SOCIAL REPRESENTATIONS OF ALCOHOLISM: EXPERIENCES OF A GROUP OF WITHDRAWING USERSABSTRACT
OBJECTIVE: to understand the social representations of alcoholism among abstinent alcoholics in a therapeutic group and their impact on care at the Psychosocial Care Center for Alcohol and Other Drugs.
Method: a qualitative study with the participation of 20 interviewees, using the technique of free association of words; a study carried out at CAPS-AD III in the city of Belém - Pará - Brazil, in 2023. Six stages follow thematic analysis to analyze data.
Results: the trajectory of problematic alcohol consumption was revealed through their social representations, in which they constructed forms of care linked primarily to common sense. It is inferred that they, suffering from alcoholism, seek dignity and a return to everyday life.
Final considerations: the study shows that unveiling social representations favors welcoming the family and mental health professionals. Hence, the Psychosocial Care Center reveals itself as a new chance for abstinent users.
KEYWORDS:
Nursing; Alcoholism; Social Representation; Mental Health; Mental Health Services.
HIGHLIGHTS
The most prevalent word evoked by users was “drink.”
Results show that perspectives and family influence are often discredited.
The very use of psychoactive substances is linked to stereotypes.
New social representations about treatment and abstinence have been established.
RESUMO:
Objetivo: compreender as representações sociais sobre alcoolismo entre alcoolistas abstêmios em um grupo terapêutico e suas repercussões para o cuidado no Centro de Atenção Psicossocial de Álcool e outras Drogas.
Método: estudo qualitativo com a participação de 20 depoentes, empregada a técnica de livre associação de palavras; estudo realizado no CAPS-AD III na cidade de Belém - Pará - Brasil, em 2023. Dados analisados por análise temática seguida de seis etapas.
Resultados: desvelou-se a trajetória do consumo problemático de álcool, por meio de suas representações sociais, nas quais construíram formas de cuidado ligadas primeiramente ao senso comum. Infere-se que eles, sofrendo com males do alcoolismo, buscam a dignidade e retorno à vida cotidiana.
Considerações finais: o estudo evidencia que desvelar as representações sociais favorece o acolhimento da família e profissionais de saúde mental, logo o Centro de Atenção Psicossocial se revela como uma nova chance aos usuários abstêmios.
DESCRITORES:
Enfermagem; Alcoolismo; Representação Social; Saúde Mental; Serviços de Saúde Mental.
HIGHLIGHTS
A palavra com maior predominância evocada pelos usuários foi “bebida”.
Resultados demonstram perspectivas, influência da família, sendo frequentemente desacreditados.
O próprio uso de substâncias psicoativas coliga-se a estereótipos.
Instituíram-se novas representações sociais acerca do tratamento e abstinência.
RESUMEN
OBJETIVO: comprender las representaciones sociales del alcoholismo entre alcohólicos abstinentes de un grupo terapéutico y sus repercusiones en la atención en el Centro de Atención Psicosocial de Alcohol y Otras Drogas.
Método: estudio cualitativo con la participación de 20 entrevistados, utilizando la técnica de asociación libre de palabras; estudio realizado en el CAPS-AD III de la ciudad de Belém - Pará - Brasil, en 2023. Datos analizados mediante análisis temático seguido de seis etapas.
Resultados: la trayectoria de consumo problemático de alcohol fue revelada a través de sus representaciones sociales, en las que construyeron formas de cuidado vinculadas principalmente al sentido común. Se puede inferir que, sufriendo de alcoholismo, buscan la dignidad y el retorno a la vida cotidiana.
Consideraciones finales: el estudio muestra que el desvelamiento de las representaciones sociales favorece la acogida de la familia y de los profesionales de salud mental, por lo que el Centro de Atención Psicosocial se revela como una nueva oportunidad para los usuarios abstinentes. seguido de seis etapas.
DESCRIPTORES:
Enfermería; Alcoholismo; Representación Social; Salud Mental; Servicios de Salud Mental.
HIGHLIGHTS
La palabra más evocada por los usuarios fue “bebida”.
Los resultados muestran perspectivas, influencia familiar, a menudo desacreditadas.
El propio consumo de sustancias psicoactivas está ligado a estereotipos.
