ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.v13i2p93-100

 

Disparity in the conceptions of psychoactive substance addiction treatment: reflexes and implications among professionals, models and institutions present in the care services

 

Disparidad de concepciones de tratamiento de la dependencia de sustancias psicoactivas: reflexiones e implicaciones entre profesionales, modelos e instituciones presente en los servicios de atención

 

 

Aislan José de Oliveira^I

^IDoctor degree student. Universidade São Francisco, USF, Brazil. Psychologist. Centro Universitário Campos de Andrade, Uniandrade. Adjunct Professor. Clinical Psychologist

 

 

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ABSTRACT

The objective in this research was to understand the theoretical background in the discourse of 17 mental health professionals working in three care models for drug addicts. The data were collected through a questionnaire and classified in three analysis categories, according to the theoretical-epistemological framework of each approach and institution, being: the biomedical model (clinical), the sociocultural model (psychosocial care center) and the psychosocial model (therapeutic communities). It was concluded that the participating professionals do not present a specific definition regarding the addict and treatment concepts of drug addiction. Also, their approaches can sometimes be contradictory to the methods and ideologies of the institutions analyzed.

Descriptors: Treatment; Dependent; Chemical Dependency; Models; Professionals; Drugs.

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RESUMEN

La presente búsqueda, tuvo el intuito de entender el fundamento teórico presente en el discurso de 17 profesionales de salud mental que actúan en 3 modelos de atención a los adictos de drogas psicoactivas. Los datos fueron colectados por medio de cuestionarios y clasificados en 3 categorías de análisis según el marco teórico/epistemológico de cada enfoque e institución, siendo ellas: El modelo biomédico (clínica), el modelo sociocultural (centro de atención psicosocial) y el modelo psicosocial (comunidades terapéuticas). Se concluyó que los profesionales participantes no presentan una definición específica sobre los conceptos de "adictos" y "tratamiento" de dependencia química. Se concluye incluso que, el enfoque de los profesionales pueden, a veces, ser contradictorios a las metodologías e idiologías de las instituciones analizadas.

Descriptores: Tratamiento; Adicto; Dependencia Química; Modelos; Profesionales; Drogas.

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Introduction

Psychoactive substance consumption is characterized as a phenomenon constituted amidst countless interfaces and articulations, amidst biological, pharmacological, psychological, sociocultural, political, economic and anthropological variables⁽¹⁾. In that sense, psychoactive substance addiction is a highly-complex phenomenon in which any attempts towards reductionist explanations are unfeasible and its multiple determinations are ignored. Although closely linked, when the variables in question are analyzed separately, they are incapable or explaining or proposing appropriate solutions⁽²⁾.

The difficulty to understand the phenomenon extends to the treatment addressed, based on dichotomous, fragmented, ahistorical, determinist and markedly reductionist theoretical and intervention processes⁽²⁾. The treatment modalities for drug addicts adopted by institutions in general are eclectic procedures of medical, psychological, social and religious action, which reduce the understanding of the determinant and complex variables of psychoactive substance addiction, leading to hardly effective treatment results and limiting the potential of care⁽³⁾.

Therefore, it should be "questioned in depth whether the effectiveness problem of the care and treatment models does not lie in the health practices themselves, which consist of a mixture of different analysis models of the drug addiction phenomenon and the use of a wide range of action methods, based on different theoretical and epistemological premises"⁽²⁾, as any health practice, whether aimed at individual, collective or institutional actions, necessarily involves underlying theoretical-methodological conceptions that serve as a guiding framework of their actions⁽²⁾.

Sometimes, these conceptions are not always clear and defined in the therapeutic practice routines, independently of the treatment modality, but they support the rationality system and certain parameters to understand the health/disease, normality/abnormality⁽⁴⁾ processes, validating actions in certain background conceptions. This evidences that the treatment form is linked to the way of thinking and understanding psychoactive substance addiction. "The theoretical-methodological based should be critically assessed in order to understand the different analysis models of drug addiction and their ontological and epistemological roots"⁽²⁾, which also extend to the treatment.

 

Treatment approaches offered in Brazil

Based on the above, different experts in drug treatment developed different models regarding the dimensions of this phenomenon, with a view to understanding the drugs use problem^(2,4). Among these, four conceptual models to analyze psychoactive substance addiction are highlighted, which are: the legal-moral, the biomedical, the psychosocial and the sociocultural models⁽⁵⁾. Each of them is based "on different theoretical-epistemological roots, which unfolds into different methodological intervention perspectives"⁽²⁾.

