia worked on the research conception and supervision, and on the writing and article review.