Acessibilidade / Reportar erro

Accountability and participation: how to overcome the tutelary character in the psychosocial care center for alcohol and drug users?

Abstract

OBJECTIVE

Analyze the degree of accountability and participation of user under treatment at the Psychosocial Care Center for Alcohol and Drug Users (CAPS-ad) from the harm reduction policy perspective.

METHODS

It is a qualitative approach study, case study type, with 12 users and four professionals from CAPS-ad in a county of Minas Gerais state. Data were collected from April to September 2017, by means of semi-structured interview, participant observation and documental analysis.

RESULTS

Based on content analysis, information was organized in two thematic categories: treatment objectives and motivation for treatment. Conclusions: the study’s findings revealed that users should be more held accountable and empowered with regard to their treatment.

CONCLUSIONS

More professional listening is suggested, favoring the constructions of goals befitting users’ interests, as contracts.

Keywords:
Mental health; Community mental health services; Drug users; Harm reduction; Patient care planning

Resumo

OBJETIVO

Analisar o grau de responsabilização e participação do usuário em tratamento no Centro de Atenção Psicossocial Álcool e Drogas (CAPS-ad) sob a perspectiva da política de redução de danos.

MÉTODOS

Trata-se de uma pesquisa de abordagem qualitativa, do tipo estudo de caso, com 12 usuários e quatro profissionais do CAPS-ad de um município de Minas Gerais. Os dados foram coletados entre abril e setembro/2017 por meio de entrevista semi-estruturada, observação participante e análise documental.

RESULTADOS

A partir da análise de conteúdo, as informações foram organizadas em duas categorias temáticas: objetivos do tratamento e motivação para o tratamento. Conclusões: os achados da pesquisa revelaram que os usuários devem ser mais responsabilizados e empoderados em relação ao seu tratamento.

CONCLUSÕES

Sugere-se maior escuta profissional, favorecendo a construção de metas condizentes com os interesses dos usuários, na forma de contratos.

Palavras-chave:
Saúde mental; Serviços comunitários de saúde mental; Usuários de drogas; Redução do dano; Planejamento de assistência ao paciente

Resumen

OBJETIVO

Analizar el grado de responsabilización y participación del usuario en tratamiento en el Centro de Atención Psicosocial alcohol y drogas (CAPS-ad) a partir de la perspectiva de la política de reducción de daños.

MÉTODOS

Se trata de una investigación de abordaje cualitativo, del tipo estudio de caso, con 12 usuarios y cuatro profesionales del CAPS-ad de un municipio de Minas Gerais. Se reunieron los datos entre abril y septiembre/2017 por medio de entrevistas semiestructuradas, observación participante y análisis documental.

RESULTADOS

A partir del análisis de contenido se organizaron las informaciones en dos categorías temáticas: los objetivos del tratamiento y la motivación para el tratamiento. Los resultados del estudio sugieren que hay que responsabilizar más a los usuarios en cuanto a su tratamiento.

CONCLUSIÓN

Se sugiere más escucha profesional, favoreciendo la construcción de objetivos coherentes con los intereses de los usuarios, además de factibles, en la forma de contratos.

Palabras clave:
Salud mental; Servicios comunitarios de salud mental; Consumidores de drogas; Reducción del daño; Planificación de atención al paciente

INTRODUCTION

Drugs have always existed in all societies with different conceptions (ideological, religious and/or political) incorporated to the culture, reaching today epidemic proportion in terms of harmful consumption. It is known the use of alcohol and other drugs is a serious public health problem in Brazil and in the world, due to the confirmed relation involving harmful consumption, physical, psychological and social injuries.

The World Health Organization estimates that around 5% of adult population with age between 15 and 64 years old (quarter of a billion people) used drugs at least once in 2015; and that 11% of those who consume drugs (29.5 million people) suffer disorder due to the use of drugs to the extent of needing treatment11. United Nations Office on Drugs and Crime [Internet]. Vienna: UNODC; c2018 [cited 2018 Apr 25]. World Drug Report 2017; [about 1 screen]. Available from: http://www.unodc.org/wdr2017/.
http://www.unodc.org/wdr2017/...
.

In Brazil, the Psychosocial Care Center for Alcohol and Drug Users (CAPS-ad) is a service modality that offers treatment to individuals with needs resulting from abuse and addiction to psychoactive substances22. Galhardi CC, Matsukura TS. The daily routine of teens at a Center for Psychosocial Care for Alcohol and Other Drugs in Brazil: realities and challenges. Cad Saúde Pública 2018;34(3):e00150816. doi: https:/doi.org/10.1590/0102-311x00150816.
https:/doi.org/10.1590/0102-311x00150816...
. It is a specialized service from the Psychosocial Care Network (RAPS) that works from the perspective of re-organization of public services’ assistance, recommending universal access and free circulation of the user in the territory, offering full care with quality, centered in demands and based on respect to human rights and autonomy of users33. Nóbrega MPSS, Domingos AM, Silveira ASA, Santos JC. [Weaving the West Psychosocial Care Network of the municipality of São Paulo]. Rev Bras Enferm. 2017;70(5):965-72. Portuguese. doi: https://doi.org/10.1590/0034-7167-2016-0566.
https://doi.org/10.1590/0034-7167-2016-0...
.