Se han establecido nuevas representaciones sociales sobre el tratamiento y la abstinencia.
INTRODUCTION
Alcoholism is still a serious public health problem marked by compulsive alcohol consumption in several countries, making individuals increasingly tolerant of it, leading to withdrawal crises when not ingested routinely. This disease is responsible for 3 million deaths every year worldwide, strongly impacting interpersonal relationships between families and society, inciting violent and conflictive attitudes, characterizing it as a financial disrupter and harmful to physical and mental health1.
And because it is a legal drug, social groups are generally tolerant of its consumption and, in the media, even encourage it. Thus, alcoholic beverages are routinely used to overcome inhibitions and reduce the worries that life imposes. In this context, understanding the consumption of alcoholic drinks and the constant encouragement by social media represent an arduous condition for users who are already in psychosocial treatment since they are in a persistent struggle against their desire to consume alcohol2.
Difficulty controlling consumption is a clear symptom of alcoholism. More importantly, refusal to acknowledge the problem is a symptom that can aggravate the situation, delay seeking treatment, and cause users to consume alcohol secretly or alone. Furthermore, the most current approaches treat alcoholism as the result of multifactorial causes, and the assertion that only one or other is assumed to be the causal factor is problematic. There is an interaction between biological, psychological, and sociocultural assumptions, which demands that, instead of opting for mutual exclusion, they complement each other in determining the etiology of alcoholism3-4.
Due to the range of causal factors, misuse causes illnesses ranging from biological systems to psychopathological and social impairments. It is, therefore, necessary to understand that alcohol is a psychoactive drug with depressive effects and leads to dependence in those who abuse it3.
Advances in knowledge about the disease have made it possible to take a new look at alcoholics, who are seen not only for their distinctive behavior but also for their conduct in society, making this disease a social problem4. Thus, to understand this behavior, it is worth mentioning that the Theory of Social Representations (TSR) aims to explain and understand social reality. This theory considers how to understand the historical-critical dimension of people and social groups in their lives. It describes how common sense is constructed, a theory of the representational process5.
In line with this, social representations are practical knowledge oriented toward communication and understanding the social, material, and ideological context. They are forms of knowledge that manifest cognitive, conceptual elements, images, theories, and categories, propagating the knowledge elaborated by nursing professionals about alcoholism, and this knowledge guides communications and operationalizes the group to act in the care of alcoholic patients6.
Therefore, it is necessary to unveil the naive universe of alcoholism since health teams are used to dealing with the evils related to the excessive use of this drug. In this respect, nursing is also a group of professionals who work directly in caring for people involved in alcohol consumption. Thus, social representations are a reality for the group; within this reality, subjects behave and relate to each other7.
They don’t necessarily propose to be the solution to questions about alcoholism. Still, they do declare their function to relieve the anxiety already known by these professionals when confronted with the unknown, in other words, when welcoming alcoholic users. This way, representations are constructed to fill these gaps, mediating between the conceptual and the perceived5.
In this sense, the Alcohol and Other Drugs Psychosocial Care Centers (CAPS-ad III) are a psychosocial support network regulated by the Ministry of Health’s Ordinance No. 336 of 2002, made up of a multi-professional team that works together, within its specificities, to meet the needs of the user as a result of the use of psychoactive substances, where CAPS-ad III (Alcohol and Other Drugs Psychosocial Care Center) operates 24 hours a day8.
The activities developed in these centers are group or individual, depending on the user, so that there is an interaction in which rehabilitative interventions can be built. Considering that social representation makes it possible to implement more efficient and effective care geared towards the particularities of social parties, this study’s guiding question is: what are the social representations about alcoholism of abstinent alcoholics who attend a CAPS-ad III therapeutic group? The objective was to understand the social representations of alcoholism among abstinent alcoholics who attend a therapeutic group and their repercussions for user care at the Psychosocial Care Center for Alcohol and Other Drugs.
METHOD
This is a descriptive study with a qualitative approach based on the Theory of Social Representations in its procedural aspect5-6. The decision to use TRS is because it is a theory that meets the expectations of the topic of abstinent alcoholics by using social representations for the universe of meanings, motivations, aspirations, beliefs, and values. The Consolidated Criteria for Reporting Qualitative Research (COREQ)9 was used to develop this study.