The legal-moral model rests on the dualist perspective of the reality and the coexistence of opposite and relentless positions (individual and drug, legality and illegality, medical and non-medical purpose). "This perspective is related with ‘educative’ and preventive measures, articulated with repressive principles"⁽⁵⁾.

The medical or public health model, also called biomedical, is predominant at medical outpatient clinics, clinics and psychiatric hospitals and "is the model with the highest usage rate at the primary health care units of the Unified Health System (SUS), hegemonic, and justified by the vagueness of the determinants that constitute the drug addiction process"⁽²⁾. In this treatment model, the focus on drug addiction is predominantly biological, which is understood as a chronic, recurring disease, whose determinants are attributed to hereditariness and/or neurochemical malfunctions⁽²⁾.

In the psychosocial model, the actions are based on the "analysis of the tripod drug-individual-midst"⁽²⁾, in which the addiction is considered based on the triangulation among the social midst and its influences on the individual, the intrinsic characteristics of the drugs and the individual’s psychological dynamics, attributing the active role in the addiction phenomenon to the latter, thus guiding that person’s actions focused on the intervention in the drug-individual dynamics. In this model, it is emphasized that the context plays a fundamental role in the phenomenon of drugs use, considering that the drug is meaningful because of the way each society defines its use. This model is widely used by therapeutic communities and is also mixed with others, being present in almost all types of services⁽²⁾.

The sociocultural model rests on the Brazilian psychiatric reform, based on Law No. 10.215, from April 6^th 2001⁽⁶⁾. The Ministry of Health (MH) adopted this law for the comprehensive treatment and care delivery to drugs users through the SUS, and mainly for the Psychosocial Care Centers (CAPS)⁽²⁾. This approach is focused on modifying the substance usage patterns, intervening in the social determinants that lead to abuse, aiming to control the damage caused by excessive consumption through the Damage Reduction Strategy (DRS) proposal^(2,6).

After the analysis of the models presented, it was evidenced that "the synthesis of this knowledge and practices constitutes the rationality or logical systems from which the different health services feed to understand and intervene in the health/disease phenomena"⁽²⁾.

For the sake of a better visualization of the main premises and characteristics of the abovementioned models, Figure 1^(2,5,7) was elaborated, in which the best accepted treatment models in Brazil are considered, representing the three main institutions that offer care services for drug addicts in the country: the Psychosocial Care Center Alcohol and Drugs (CAPS ad), the clinics and hospitals and the Therapeutic Communities (TC)^(8-9), core themes in this research.

 

 

Hence, the difficulty found in the literature to obtain a clear and specific definition of drug addiction treatment is evidenced, as there is no single definition of the treatment model or approach, but different forms of intervention⁽¹⁰⁾.

In Figure 1, the conception of the problem at each of the institutions is succinctly identified, evidencing the models adopted, the treatment concepts used and their objectives, etiologies, besides the advantages and disadvantages at each. Then, we tried to understand the concepts of treatment and drug addict of the professionals working at the three institutions that participated in the research, and whether they were in line with the therapeutic intervention proposal of each institution.

 

Method

This study derives from a Master’s thesis approved by the Ethics Committee at Faculdade Evangélica do Paraná (Fepar), under No. 5715/11. An exploratory and descriptive study with a qualitative approach was undertaken (Cozby)⁽¹¹⁾. Initially, we aimed to identify the main models the treatment institutions use in drug addicts^(2,4-5,7). In another analysis, three types of care institutions for drug addicts could be identified in Brazil with a larger supply of care and treatment services^(8-9), which are: TCs, clinics and CAPS ad, understood and studied in this research as analytic categories.

 

Participants

Seventeen technical and higher education professionals from three drug addiction treatment institutions participated in the research, who agreed to answer the questionnaire, independently of age and sex. The sample consisted of professionals from the fields of psychology, medicine, social service, nursing, occupational therapy, physical education and rehabilitation technicians in chemical addiction. The sample of institutions consisted of three care models for drug addicts, a clinic and TC in Curitiba, PR, Brazil and a CAPS ad in Metropolitan Curitiba, PR, Brazil.

 

Instruments

The data were collected between January and March 2012, through a self-reported questionnaire, with survey questions about the participants’ socioeconomic situations, one open question, in which the participants were asked to associate five words related to the terms addict and treatment (of psychoactive substances) according to each professional (question 1) and one open question (question 2), the latter on a Likert scale ranging from 1 to 3 points, with 1 indicating I agree, 2 I partially agree and 3 I disagree. Each topic in this question was previously elaborated and refers to one of the specific approach models. In the analysis of this item, only the answers marked as I agree were considered.