At CAPS-ad, the harm reduction approach is often used as guide for teams’ conduct, as political and health care guideline, but sometimes its interventions are disregarded, becoming an optional action only when abstinence can’t be achieved. It is, therefore, a strategy that aims at breaking with models of drug stigmatization to promote the emergence of other therapeutic possibilities for use and addiction44. Carvalho B, Dimenstein M. [Discourse analysis about harm reduction in a CAPSad III and a therapeutic community]. Temas Psicol. 2017;25(2):647-60. Portuguese. doi: https://doi.org/10.9788/TP2017.2-13.
https://doi.org/10.9788/TP2017.2-13...
. Different harm reduction interventions should be implanted to minimize harms and injuries associated to drug consumption55. Bosque-Prous M, Brugal MT. Intervenciones de reducción de daños en usuarios de drogas: situación actual y recomendaciones. Gac Sanit. 2016;30(S1):99-105. doi: https://doi.org/10.1016/J.GACETA.2016.04.020.
https://doi.org/10.1016/J.GACETA.2016.04...
.

This approach aims at minimizing harms and consequences to health as well as social and economic circumstance associated to drug use, and interventions are intended for persons who can’t or don’t want to interrupt drug consumption. It recommends that the management of individual issues related to consumption should consider each person’s singularities, and strategies should be built in a participating way together with each subject, in a process of co-accountability for the choices made66. Pinto LO, Oliveira DJ, Duarte FMR. [Informative group: harm reduction strategies for people apprehended for illicit drug consumption and/or possession]. Interface (Botucatu) 2015;19(supl 1):965-93. Portuguese. doi: https://doi.org/10.1590/1807-57622014.0870.
https://doi.org/10.1590/1807-57622014.08...
.

Harm reduction is an important guideline for the work of professionals from CAPS-ad, because it proposes a new look at drug abuse while seeking to respect the user free will to decide for use moderation or abstinence of drugs and favoring access and effective participation in health care services. Thus, the main aspect of this approach is the inclusive attitude, without prejudices, which results in more flexibilization to negotiate and set objectives and goals to be reached with the treatment.

Starting from the practical dimension of health care in a specialized service, we can ask: How is the drug user participation and involvement in his/her treatment? This paper sought to analyze the degree of accountability and participation of the user under treatment at CAPS-ad from the harm reduction policy perspective.

It is considered necessary to reflect on traditional assumptions that guide practices in the ambit of public policies in Brazil, because users of health care services are hardly ever questioned about their participation and protagonism in the formulation of health programs and actions in the services’ routine. With regard to drug users, the scientific literature reports that this is not different, because they are often considered passive agents in this relation 33. Nóbrega MPSS, Domingos AM, Silveira ASA, Santos JC. [Weaving the West Psychosocial Care Network of the municipality of São Paulo]. Rev Bras Enferm. 2017;70(5):965-72. Portuguese. doi: https://doi.org/10.1590/0034-7167-2016-0566.
https://doi.org/10.1590/0034-7167-2016-0...
.

METHOD

This research was built with the Professional Master Degree in Prevention and Assistance to Alcohol and other Drugs Users77. Santos JM. A participação dos usuários no plano de tratamento em um CAPS-ad: um estudo de caso [dissertação]. Porto Alegre (RS): Hospital de Clínicas de Porto Alegre, Mestrado Profissional em Álcool e outras Drogas; 2017., promoted by Porto Alegre Clinics Hospital (HCPA), in a partnership with the National Secretariat for Policies on Drugs of the Ministry of Justice. It is a qualitative approach research, with case study type design88. Yin RK. Pesquisa qualitativa: do início ao fim. Porto Alegre: Penso; 2016., made in the CAPS-ad of Ouro Preto, Minas Gerais, Brazil. Such service offers stay-day and outpatient services to alcohol and other drugs users, and count on a multi-professional team comprising general practitioner, psychiatrist, nurses, psychologists, occupational therapists, licensed practical nurses and monitors for therapeutic workshops. It is open from 8 am to 5 pm, from Monday to Friday, with duties during the whole working hours to assist new cases.

This service interacts with the county RAPS and other partners like Casas de Cultura, Universidade Federal de Ouro Preto, Fundação de Arte de Ouro Preto, association of users and families of RAPS and income generating workshops.

Information collection occurred from April to September 2017, at the service’s premises, and different techniques were used for data collection, like documental analysis (DA), participant observation (PO), semi-structured interviews with users (UI), and with professionals (PI). Twelve users and four professionals from CAPS-ad were interviewed and data collection was made by one researcher, member of the service’s care team.

The interviews with users addressed themes like: objectives, motivations and participation in the treatment. The interviews with professionals the following themes were addressed: participation and objectives in the conduction of the treatment of a user of his/her reference. Services for review of PTS (single therapeutic project) were observed as to objectives and participation of the user in the treatment, and the interaction of professionals with users. In the documental analysis, objectives, motivations and proposals of treatments recorded were verified.