From January to February 2023, the setting was a Psychosocial Care Center for Alcohol and Other Drugs-CAPS-AD III-in Belém, the capital of Pará. The institute was chosen because it is a state-run public health service with a multi-professional team that provides biopsychosocial rehabilitation, social reintegration, and support for family members.
Twenty users took part precisely because this is the minimum number needed to characterize a group of individuals as a social group, and only this group is representative of the genesis of social representations5-7. It should also be noted that the participants were of both sexes and registered and monitored at CAPS-AD III. Another point is that the belonging group is made up of those who hold the same attitudes and behaviors present in their reports, sustaining the common sense of alcohol as a permissible product. We therefore included users being monitored in the therapeutic group: abstinent, aged 18 or over, with the ability to understand and communicate verbally to answer the questionnaires. Users with mental disorders were excluded.
The data was collected in person, by appointment, according to the interviewee’s availability. As a collection tool, the Free Association of Words Technique (FAWT) was demonstrated and used, referring to the inducing terms: alcoholism and mental health. The FWAT is widely used in research involving the study of social representations, as its purpose is to learn and reason about a person’s most hidden thoughts based on evoked words5-7.
The reports were recorded on digital MP5 media from the cell phone in person, according to the participants’ prior authorization, which had already been agreed upon at the outset. After the interviews were completed, they were manually transcribed.
The data collected - obtained from the FAWT - was organized in a Word® 2023 document and initially submitted for analysis using the ATLAS.ti® version 24 software was used in the inductive mode of study. Subsequently, the 20 papers were identified with the term “documents” created by the software itself, ranging from D1 to D20, which consisted of the 20 interviews produced by the research participants. Using the quotes transcribed from the study participants’ speeches, codes generated by the researcher himself were created based on the meaning that emerged from the quote, in the case of FAWT, when the participants were asked why they conjured up that word. Thus, the previously developed code was linked to each word evoked by creating quotes.
Thus, according to the inductive themes prevalent in FWAT, the number of codes needed was named when no new codes were found, only those already created. This led to creating a “language of codes,” organized by groups of codes classified by common meanings. The report of groups of codes was generated in the Word 2023® software version.
Thematic Analysis (TA)10 was used as a qualitative data analysis method to identify, analyze, interpret, and report patterns (themes) from qualitative data. The choice of thematic analysis is justified by the flexibility required in applying the TA stages and understanding the research questions. This confirms that the analysis process is not linear; it is not continuous but moves back and forth according to the stages’ needs.
Finally, after coding in the ATLAS.ti® version 24 software and generate code reports in the Word 2023® software, Thematic Analysis (TA)10 was used to identify, analyze, interpret, and report patterns (themes)11. It should be noted that, as the ATLAS.ti® version 24 software speeds up the coding of documents generated by the study’s interviewees, so it is necessary to use an analysis technique to convert these codes into themes. For this reason, the choice of thematic analysis (TA) is justified by the flexibility required in applying the TA stages and understanding the research questions, and is segmented into six phases: 1) Formation of the similarity of elements; 2) Genesis of indicators; 3) Search for possible objects; 4) Continuous review of the points giving rise to a “synoptic table” of diagnostic ideas; 5) Demarcation of topics; and 6) Creation of the elucidating report10.
The interview was approved by the Research Ethics Committee, under opinion no. 5.175.204. The statements are identified by the letter “P” for “participant,” followed by the order in which the interview was conducted (01, 02, 03, among others).
RESULTS
After processing the data, ATLAS.ti® version 24 software was initially used, and later, by thematic analysis of the inducing words, several evocations emerged that represented the most primitive symbolic ideas. They were free of prior contamination by the researcher, which means authentic social representations, which can be seen in the table below:
Based on the words evoked by the participants about the terms inducing the study, it was possible to construct the table above. This enabled us to build the thematic units to be discussed and their consensual meanings below:
Drinking - Excessive consumption
The word “alcoholism” was mentioned to the participants as a first inductive stimulus related to psychosocial meanings and interpretations. The following question was asked: “When discussing alcoholism, what comes to mind? Why?” The most common word evoked by users was “drink,” referring to excessive consumption, a high degree of alcohol craving, and self-recognition of an addiction.