 

Data analysis

In question 1, the participants were asked to associate five words with the terms addict and treatment (of psychoactive substances). All words were analyzed according to the respective meanings by consulting psychology and psychiatry experts in the treatment of chemical addictions, and were then categorized according to the treatment models, as exemplified in Figure 2.

 

 

After the analysis and ranking, it could be identified in which treatment model each institution obtained the highest answer frequency.

In question 2, 40 statements related to the management, perception and treatment of addictions were presented to the participants, related to the three categories/institutions mentioned, with the following distribution of questions: 10 questions related to the medical approach, 10 to the legal-moral approach, 10 to the sociocultural approach and 10 to the psychosocial approach.

Next, the number of answers in each category was calculated for each of the institutions in percentage form. Therefore, the number of respondents at each institution was multiplied by the maximum number of answers for each category (10 for each category). Thus, the percentage of answers could be calculated and, based on the obtained results, Figure 3 was elaborated, in which the highest incidence of answers is indicated for each analysis category. Next, the answers are illustrated in the form of a histogram.

 

 

Results

In question 1, the participants were asked to write five words related to the terms chemical addiction treatment and chemical addict. The data for the participants in the three groups, CAPS ad, clinic and TC, were compared to identify the prevalent theoretical background in the professionals’ discourse at the three institutions. The analysis of the associations of words (question 1) are represented in Figures 3 and 4. In Figure 3, the results for the term treatment are displayed.

 

 

In Figure 3, it is shown that, at the clinical institution that fits into the category biomedical approach, a higher incidence of answers associated with the term treatment was found, according to the sociocultural approach. At the CAPS ad, where answers close to the sociocultural approach were expected, the results showed a higher incidence of the biomedical approach. At the TC, a higher frequency of answers was related to the term treatment, according to the legal-moral approach, although the literature appoints that this treatment institution is the most aligned with the base of the psychosocial model.

As for the words associated with the term addict, the results are shown in Figure 4.

According to the analysis of Figure 4, at the clinical institution that is related with the biomedical approach, a higher incidence was found of words associated with the term addict (of psychoactive substances) according to the legal-moral category. At the CAPSad, a higher incidence was found of words correlated with the biomedical model, considering that the treatment model of this institution is aligned with the psychosocial approach.

At the TC, the term treatment prevailed, according to the religious-moral category and the term addict, the sociocultural category, considering that, for this institution, the psychosocial model serves as a reference model for its actions.

After the data analysis, it could be observed that, at the three institutions, answers to question 2 were predominantly related to the biomedical approach. In Figure 5, the highest answers frequency of the three institutions is shown, concerning the current approach, as collected in question 2.

 

 

At the TC, the biomedical model obtained 61.1% of possible answers for this approach, followed by 50% of the answers for the sociocultural approach. At the CAPSad, 52.4% of agreement was found with the biomedical approach and 33.3% with the sociocultural approach. Finally, at the clinical institution, 40.7% of the answers agreed with the biomedical approach and 37.50% with the psychosocial approach.

 

Discussion

Among the three institutions that participated in the research, the number of professionals in each educational area who answered the questionnaire exerted a preponderant influence in the analysis of the results, as it indicated some prevalence in the interpretation of the data, in line with each activity area. At the CAPS ad, a larger number of physicians (three) participated in the research; at the CT, there were more psychologists (three). At the clinic, only one professional from each area participated in the research. Taking into account the number of professionals from each specific area is important because "any professional activity or service organization necessarily has an underlying theoretical-methodological rationality that guides his actions. This background is a specific product of the socio-historical process of each historical time"^(4,10).

These conceptions guide professionals, patients, their understanding on the problem and the possible intervention strategies^(4,10). In this line of reasoning, in each professional activity area, there is a certain underlying knowledge, which can be confronted with the characteristic intervention proposal of each institutional model. Despite establishing procedures and a theoretical-methodological background to guide the actions, the practices at the institutions analyzed rest on their professionals’ concepts^(10-12).

Each model "rests on different theoretical-methodological concepts about the phenomenon of addiction, objectified in different practices and antagonistic and to a certain extent mutually different discourses. This disparity rests on the complexity of the phenomenon, whose essence departs from the interweaving of countless variables and determinants, as well as on the diverse educational backgrounds of the professionals and agents working in the health area"^(2,10).