The users of CAPS-ad were selected per convenience and inclusion criteria adopted were: be user of alcohol and/or other drugs, be 18 years old or more and under treatment at CAPS-ad for at least three months, in intensive or semi-intensive treatment modality. Thus, the users interviewed were under Stay-Day regime, attending the CAPS-ad during part of the day and participating in the activities proposed. Users with marked cognitive impairment, severe psychiatric co-morbidity or intoxicated at the moment of the interview were not included. Interviews were made with users until content repetition was identified in interviewed speeches, according to data saturation criterion where there is sufficient number of interviews that permits certain reincidence of information88. Yin RK. Pesquisa qualitativa: do início ao fim. Porto Alegre: Penso; 2016..

With regard to professionals, all those who were reference in the preparation and conduction of the Single Therapeutic Project (PTS) for users in the service were interviewed, with at least one year experience at CAPS-ad. Each participant in the study (users and professional) was interviewed only once. The participant observation was made during PTS review services, with the presence of the user’s reference professional, that is, the one accountable for the PTS of the respective user. Documental analysis was directed to PTS medical records and forms, contemplating all users interviewed.

The final sampling comprised: five PO, 14 DA, 12 UI and four PI. All users and professionals involved in the study signed the Free and Informed Consent Term (TCLE). Data collected were identified by initials of the research technique and corresponding number, to facilitate quotes and preserve participants’ anonymity (Ex. PI-01, PO-7).

All techniques had specific scripts for the field work. No change was made in the scripts after the pilot test and interviews lasted from 10 to 40 minutes. With the collection techniques, triangulation of data was possible, and the participation and accountability of the user in the treatment could be analyzed, providing more validity to the study’s findings88. Yin RK. Pesquisa qualitativa: do início ao fim. Porto Alegre: Penso; 2016..

Interviews were recorded and transcribed, and kept with DA and PO records, and later on Bardin’s thematic content analysis was performed99. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2015.. Such analysis comprises three stages: pre-analysis (data organization and classification, using skimming reading, preparation of hypotheses and objectives the ground the interpretation); exploration of the material (re-readings and codification of data based on record units); treatment of results and interpretation (data categorization and classification in thematic categories and subcategories)99. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2015.. Then, data were organized in two thematic categories: objectives of users in the treatment and motivation of users for the treatment.

Information collection only started after approval by the Research Ethics Committee from HCPA (opinion n.º 1.887.083 of 01/04/2017) and upon signature of TCLE by participants before each stage of the study, following legal orientations.

RESULTS

To analyze the user participation and accountability for the treatment in CAPS-ad, from harm reduction perspective, information referring to motivations, objective and ties of the treatment were raised. Based on the analysis of users and professionals’ interviews content, observations made in services and assessment of PTS forms and users’ medical records, triangulation of data collected was possible, with convergence of results from different sources, validating the information88. Yin RK. Pesquisa qualitativa: do início ao fim. Porto Alegre: Penso; 2016..

Twelve users were interviewed with ages between 39 and 61 years old, eight men, seven with incomplete middle school, two with secondary technical school level, all of them alcohol users. Four of them were also crack users; however some were abstinent of at least one of these drugs. With regard to the professionals interviewed, their experience in this CAPS-ad ranges from three to eight years.

Users’ objectives with the treatment

One of the main objectives of users in the treatment was abstinence; however, in the practice of follow-up of these users in CAPS-ad, it was observed that this objective many times was not achieved.

Though the main focus of the users interviewed is abstinence, some expressed the intention to reduce harms associated to consumption, expecting to be able to keep a controlled use. In addition to these objectives, few users pointed out improvement in their well-being and recovery of health and self-esteem.

Stop drinking, really, and stop using drugs. (UI-06)

Here [CAPS-ad] I don’t feel like drinking. (UI-09)

The intention is to stop, not totally, because if you stop totally at once it is worse. What is killing me is cachaça, I can drink beer, drink wine, and they do me no harm. (UI-11)

Take more care of my health. Once in a while I drink a beer, but it is very rare, for not to relapse. What I fear is relapse. (UI -05)

Seek my treatment of reconcile with myself. (UI -01)

Have a better life, in general, in personal, professional and health terms. (UI -03)

On the other hand, the documental analysis revealed that the main objective defined in PTS forms are re-socialization and social re-insertion of the user. It was verified that these objectives recorded by the professional were repeated, as a kind of “standard indication” for all users, somewhat vague, suggesting poor assessment and analysis of the needs and singularities of the individual in PTS preparation. Moreover, these records did not include specific actions informing how these objectives would be reached, that, there was no information on concrete strategies to reach such objectives.

It was very hard to him [work on motor coordination], not to do it, but the desire to be there doing, to interact with that task [...]. Even when the PTS was made considering skills for him to work on, he is very resistant to what he doesn’t like. (PI-01)

For her to be the master of her actions, [...] to be more prudent with life. (PI -03)

Re-socialization in group and social re-insertion. (DA-01 and DA -09)

Professional suggests abstinence but the user denies that he makes abusive use. Participation in AA [alcoholics anonymous] is proposed. (DA -13)

‘I don’t want to be fully sober, I like social life’ [user]. (PO-05)

In professional PI-01 report, it can be observed that the user objective does not match the objective proposed by the PTS professional, showed by his superficial adhesion to the activities proposed. The reference therapist intends to preserve or develop the user motor coordination, prejudiced by alcoholism, but such objective does not correspond to the user’s expectations and priorities. There is divergence of perspective and interests of the reference therapist and those of the user, which also appears in user UI-11 speech, who intends to reduce harms associated to abusive consumption of alcohol, while the reference therapist suggests abstinence (DA-13). The therapist suggestion is based on the assessment of market risks and harms in the user clinical condition, showing certain distance between user and professional objectives.

