ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.smad.2018.000383

 

The need for night admission to a Psychosocial Care Center: perceptions of drug users*

 

La necesidad de la acogida nocturna en un Centro De Atención Psicosocial: percepciones de la persona que consume drogas

 

 

Thyara Maia Brandão^I; Mércia Zeviani Breda^II; Débora de Souza Santos^II; Maria Cícera dos Santos Albuquerque^II

^IUniversidade Estadual de Ciências da Saúde de Alagoas, Maceió, AL, Brazil
^IIUniversidade Federal de Alagoas, Escola de Enfermagem e Farmácia, Maceió, AL, Brazil

 

 

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ABSTRACT

OBJECTIVE: to apprehend the need for night admission as perceived by people attended to at a psychosocial Care Center for Alcohol and Other Drugs 24h.
METHOD: qualitative approach, with participation of 12 users with experiences of nighttime admission to this service. Data were collected by interview, field diary and systematic observation. Content analysis of the thematic type was used to treat, categorize and interpret the information.
RESULTS: there was a perceived need for night admission due to the loss of control over drug use, damage caused by addiction, and difficulties in living on the street.
CONCLUSION: individualized care should be the focus of nighttime admission and in other services of the Psychosocial Care Network.

Descriptors: Mental Health; Related Disorders Use of Substances; Mental Health Services; User Embracement.

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RESUMEN

OBJETIVO: comprender la percepción de la necesidad de la acogida nocturna de las personas asistidas en el Centro de Atención Psicosocial -Alcohol y otras Drogas 24 horas.
MÉTODO: enfoque cualitativo, con la participación de 12 usuarios con vivencias de acogida nocturna en este servicio. Los datos fueron recolectados por entrevista, diario de campo y observación sistemática. El análisis de contenido de tipo temático fue utilizado para el tratamiento, la categorización y la interpretación de las informaciones.
RESULTADOS: hubo percepción de la necesidad de acogida nocturna ante la pérdida del control bajo el consumo de drogas, los daños causados por la dependencia y las dificultades de vivir en la calle.
CONCLUSIÓN: se señala la necesidad de centrarse en la atención particularizada en la acogida nocturna y en los demás puntos de la Red de Atención Psicosocial.

Descriptores: Salud Mental; Trastornos Relacionados al Uso de Sustancias; Servicios de Salud Mental; Acogimiento.

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Introduction

People with drug addiction need new projects and health care devices that reach beyond the focus on abstinence and hospitalization, respect their subjectivities and singularities, consider the potency of subjects and be producers of life.

In Brazil, the Policy of Attention to Alcohol, Crack and Other Drugs has been weaving a service network that works on the principles of harm reduction and psychosocial attention. One of the strategic points of attention of this network is the Psychosocial Care Center for Alcohol and Other Drugs 24 hours (CAPSad 24h), an extra-hospital service in which nighttime admission is presented as technology of care for people with attention needs as a result of using psychoactive substances^(1-4).

CAPSad 24h is part of the Psychosocial Care Network (RAPS), as a substitute for hospital admissions. It provides comprehensive, community and continuous care to people with drug use needs. In cases where the person is in critical periods that require more attention, he/she can stay overnight for up to fourteen consecutive days, considering a period of thirty days⁽⁵⁾.

In this service, night admission represents the opportunity for continuous monitoring, with day and night stay. The person is placed in a plan of care, because it is a time when he/she seeks help and is usually more willing to talk with the health team⁽⁶⁾.

Night admission presents a differential in the institutional format, as it translates into practices guided by the theoretical concepts of deinstitutionalization and extended practice. It causes a reorganization of the work process in the daily life of the professionals of this service, in which new senses of care are created⁽⁷⁾.

Imbued with a welcoming attitude, night admission values freedom and interpersonal contact, consisting in actions of getting closer, "being with" and "being close to", an attitude of inclusion. This welcoming action can be described as a technology of encounter, of conversation that affirms relations, of power in the processes of health production, and which extends to all places and times of psychosocial care service⁽⁸⁾.

Considering the leading role of the individual and the scarce scientific production that captures the voice of drug abusers, this study was designed to apprehend the perception of night admission by people attended to in a Psychosocial Care Center for Alcohol and other drugs 24h.

 

Method

This is a qualitative, descriptive research study of exploratory character. Qualitative research is characterized by understanding phenomena from symbols or meanings attributed to them⁽⁹⁾. This methodological modality proved to be most adequate because it allows the description of night admission, still little explored, in an attempt to work out meanings and intentionalities of verbal and gestural expressions of the subjects in question.

The study scenario was the Psychosocial Care Center for alcohol and other drugs in a Brazilian capital. Founded in 2006, the service is part of the CAPSad 24-hour modality since 2013 and has a multiprofessional health team. The service provides, among other activities, Night Admission for situations of social risk or drug relapse, as well as in cases that require permanence in the facility. In this mode, the user spends up to 14 consecutive days in the center, during which time he/she will also sleep at night. There are 14 beds available, 7 for men, 5 for women and 2 for adolescents/children.