I was drinking because I used to drink a lot. I got drunk every day. (P14)
[...] I’m drinking because I still haven’t managed to stop. The urge comes, and there’s no way out of it. (P15)
[...] Alcohol, because I tried it once to get a taste and ended up getting hooked, didn’t I? (P16)
The word addiction is like alcoholic compulsion, as it is associated in popular belief as a “bad habit,” and this belief blames them for not having the self-control to overcome their addiction. Consequently, it brings a direct social stigma in the perception of belonging to a stereotype. It should be noted that the mass media links alcoholic beverages to a legal, marketable drug, facilitating its acquisition and social, abusive, and compulsive consumption.
However, the media, which encourages the use of alcohol as a form of socialization, also brings the symbolic image of a marginal addict, generating a new psychosocial identity linked to groups that share the experience of being an alcoholic, such as Alcoholics Anonymous and Narcotics Anonymous. These individuals suffer from stigma, characterized as a social mark, in the case of alcoholics, linked to the effect of drunkenness - and this is so strong that the bearer of this sign inserts it into their cognition, becoming a representation. This consensual universe emerges through the processes of elaborating representations: objectification and anchoring.
These people, even if they don’t resort to alcohol, are conceived of as would-be alcoholics by the social environment who won’t maintain their sobriety and are bound by this prejudice. However, the identity of an alcoholic is now more closely linked to being a carrier of a disease (alcoholism) and no longer as a drunk since they are abstinent. In this way, the following words were observed in their speeches: “bad, negative, and disease,” associated with a sense of repulsion towards the act of drinking. After joining CAPS-ad III and becoming more acquainted with the multidisciplinary team, they see the professionals as rich in academic knowledge and not just from the social masses. Consequently, their representations make them recognize themselves as suffering from a progressive and fatal mental illness.
[...] I think it isn’t nice. In the end, it only brings tragedy. I see alcohol more in a negative light because everything is complicated, everything is difficult in our lives [...] (P11)
[...] Only bad things, because drinking is a bad thing. (P18)
[...] It’s like this: a disease because you start from nothing. No, this is a joke we have here. It starts slowly and so on [...] (P7)
[...] An illness, because I feel ill. (P10)
This new representation is also strengthened and erected by sharing experiences exchanged at the CAPS with group activities - such as the one called New Look at Alcohol. Most of the interviewees attend the Alcoholics Anonymous (AA) group - a type of group that also has a vast literature that contributes to the dissemination of reified knowledge. It should be noted that AA imposes criteria for belonging to the group and attending meetings, such as abstinence for 24 hours. Still, regardless of the period of abstinence, relapses are understood at CAPS as a component of treatment.
Caring for the mind is caring for life.
The term “mental health” was used with the participants and reflected in the following generating question: “When I talk about mental health, what comes to mind? Why?”. The word most evoked by the participants was “treatment,” which alludes to the practice of caring for the mind with psychotropic drugs to stabilize and treat emotions, anxiety, agony, depression, insomnia, forgetfulness, alcohol compulsion, and thus “mental illness.” It’s worth mentioning that all the interviewees were undergoing the harm reduction treatment recommended by CAPS-ad III.
They also mentioned CAPS-ad III as a support network and the importance of the multi-professional team for their therapeutic progress. They also verbalized their concern to regain and take care of their families, just as they did before their addiction, and were accepted, as shown in their speeches:
[...] For me, mental health, as they say, is a treatment that I’m doing, right, to reach abstinence from alcohol and, with that, to lead my family members to be happier with me, so we can go out, go for a walk, go to the woods, you know so that we can go to the museum [...] (P9)
[Mental health? It’s taking care of your mind. I only think about good things in my mind. Good things, right? Working. Having our own money. Being healthy. Taking care of our family. Everything good. Going to the CAPS is also taking care of our mental health because they take care of us [...] (P11)
[...] My head. I kept seeing things because mine was not very good. Words come into my mind and talk to me. It’s a hallucination. It’s stopped now. I’m taking my medication, a vitamin that also helps my head and my mind because my mind is feeble. Not now, I’m getting better [...] (P15)
One can see the worry and fear of approaching an advanced stage of mental illness, as observed in the words “going crazy” and “worry”:
[...] Worry because it’s a difficult stage we reach when we become sick in the head, and treatment is the best path the individual must seek. (P20)
They evoked “balance, joy, no depression, and self-control” because they aspire to a certain quality of life by being present in social relationships. On the other hand, they affirm the daily struggle for self-control and the fear of relapse:
[...] Balance, because health is something good, a sound mind, you know (P13).