Though it is acknowledged that the professional should be attentive to alcoholism psychodynamic processes, like denial and minimization of abusive use of substance and its losses, the use of care strategies based on harm reduction as a professional method to assist the user, conciliating, as much as possible, his interests as health professional with the user’s interests, as the most interested part in the treatment is not explicit.

Users’ motivation for the treatment

With regard to motivation, considered an important factor in the treatment, users were questioned about their motivation to undergo treatment. Large part of them mention the sought for improvement of their health and relationship with family (sons and siblings) as the most motivating factors.

Relationship with my siblings. (UI-03)

For me to get better [...] I’ve seen death before. (UI-05)

First my kids, they all demand it. (UI-07)

First is my health. (UI-11)

Among the motivating aspects mentioned in interviews, we can see that family plays an important role in users’ motivation for the treatment. Despite this relevance, in this study it is little mentioned in records analyzed (medical reports and PTS forms), evidencing poor visibility of its involvement in the user treatment. The cases that presented records of more family presence were situations of users with severe depression, with accidents caused by abusive use and in situations of family demand for involuntary admission.

Another issue reported as motivating factor for users was the CAPS-ad team itself, because the interaction provided by professionals leads to the creation of bonds that have positive repercussion in their motivation.

Their willingness to see us well, the team [...] to see me sober [...] gives me strength to be here every day. (EU-01)

The respect the employees here show to us [...] Their education, they treat us so well [...] And to say that we are not well taken care of [....] Here we learn to respect other people out there, because employees here advise us on how to behave in the streets, with people, respecting each other and everyone’s right to come and go. (UI-02)

It was observed that users consider their relation with CAPS-ad professionals meaningful in their networks of social relations, because they feel motivated with the treatment, based on the way professionals interact with them (respect to the user dignity), and the way these professionals provide guidance for their conducts in social life (counseling of forms of social life and citizenship).

In addition to family and respect by CAPS-ad professionals’ respect, some users indicate financial losses and achievement of social integration as motivating factors of the treatment.

First came losses [...] I sold the last car, exchanged for a VCR [...] No longer suffer losses and create accountability, which I didn’t have. (UI-08)

To be more integrated in society. (UI-12)

Though financial losses were little mentioned by users in this research, in the service routine they represent an important motivating factor for the treatment due to estate compromise and debts made. Besides, being integrated in society, also little mentioned by the user, is a fundamental goal that coincides with psychosocial rehabilitation proposals targeted by mental health policies.

In the user speech recorded in PO-05, it is evident his consideration of a risk situation that denotes implication of the user in the treatment. In the PI-04 interview, on the other hand, a tutelary character can be observed in the approach to the user, who, in his turn, while answering the reference therapist, demonstrates disengagement with the treatment and life projects.

Always demands attention, [...] managing of his money, always requesting me, but he doesn’t adhere to the activities proposed [...] when he is not here, he will stay all day in the streets [...] using. [...]. It is hard to think of a therapeutic project for him because he is resistant [...] any activity, anything that makes him do more, for any change, [...] ‘but you are falling, you are getting hurt, you can die [...]’ [professional], and the user says: ‘If I die I’m dead’. (EP-04)

‘Money is my risk [...] sometimes you don’t fall the first time you receive, but you may fall in the second, or third time [...] my risk is during the 4 days after pay’ [user]. (PO-05)

The PI-03 interview presents an expanded concept of PTS, where the treatment plan is entangled with the user life itself, constantly changing, being dynamic and differentiated for each location where the user circulates.

I no longer see the person functioning in one way [...] but it multiplies as his horizons expand, so I think that for each moment of life, for each place, treatment possibilities increase, for example, if the person has a bond in church [...] a bond in the school where he studies, a bond with art, with the health clinic, in fact, each of these places, each territory, will make possible for him to de-territorialize, make different care plans, at each place he will care differently. It is obvious that deep down it is care to this person, by this person has a multiple life. (PI-03)

I like to participate in travels [...] for me is a learning [...] I have such ideas [...] I thought that I would arrive at CAPS today and would talk about that in the meeting, and sometimes I heard the thing I wanted to talk about in the meeting, I see it repeated on the radio, even in politics. (UI-08)

The PI-03 interviewed brings the concept of territory in motion, that is, with exits from their own space (geographical and relational) and occupation of other spaces, because the user is inserted in different contexts, like family, church, school, health clinics, CAPS-ad, relations, among others. The reference therapist has no control on users’ activities and actions in their life contexts, but when the professional becomes familiarized with the choices made by one user, a complicity space is created that makes possible therapeutic follow-up in the different territories, which are the different care plans. Understanding this dynamics is walking along with user, under the principles of harm reduction, in a process that involves listening, direction, acceptance and adaptation.

The report of user UI-08, who integrates the users association shows this territory concept with its movements of leaving and re-occupation. The frequent travels and participation in events, meetings and conferences lead these users to appropriate themes related to the policy and citizenship actions, favoring to the individual the multiplicity of life. So, the user gets involved and holds himself accountable for his life and his own treatment.