Based on the analyzed data, it is shown that the treatment of psychoactive substance addictions depend, in the first place and fundamentally, on the concept of addictions and treatment of drugs adopted by the professionals involved in the service, which can be influenced by the cultural and political assimilation of each, the type of substance used the individual’s motivation and biological predisposition⁽¹²⁾. These factors are subject to different networks of meanings by the same professionals⁽¹⁰⁾.

This analysis supports the data obtained in Figures 3, 4 e 5, in which the mixture of concepts among the models at each institution is indicated. In the first question, illustrated by Figures 3 and 4, answers are shown that sole and exclusively depart from the professional’s own understanding of the terms addict and treatment (of psychoactive substances). In question 2, illustrated by Figure 5, the answers depart from assertions on the professionals’ activities in view of the problem.

We consider that the proposals and treatment models for the drug addicts tend to be eclectic procedures, with different actions, while pure models are uncommon to find^(5,10). In the past decade, a range of approaches emerged for addiction treatments and, to achieve the proposed targets, a wide range of means are adopted⁽¹³⁾. These different combinations and mixture of concepts indicate the lack of objective criteria and parameters to establish care protocols and intervention processes. Thus, although the differences and contradictions in the epistemological proposals of each model are clear, in professional practice, they are not evident.

What the professional education is concerned, it is important to highlight that, at the three institutions, the staff presented some supremacy concerning the educational area. At the CAPS ad, a larger number of medical respondents was found, against psychologists at the TC and the same number of professionals from each area at the clinic. Different professionals deliver services in addiction care, but Brazil has no specific legislation to define each professional’s role in the practices according to the therapeutic proposal⁽¹⁴⁾.

It is equally important to register that only two professionals out of 17 held a specialization degree, although the three institutions are specialized in addiction treatment. Professionals who deal with this issue today have no specific education on the theme, as undergraduate programs often do not present options in that sense^(10,15), which indicates that, in Brazil, the majority of the services are sole and exclusively based on their members’ effort and good will⁽¹⁴⁾, limiting the effectiveness of the services, detached from the local needs. The hypothesis is raised that the specific education for professional action in the treatment is no source of concern for the institutions that call themselves experts.

 

Conclusion

In view of the presentation and analysis of the data, it is highlighted that the treatment proposals and models for drug addicts analyzed present no specific philosophy guiding their work. In addition, there is the fact that each professional’s educational background can influence and oppose the philosophy and work ideology of the institutions analyzed, as each knowledge area departs from a certain specific theoretical-methodological framework. The approaches at the institutions under analysis are directly linked to the way of thinking and understanding the origin and evolution of the addiction, conceiving its origin based on biological, psychological and social factors underlying the perception of its sinful or criminal genesis.

As a result of the incongruent understanding about the phenomenon of drug addiction, treatment institutions emerge with a great mixture of approaches and intervention models in the same activity locus, including mixtures of interventions based on various etiological and epistemological premises, making any coherent discourse unfeasible, which is committed to the efficient therapeutic project, proposing positive perspectives for the service users.

Then, it should actually be considered whether the root of the problem, reflected in low recovery rates, does not lie in the methodological activity practices themselves, considering that, in the available treatments, in the public as well as the private sphere, no adequate solutions have been proposed yet, generating more doubts than answers on the phenomenon and the care. The fact is that many individuals return to the drug use pattern after seeking these treatment services, questioning their efficacy. Thus, this research contributes to the expansion of the understanding that the patient cannot be the sole responsible in case of return to the drug use.

In the context of the cultural transformation of the treatment models in mental health, which used to be based on the hospital-centered model, not only the establishment of new service models is encouraged, driven by the psychiatric reform, but also the need to transform the care and attendance practices.

Future studies, in which clear and objective definitions are elaborated about the treatment and addiction concepts of psychoactive substances, in line with the different knowledge areas (multidisciplinary), followed by the adaptation and definition of each professional’s role at the institutions, would support more effective treatment services that are clear and accessible to professionals and users. This kind of studies, translated into public policies, can significantly contribute to the efficiency and effectiveness of the care services for drug addicts, as well as scientific and statistically significant measures, indicating the effect of the interventions the service users submit to.

 

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Received: July 21^st 2016
Accepted: March 27^th 2017

Corresponding Author:
Aislan José de Oliveira
Centro Universitário Campos de Andrade – Uniandrade
Rua João Scuissiato, 01
Bairro: Santa Quitéria
CEP: 81220-090, Curitiba, PR, Brasil
E-mail: aislan_jo@hotmail.com