Data collection was performed at CAPSad 24h from January to March, 2015. Information production was obtained through triangulation of individual in-depth interviews, field diaries and systematic observation. Triangulation is about the commitment to deepen the understanding of the studied phenomenon, seeking greater methodological rigor by using three distinct data collection tools⁽¹⁰⁾.

The interviews were guided by a script with 25 questions distributed in six sections: Identification data; Reasons for requiring night admission to CAPSAd; Night reception; Experience during admission to CAPSAd; night nursing care and other important accounts. All of the interviewees chose the location they felt most comfortable with to contribute to this study, and their privacy was assured. They were encouraged to express their views, with no interference or judgment by researchers. The interviews lasted, on average, 80 minutes, and were recorded in audio and fully transcribed.

Systematic observation was guided by a script to record interviewees’ nonverbal manifestations, such as facial expressions, voice modulation, body movement, crying, laughing, pauses. A field diary was used to record the interviewer’s personal impressions on the contents from systematic observation, functioning and routines of 24-hour CAPSad, scenes and occurrences that allowed revealing the investigated phenomenon. Note-taking was by hand, then typed and consolidated.

Content Analysis⁽¹¹⁾ of the thematic type was used for treatment, codification, categorization and interpretation of empirical material. The next steps ⁽¹¹⁾ were as follows: 1) Pre-analysis, 2) Data Exploration and 3) Treatment, inference and interpretation of results. In the first step, after repeated readings the material was organized so as to make it operational, systematizing the initial ideas. In the second step we performed clippings of significant and repeated statements and records, seeking to identify and classify registration units and context, in order to categorize the data into explanatory themes of the study object – user perception about the need for night admission. Finally, in the third step themes and their contents were interpreted critically in light of the literature.

The interpretative process was supported by the theoretical references of the National Policy on Mental Health and Attention to the use of crack, alcohol and other drugs^(4-5,12).

The themes from the analysis showed that users perceived the need for night admission to CAPSAd 24h as a result of: I. Loss of control over drug use; II. Damage caused by such use; and III. Street experience.

The identity of participants has been preserved, ensuring the confidentiality required in human research. The Research Ethics Committee, substantiated opinion # 937.076, approved the study.

 

Results

The research subjects were 12 service users who fulfilled the inclusion criteria: over 18 years of age, history of psychoactive substance use, tracked at the service, with a night admission experience, presenting with no signs and symptoms of withdrawal, such as aggressive behavior and language difficulties.

Participants were between 24 and 57 years of age, seven were male, five were female and one was pregnant. As for schooling, 9 did not finish elementary school and 3 completed elementary education. As for occupation, 11 did not have any work activity and 1 woman worked with handicraft in an autonomous way. Regarding marital status, 6 participants were unmarried, 4 were in common-law marriage, 1 was married and 1 was divorced. As for housing, half of the interviewees lived in outlying districts with their families, while the rest were living on the streets, with only 2 of them counting on overnight stays in shelters. All reported having sought the service of their own free will, from encouragement of family and professionals of the Street Office and/or CAPSad 24h itself.

Perception of loss of control over drug use: the need for help

In the reports on the demand for night admission, respondents described constant drug use, which was producing damage, as they could no longer remain abstinent. They reported the need for help, describing that drug use took them much of the time of daily life, harming health. (...) I was drinking straight from Christmas, I drank every day. Every day drinking, I realized I needed help (E1); I no longer had any strength, to control the drug, had already hit bottom, considered weak ... then they were inaugurating this 24-hour [CAPSad Type III] (E3); I was very debilitated because I was no longer enduring the life I was leading, had no control over the drink. I needed help (E6); I was very much in use, crack, marijuana, booze, I was abusing (E7).

The perception of the need for help led the interviewees to seek the service on their own: I decided to come, I was already aware that I needed hospitalization and treatment (...) (E2); What made me decide was the will to live, it was not because somebody forced me to do so, it was because I wanted to be reborn (...) (E5); I came of my own will, they indicated to me, I came, they took me in (E6); I asked, they sent me to a psychiatrist and I stayed, 15 days. It was the opportunity I had, right? (E10).

The words show that interviewees’ perceived loss of control over substance use and the will to live led them to seek night admission to the CAPSad 24h, by their initiative and acceptance, when the opportunity of change was perceived.

The search for help happens as a response to the situation of dependence and disadvantage that marks the lives of drug users, driven by the effort to find ways to overcome pain and suffering.

Perception of addiction: Harms and ways out

If on the one hand the perception of physical, emotional and material damage caused by drug use generates impoverishment, pain, shame, exclusion and loss of life’s meaning, on the other hand it impels people to search for a way out.

The dependence on crack was bringing me a lot of damage, in money, health, material, physical, everything (...). It was a mess! I was depressed, I went into depression... at the beginning of my addiction I tried to commit suicide twice [...]. I did a lot of bullshit, I sold everything from inside home, I sold my bike, I left a woman, I left my mother, I left my life (...) (E2); Family moving away, friends, the community runs away from the person, away. Then the guy gradually get sad, alone, I saw myself inside a hole. There was nothing left for me to hold onto, neither family nor friend, nothing at all (...) I woke up one day and there was nothing to eat, I had to pick up garbage, to eat bread from garbage (E7); It was all an illusion, it passed, left sequelae, and when I realized I was already sunk, I had already destroyed family (...) it was hopeless, for me only death would do ... you losing everything, that took so many years to built, so I came here, I wanted to get out of this (E3).