DISCUSSION

In the present study, the users’ objectives in the treatment partially differ from the professionals’ objectives, because these latter determine as main objective the abstinence of drugs due to clinical issues identified, regardless of users’ participation in this definition. The users’ involvement in alcohol and other drugs treatment has high potential to work on objective from different groups, exploring their specific needs to adapt health care services1010. Crabtree A, Latham N, Bird L, Buxton J. Results of a participatory needs assessment demonstrate an opportunity to involve people who use alcohol in drug user activism and harm reduction. Harm Reduct J. 2016;13:37. doi: https://doi.org/10.1186/s12954-016-0126-x.
https://doi.org/10.1186/s12954-016-0126-...
.

These objectives can be based on care strategies grounded in harm reduction principles, reconciling the user and the professional’s interests by proposing specific actions to reach the negotiated objectives. However, the lack of knowledge on alcohol harm reduction, along with racism, violence and marginalization, constitute barriers to the collaboration and engagement of these groups in the treatment, because the harm reduction strategies worked on in services (supposing they are) are still focused on illegal drugs1010. Crabtree A, Latham N, Bird L, Buxton J. Results of a participatory needs assessment demonstrate an opportunity to involve people who use alcohol in drug user activism and harm reduction. Harm Reduct J. 2016;13:37. doi: https://doi.org/10.1186/s12954-016-0126-x.
https://doi.org/10.1186/s12954-016-0126-...
. Despite the evident progress achieved in harm reduction, it is important that it is not restricted to the consequence of the use of intravenous drugs, but is concerned with programs related to other substances and other consumptions like alcohol, tobacco55. Bosque-Prous M, Brugal MT. Intervenciones de reducción de daños en usuarios de drogas: situación actual y recomendaciones. Gac Sanit. 2016;30(S1):99-105. doi: https://doi.org/10.1016/J.GACETA.2016.04.020.
https://doi.org/10.1016/J.GACETA.2016.04...
and cocaine/crack (snorted and smoked).

The management of this care, as organized in PTS, can be done in case management modality, considered by the international literature as an appropriate approach to meet the multiple and complex needs of drug users1111. Morandi S, Silva B, Golay P, Bonsack C. Intensive case management for addiction to promote engagement with care of people with severe mental and substance use disorders: an observational study. Subst Abuse Treat Prev Policy. 2017;12:26. doi: https://doi.org/10.1186/s13011-017-0111-8.
https://doi.org/10.1186/s13011-017-0111-...
, obtaining promising results when this modality is combined with other care strategies1212. Savic M, Best D, Manning V, Lubman DI. Strategies to facilitate integrated care for people with alcohol and other drug problems: a systematic review. Subs Abuse Treat Prev Policy. 2017;12:19. doi: https://doi.org/10.1186/s13011-017-0104-7.
https://doi.org/10.1186/s13011-017-0104-...
.

Studies demonstrate that family can influence the production of drug abuse, as risk facto or as protection to its members, thus playing a relevant role in users’ motivation for the treatment1313. Vasconcelos ACM, Araújo LN, Porto LGM, Rocha NNV, Oliveira EN, Albuquerque JTP. [Family relationships and chemical addiction: a literature review]. Rev Bras Ciênc Saúde. 2015;9(4):321-6. Portuguese. doi: https://doi.org/10.4034/RBCS.2015.19.04.11.
https://doi.org/10.4034/RBCS.2015.19.04....
. When the family is affectively distant, with little dialogue and poorly defined boundaries, the use of substances is favored; but when the family is welcoming, develops appropriate communication and promotes affection and protection, it assumes a protective role against drug abuse1414. Paz MF, Colossi PM. [Chemical dependence family dynamic aspects]. Estud Psicol. 2013;18(4):551-8. Portuguese. doi: https://doi.org/10.1590/S1413-294X2013000400002.
https://doi.org/10.1590/S1413-294X201300...
.

The drug user family is an important part of this process, because the user relations with his social and family context should be contemplated in the integral care1313. Vasconcelos ACM, Araújo LN, Porto LGM, Rocha NNV, Oliveira EN, Albuquerque JTP. [Family relationships and chemical addiction: a literature review]. Rev Bras Ciênc Saúde. 2015;9(4):321-6. Portuguese. doi: https://doi.org/10.4034/RBCS.2015.19.04.11.
https://doi.org/10.4034/RBCS.2015.19.04....
. The insufficient participation of users and their family in PTS negotiation, combined with the difficulty to extend actions to beyond CAPS (care and social support network) are barriers for an appropriate treatment plan1515. Vasconcelos MGF, Jorge MSB, Catrib AMF, Bezerra IC, Franco TB. [Therapeutic design in Mental Health: practices and procedures in dimensions constituents of psychosocial care]. Interface (Botucatu). 2016;20(57):313-23. Portuguese. doi: https://doi.org/10.1590/1807-57622015.0231.
https://doi.org/10.1590/1807-57622015.02...
.

The present study demonstrated that family has little involvement in users’ treatment in CAPS-ad. Thus, in order to avoid a limited care approach, the family can be an important partner in the preparation and monitoring of PTS, and so, strategies should be created to involve relatives (family) in this construction, holding them accountable for this process as well.