[Mental health is without depression, without alcohol. It’s sleeping at night and not having nightmares. It’s getting up in the morning in a good mood. It’s not having agony. It’s not feeling short of breath. It’s not having a hangover, isn’t it [...] (P1)
Other words evoked in alcohol reduction to escape a relapse are: “strategies, walks and activity,” meaning skills and talents to “trick” the mind into forgetting about alcohol. Participants emphasized walks, outings, reading, and therapies, among others:
[...] Walks. I do it three times a week. It’s good for my health. I feel light, well. It puts me in the mood to do something else. The NOA group. THE CAPS. It’s good for me. They’re all good for my mental health [...] (P7)
[...] Occupation, because when we work or do something, we’re occupying our minds with something good, something healthy [...] (P12)
The words evoked so far enrich the group’s understanding of the social representations that connect self-knowledge, dependence on alcohol, concern for self-care, and weakened family and social ties in a broader context of mental health.
DISCUSSION
In this context, the process of alcoholics becoming ill is evident, as it involves many aspects, mainly at the family level. Families who have patients involved with alcohol are faced with a new reality that can affect them economically, physically, affectionately, and morally. In coping with the treatment process, the descriptor “addiction” is linked to chemical dependency, subjecting the user to frequent relapses and strain on affective relationships5-12.
The word “addiction” has various meanings under society’s pejorative gaze, signifying a repetitive habit that degenerates. In this case, alcoholics have often been nicknamed “addicts,” consequently affecting their relationship with the state, individuality, ethics, and morals, and even under religious interpretations, “addiction” is seen as something harmful, inappropriate, socially repressible, abusive, and shameful12.
This social representation leads to codependency among family members12, since “addiction” is an aspect that interferes in the lives of the addict’s family members, which translates into psychological suffering. The codependent family member feels guilty about the other person’s situation and family relationship, generating family overload7-13.
Identity is an essential factor for analysis because the subject must recognize themselves as “me” while perceiving the “other” as a singular and subjective person based on the relationship they establish with other social subjects. Regarding this, in the analysis of the Social Representations of alcoholics, the trajectory of individual contact with alcohol was identified as the main factor. In this sense, their self-care and care become impaired5.
It is worth pointing out that the terms self-care and self-care, although similar, have different meanings. Self-care was first mentioned in nursing in 1958 when nurse Dorothea Orem began to reflect on why individuals need nursing help14. In rescuing the term self-care, we look to history, philosophy, and Foucault’s works. For Foucault, care is replaced by self-care, understood as the art of existence, meaning it is appropriate to care for oneself, deriving from social imperatives and collective knowledge15.
A subject’s identity is a representation of themselves generated from an articulation between their presupposed identity, derived from their social role, and their actions. Drinking is seen as a principle of identification with a group, presenting it as a product of social action in collectives. Alcohol use has been observed as a functionally specific element of social interaction, eliminating individual differences in the stages of alcoholization, according to alcoholics5-16.
In the process of abstinence, there is a struggle on the part of the individual who needs alcohol, impregnated by the vision of a person who may relapse several times. Society is based on stigma and stereotypes that contribute to the devaluation and prejudice of alcoholics. Because of this, alcoholics need to deconstruct the historical and social phenomena that help maintain the various forms of discrimination. In this way, social representations help develop social identities and cooperate in constructing a chronic reality of the subject related to a social set in which they are inserted7.
These social representations categorize subjects through beliefs, images, symbols, and language. In other words, they are a set of concepts shared socially by a group, affecting their conduct, behavior, and attitudes in a historical-cultural context. Thus, social representations are organized as systems of interpretation6. In this context, society must welcome alcoholics. It should be noted that this movement to (de)construct a social stigma about alcoholism occurs through the representations that the social group elaborates in the collective5-7.