The current model for drug user care assign new roles to professionals, users and relatives, emphasizing the sharing of accountability by those involved in1616. Oliveira EN, Santana MMG, Eloia SC, Almeida PC, Felix TA, Ximenes Neto FRG. Projeto terapêutico de usuários de crack e álcool atendidos no centro de atenção psicossocial. Rev Rene. 2015 [citado2018 abr 10];16(3):434-41. Disponível em: http://www.periodicos.ufc.br/rene/article/view/2819.
http://www.periodicos.ufc.br/rene/articl...
. This research showed that users’ bonds with professionals and the service are strong and affectionate, due to the efforts made by professionals in accepting and taking care of users, thus serving as motivating factors for their attendance to the service, which has favored their self-esteem and social relations.

The development of therapeutic project in mental health services like those of CAPS-ad is a central strategy for care production while seeking to implement horizontal relations (professional-user-relatives), upon acceptance, bond, accountability by users and guarantee of continued and integral attention1616. Oliveira EN, Santana MMG, Eloia SC, Almeida PC, Felix TA, Ximenes Neto FRG. Projeto terapêutico de usuários de crack e álcool atendidos no centro de atenção psicossocial. Rev Rene. 2015 [citado2018 abr 10];16(3):434-41. Disponível em: http://www.periodicos.ufc.br/rene/article/view/2819.
http://www.periodicos.ufc.br/rene/articl...
. However, in this study, moments when the acceptance placed the user in a passive position before the service were also observed, while deciding for him/her the treatment objectives and therapeutic actions, disregarding their desires and interests, going against the guidelines of PTS.

Every health professional is an operator of care, and as such should be qualified to produce acceptance, accountability and bond. While being identified as the professional accountable for PTS, he lives a double process as care operator and manager of the process of caring by administrating a whole network required for this project execution1717. Merhy EE. O cuidado com o cuidado em saúde: saber explorar seus paradoxos para um agir manicomial. In: Merhy EE, Amaral H. A reforma psiquiátrica no cotidiano II. São Paulo: Aderaldo & Rothschild; 2007. p.25-37..

Thus, clinical issues with higher risks are assumed as exclusive responsibility of the reference therapist, which usually recommends abstinence of drugs to the user in order to promote his health. The operationalization of actions involving welcoming, accountability and bond, from harm reduction perspective, seem incompatible with attitude expected from a reference therapist, because, while producing “welcoming”, he becomes excessively responsible for the user instead of promoting his co-accountability in the process. On the other hand, this professional-user bond built suggests tutelary relation, promoting excess of dependence of the user on the reference therapist and service, weakening his autonomy and participation.

Thus, the act of caring may have tutelary character, and may not promote in the user the accountability for the treatment. So, it is necessary to explore therapeutic possibilities of these interventions by means of a differentiated listening to set contract based on common objectives, agreed upon between user and reference therapist, favoring effective gain of autonomy by the user.

Sometimes, there is excessive accountability of professionals by users and promotion of dependence relation of users with the service1818. Marchesan RQ, Ferrer AL. A terapêutica em um Centro de Atenção Psicossocial à luz do dispositivo "Projeto Terapêutico Singular". Saúde (Santa Maria). 2016;42(2):137-48. doi: https://doi.org/10.5902/2236583421662.
https://doi.org/10.5902/2236583421662...
. However, the act of caring may have tutelage connotation that breaks the logics of dependence on the other (withholding), implying effective gains in progressive autonomy to the user aiming at his freedom to construct autonomy in life. This last seeks to product movements all the time during interaction, where one triggers life production in the other1919. Ferreira TPS, Sampaio J, Souza ACN, Oliveira DL, Gomes LB. [Care production in mental health: the challenges beyond institutional walls]. Interface (Botucatu). 2017;21(61):373-84. Portuguese. doi: https://doi.org/10.1590/1807-57622016.0139.
https://doi.org/10.1590/1807-57622016.01...
.

Besides, the conduction of an effective therapeutics demands accountability, bond and strengthening of actions to outside the service, articulated with other points of the sectorial and inter-sectorial network1818. Marchesan RQ, Ferrer AL. A terapêutica em um Centro de Atenção Psicossocial à luz do dispositivo "Projeto Terapêutico Singular". Saúde (Santa Maria). 2016;42(2):137-48. doi: https://doi.org/10.5902/2236583421662.
https://doi.org/10.5902/2236583421662...
, in a movement to open to the geographic and existential territory of persons in a community (institutions, network of relations, local culture). That because the specialized service for drug treatment is still overrated and the offer of attainable actions to individuals is still precarious2020. Schneider JF, Roos CM, Olschowsky A, Pinho LB, Camatta MW, Wetzel C. Care for drug users in the perspective of family health professionals. Texto Contexto Enferm. 2013;22(3):654-61. doi: http://dx.doi.org/10.1590/S0104-07072013000300011.
http://dx.doi.org/10.1590/S0104-07072013...
.

A territory-based service means to be in a certain geographic space and at the same time belong to a certain world, inhabited by persons who produce singular ways of living1919. Ferreira TPS, Sampaio J, Souza ACN, Oliveira DL, Gomes LB. [Care production in mental health: the challenges beyond institutional walls]. Interface (Botucatu). 2017;21(61):373-84. Portuguese. doi: https://doi.org/10.1590/1807-57622016.0139.
https://doi.org/10.1590/1807-57622016.01...
. In this conception, territories comprise vectors of de-territorialization and re-territorialization. The first indicates that there is no territory without a vector to leave it, and the second shows that, when there is escape, there is also an effort to re-territorialize elsewhere 2121. Enes ENS, Bicalho MGP. Desterritorialização/reterritorialização: processos vivenciados por professoras de uma escola de Educação Especial no contexto da educação inclusiva. Educ Rev. 2014;30(1):189-214. doi: https://doi.org/10.1590/S0102-46982014000100008.
https://doi.org/10.1590/S0102-4698201400...
. Therefore, de-territorialization occurs all the time, and in a globalized world, it becomes even more intensive, with connection of people from other countries, languages and ethnic groups, and the possibility of experiencing different cultures, with territorial limits increasingly finer. Thus, de-territorialization of users may occur with regard to drug use spaces, driving them to circulate in other territories, and not just those associated to drug consumption.

Therefore, the work in the territory should be extended to re-territorialization movements, favoring the occupation of new spaces by the users, in a continuous transformation movement. Their presence in the association of users, in CAPS-ad and in spaces outside the service’s premises favors movements that drive re-dimensioning and new choices, as well as participation in the formulation of policies involving mental health treatment, encouraging users’ protagonism and rescue of citizenship.

CONCLUSIONS

The present study analyzed the drug user accountability in the treatment made at CAPS-ad in the light of the harm reduction policy. It was based on the objectives and motivations of users and professionals that favor the user commitment with his own treatment in CAPS-ad, within a logic of harm reduction, social inclusion and rescue of citizenship.

One important contribution of this study was to give voice to users and professionals, promoting an attentive listening, favoring the understanding of subjective issues associated to participation in the treatment. Therefore, the need of users to leave the position of spectators and act as protagonists in their treatment was evidenced.

Divergences were observed between user and reference therapist objectives, with excessive focus on clinical issues by professionals while users present other interests.

Users consider as motivating factors for the treatment their relation with family members, recovery of health and the affectionate relation with the service’s professionals. However, family is little integrated in the treatment in CAPS-ad, and specific interventions are needed for this adhesion.

The research results suggest that the welcoming and accountability of the user for his own treatment should occur synchronically, favoring the user autonomy and effective participation, so as to avoid that bonds between professionals and users adopt a tutelary nature. Users should be encouraged to be accountable for their attitudes, leading them to reflect on their choices in life and in the treatment. For such, a qualified listening and a treatment plan befitting their interests are necessary, organized and agreed upon in the PTS. Users must extend the occupation of spaces in the territory to favor protagonism, social inclusion and the rescue of their citizenship, in a challenging process that meets the premises of psychosocial attention advocated in mental health policies.

The limitations in this study are the unique case study and the fact that data collection was made by a professional from the care team of the CAPS-ad studied (possible tendentious bias). New studies are suggested in multiple case studies modality to expand the analysis by comparing with other realities. The findings of this research may contribute to assistance and teaching in health and nursing, because they provide important knowledge on the level of involvement and participation of the drug user in his treatment, leading to reflections on the health team work process in CAPS-ad. Such reflections are expected to favor the construction of a dialogical listening relation with the user and promotion of protagonism, autonomy and accountability in the treatment, seeking to overcome the tutelary character of institutions in the care of drug users.