Regarding the uniqueness of the alcoholic subject’s existentialism, it is essential to carefully observe the living conditions of this individual, considering the possibility or impossibility of being unequal in a rationalist, productivist, and consumerist world. In such a way, the representation of taking care of oneself implies a separation from society and a concern for one’s integrity, whether due to financial and social instability or the fragility of the support network that the subject goes through15-16.
It is important to note that the mental health approach does not only discuss individual behavioral characteristics but also their inclusion in each socio-cultural and political context. It is considered a significant demand for public health, culture, social relations, scientific-professional standards, and social representations from a broader perspective of living together.
It should be noted that the very use of psychoactive substances is linked to stereotypes, socially speaking, and to this is added the social stigma related to mental illness17-18.
However, some weaknesses were seen in the management of care in the RAPS (in Portuguese) because when the user is seen at another level of care, there is no sharing of the Singular Therapeutic Project (STP) nor data on the individual’s history and treatment, reducing the continuity and effectiveness of the user’s treatment. To address the biopsychosocial dimension of users19, it is necessary to interact with institutions, care, health, and social assistance networks. RAPS services must guarantee the user’s right to treatment, respecting their territorial boundaries20.
The limitation of this study was methodological, as it was carried out during a period in which the services were being reorganized due to some restructuring. In this sense, these factors contributed to the difficulty in attracting participants, and it should also be pointed out that it was not possible to sample considerably to construct individualized representations for each month of treatment, as it was not possible to identify an appropriate number of individuals for each class of this variable.
FINAL CONSIDERATIONS
Through the thematic nuclei created categories such as “Drinking - Excessive Consumption” and “Taking care of your mind is taking care of your life” were used to understand how the subject is associated with alcoholics. The results show that the perspectives, the influence of the family, and the environment in which the patients are inserted are often discredited (even by themselves). Social representations are forms of knowledge generated in the social environment from scientific knowledge, which are the foundations for constructing these social representations in the form of consensual knowledge. This knowledge, being present in the subjects of the study, was created through communication, which is responsible for the formation and maintenance of common-sense knowledge. The health-disease process is still centered on the biomedical model, which weakens the psychosocial care of alcoholics due to the credibility of a treatment based on a cure through drug therapy.
The conclusion is that the care of these users should be outlined by two frameworks: self-care and care of the self, which are not simply semantic contestations but paradigmatic ones. Similarly, at CAPS-AD III, participants established new social representations that generated social identities of alcoholics. They came to understand that abstinence is not the only form of treatment for alcohol dependence but rather a set of biopsychosocial factors.
Therefore, for mental health and nursing, it is necessary to understand the social representations of people who consume alcohol problematically and are abstinent because, from this empirical knowledge, one can act, elaborating forms of care created from this form of naive knowledge. In this way, you can act on the problem in question from the point of view of those who have suffered from the disease and are in rehabilitation - the abstinent addicts.
ACKNOWLEDGEMENTS
This study was carried out with the support of the Amazon Foundation for Studies and Research (FAPESPA) (Fundação Amazônia de Amparo a Estudos e Pesquisas (FAPESPA) and the UFPa Pro-Rectory for Research and Postgraduate Studies (PROPESP/UFPa) (Pró-Reitoria de Pesquisa e Pós-Graduação da UFPa) (PROPESP/UFPa).
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HOW TO REFERENCE THIS ARTICLE:Silva SED da, Rodrigues DM, Oliveira MAF de, Araújo JS, Rodrigues DP, Santos AL dos, et al. Social representations of alcoholism: experiences of a group of withdrawing users. Cogitare Enferm. [Internet]. 2024 [cited “insert year, month and day”]; 29. Available from: https://doi.org/10.1590/ce.v29i0.96865.
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Article extracted from the master’s thesis: “REPRESENTAÇÕES SOCIAIS SOBRE ALCOOLISMO ENTRE ALCOOLISTAS ABSTÊMIOS EM TEMPOS DE PANDEMIA”, Universidade Federal do Pará, Belém, PA, Brasil, 2022.
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Associate editor:
Dra. Susanne Betiolli