REFERENCES

  • 1
    United Nations Office on Drugs and Crime [Internet]. Vienna: UNODC; c2018 [cited 2018 Apr 25]. World Drug Report 2017; [about 1 screen]. Available from: http://www.unodc.org/wdr2017/
    » http://www.unodc.org/wdr2017/
  • 2
    Galhardi CC, Matsukura TS. The daily routine of teens at a Center for Psychosocial Care for Alcohol and Other Drugs in Brazil: realities and challenges. Cad Saúde Pública 2018;34(3):e00150816. doi: https:/doi.org/10.1590/0102-311x00150816.
    » https:/doi.org/10.1590/0102-311x00150816
  • 3
    Nóbrega MPSS, Domingos AM, Silveira ASA, Santos JC. [Weaving the West Psychosocial Care Network of the municipality of São Paulo]. Rev Bras Enferm. 2017;70(5):965-72. Portuguese. doi: https://doi.org/10.1590/0034-7167-2016-0566
    » https://doi.org/10.1590/0034-7167-2016-0566
  • 4
    Carvalho B, Dimenstein M. [Discourse analysis about harm reduction in a CAPSad III and a therapeutic community]. Temas Psicol. 2017;25(2):647-60. Portuguese. doi: https://doi.org/10.9788/TP2017.2-13
    » https://doi.org/10.9788/TP2017.2-13
  • 5
    Bosque-Prous M, Brugal MT. Intervenciones de reducción de daños en usuarios de drogas: situación actual y recomendaciones. Gac Sanit. 2016;30(S1):99-105. doi: https://doi.org/10.1016/J.GACETA.2016.04.020
    » https://doi.org/10.1016/J.GACETA.2016.04.020
  • 6
    Pinto LO, Oliveira DJ, Duarte FMR. [Informative group: harm reduction strategies for people apprehended for illicit drug consumption and/or possession]. Interface (Botucatu) 2015;19(supl 1):965-93. Portuguese. doi: https://doi.org/10.1590/1807-57622014.0870.
    » https://doi.org/10.1590/1807-57622014.0870.
  • 7
    Santos JM. A participação dos usuários no plano de tratamento em um CAPS-ad: um estudo de caso [dissertação]. Porto Alegre (RS): Hospital de Clínicas de Porto Alegre, Mestrado Profissional em Álcool e outras Drogas; 2017.
  • 8
    Yin RK. Pesquisa qualitativa: do início ao fim. Porto Alegre: Penso; 2016.
  • 9
    Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2015.
  • 10
    Crabtree A, Latham N, Bird L, Buxton J. Results of a participatory needs assessment demonstrate an opportunity to involve people who use alcohol in drug user activism and harm reduction. Harm Reduct J. 2016;13:37. doi: https://doi.org/10.1186/s12954-016-0126-x
    » https://doi.org/10.1186/s12954-016-0126-x
  • 11
    Morandi S, Silva B, Golay P, Bonsack C. Intensive case management for addiction to promote engagement with care of people with severe mental and substance use disorders: an observational study. Subst Abuse Treat Prev Policy. 2017;12:26. doi: https://doi.org/10.1186/s13011-017-0111-8
    » https://doi.org/10.1186/s13011-017-0111-8
  • 12
    Savic M, Best D, Manning V, Lubman DI. Strategies to facilitate integrated care for people with alcohol and other drug problems: a systematic review. Subs Abuse Treat Prev Policy. 2017;12:19. doi: https://doi.org/10.1186/s13011-017-0104-7
    » https://doi.org/10.1186/s13011-017-0104-7
  • 13
    Vasconcelos ACM, Araújo LN, Porto LGM, Rocha NNV, Oliveira EN, Albuquerque JTP. [Family relationships and chemical addiction: a literature review]. Rev Bras Ciênc Saúde. 2015;9(4):321-6. Portuguese. doi: https://doi.org/10.4034/RBCS.2015.19.04.11
    » https://doi.org/10.4034/RBCS.2015.19.04.11
  • 14
    Paz MF, Colossi PM. [Chemical dependence family dynamic aspects]. Estud Psicol. 2013;18(4):551-8. Portuguese. doi: https://doi.org/10.1590/S1413-294X2013000400002
    » https://doi.org/10.1590/S1413-294X2013000400002
  • 15
    Vasconcelos MGF, Jorge MSB, Catrib AMF, Bezerra IC, Franco TB. [Therapeutic design in Mental Health: practices and procedures in dimensions constituents of psychosocial care]. Interface (Botucatu). 2016;20(57):313-23. Portuguese. doi: https://doi.org/10.1590/1807-57622015.0231.
    » https://doi.org/10.1590/1807-57622015.0231.
  • 16
    Oliveira EN, Santana MMG, Eloia SC, Almeida PC, Felix TA, Ximenes Neto FRG. Projeto terapêutico de usuários de crack e álcool atendidos no centro de atenção psicossocial. Rev Rene. 2015 [citado2018 abr 10];16(3):434-41. Disponível em: http://www.periodicos.ufc.br/rene/article/view/2819
    » http://www.periodicos.ufc.br/rene/article/view/2819
  • 17
    Merhy EE. O cuidado com o cuidado em saúde: saber explorar seus paradoxos para um agir manicomial. In: Merhy EE, Amaral H. A reforma psiquiátrica no cotidiano II. São Paulo: Aderaldo & Rothschild; 2007. p.25-37.
  • 18
    Marchesan RQ, Ferrer AL. A terapêutica em um Centro de Atenção Psicossocial à luz do dispositivo "Projeto Terapêutico Singular". Saúde (Santa Maria). 2016;42(2):137-48. doi: https://doi.org/10.5902/2236583421662
    » https://doi.org/10.5902/2236583421662
  • 19
    Ferreira TPS, Sampaio J, Souza ACN, Oliveira DL, Gomes LB. [Care production in mental health: the challenges beyond institutional walls]. Interface (Botucatu). 2017;21(61):373-84. Portuguese. doi: https://doi.org/10.1590/1807-57622016.0139.
    » https://doi.org/10.1590/1807-57622016.0139.
  • 20
    Schneider JF, Roos CM, Olschowsky A, Pinho LB, Camatta MW, Wetzel C. Care for drug users in the perspective of family health professionals. Texto Contexto Enferm. 2013;22(3):654-61. doi: http://dx.doi.org/10.1590/S0104-07072013000300011
    » http://dx.doi.org/10.1590/S0104-07072013000300011
  • 21
    Enes ENS, Bicalho MGP. Desterritorialização/reterritorialização: processos vivenciados por professoras de uma escola de Educação Especial no contexto da educação inclusiva. Educ Rev. 2014;30(1):189-214. doi: https://doi.org/10.1590/S0102-46982014000100008
    » https://doi.org/10.1590/S0102-46982014000100008

Publication Dates

  • Publication in this collection
    29 Nov 2018
  • Date of issue
    2018

History

  • Received
    27 Apr 2018
  • Accepted
    23 Aug 2018
Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
E-mail: revista@enf.ufrgs.br