A sense of loss accompanies the addicted person deeply, in various spheres of life, especially in affective relationships. Loss of family and friendship ties is reported with regret and guilt as being the result of mistakes ("bullshit") done to sustain use.

Absent from their affective nuclei of relationships, the people interviewed see night admission as a chance of change. The service allows removal, even if temporary, from the streets and their degrading conditions.

Living on the streets

The perception of a condition of social vulnerability, marked by the violence they are exposed to when living on the streets, generates fear and also the desire for a safer and healthier life. Experience shows that drug use can lead people to live on the streets, or vice versa, and in both situations there are sensitive services that are turned to, such as CAPSad 24h, the locus of this study.

Despite the conditions of vulnerability on the streets, there is a search for night admission, especially as mediated by professionals from the Street Office (CnaR). I want to try another life (...) many deaths, I saw three colleagues of mine die in front of me, two by shooting and the other by knife, on the street. Because of the drug (E11); It was my choice for drugs that took me to the streets (...) it is a false way of living (E3); My brother! Look where I am. Bread in the garbage I never ate! (...) I did not want to lose my family like this, to go back to the streets, so I came here (E7); I came stitched all over, I did not even come because of the stitches, I came because I decided to stay. But if I did not want to, I would not have stayed (...) (E12).

Alongside living on the streets is the desire for a new life. The mediation of a CnaR or CAPSad professional in deciding to seek help and be rescued from cruel situations also appears as a necessity. In any case, the decision is always private and depends on the will and strength in each one. I looked for the coordination of street (Street Office), then they resolved (E8); So-and-so (CAPSad worker) came and talked to me, if I wanted help, again, this time I should do otherwise, I accepted, not quite, I made the decision. They called me and I went for it (E3); (...) I relapsed, they came to me, they rescued me... sometimes I did not sleep, the day dawned, I used to prostitute myself to earn drug money... (E9); I came spontaneously, no one asked me to bring me in, no one forced me to come, they just told me "look, there is treatment, don’t you want to go take a look?" I came (E11).

The street is a place where drug addiction is deepened and the risks related to maintaining physical integrity are aggravated. In this context of struggle for life, psychosocial support services act as instruments open to admission, guidance and "rescue" of the person suffering from drug use.

 

Discussion

The perception of loss of control over drug use and the need for help, which culminated, among the interviewees, in the search for nighttime care at CAPSad 24h, showed a pattern of harmful use. Harmful use of a chemical is characterized by development of tolerance, inefficient effort to reduce or control use, and the presence of withdrawal signs and symptoms⁽¹³⁾.

The interviewees refer to the night admission service as hospitalization, even though this is not the proposal or terminology used by CAPSad 24h. This perception is probably due to the user’s exclusive permanence in a place where work processes are similar to those of a hospital unit, although for a short period, open to visitation and participation in external group activities. According to the national psychosocial care policies, night admission to CAPSad 24h is provided as a provisional and intensive form of psychosocial care, so that care is delivred to people who, in situations of drug abuse or crisis, seek help in this service. This care is accompanied by a multidisciplinary team, focused on harm reduction and search for integral and humanized attention to the service user⁽⁵⁾.

The perception of harmful use led the interviewees to seek CAPSad 24h because of affective and material losses, loneliness, lack of support and various predicaments, such as having nothing to eat or wanting to take one’s own life.

The condition of dependence that is gradually established, added to the loss of control over use, generates impairment of social skills, such as those of facing difficult situations, resulting in physical and emotional impairment, to the point that, often, suicidal ideation develops⁽¹⁴⁾ .

Many are the harms arising from drug use; however, such harms are often only perceived by the actual installation of physical and/or psychic addiction and when such addiction causes disintegration of social contexts, which leads these individuals to search for help⁽¹⁵⁾.

Regarding the use of substances, most of the users interviewed reported suffering from family and marital conflicts, as well as damage in their work. Thus, harmful use has negative implications in social relationships, whether in the family, at work or in friendship circles, and contributes to the development of violence, which requires serious investments in public policies aimed at repairing such damage⁽¹⁶⁾.

Functioning and structure of a household where one member is experiencing a period of crisis due to harmful use of psychoactive substances are changed, and all members may be affected by great emotional distress. Family support from well-structured relationships is a necessary but sometimes compromised aspect. Interaction and family involvement, when positive, mobilize the distressed person in the battle against addiction⁽¹⁷⁾.

Otherwise, social exclusion resulting from abandonment by family, for example, may induce the adoption of high-risk strategies for obtaining drugs. The reports of interviewees living on the streets, who usually live in extreme social vulnerability, are headed in this direction, where there is damage or compromise of family relationships, violence with death outcomes, mainly in the places of purchase, sale and use of drugs like cocaine crack⁽¹⁷⁾.

In this research, all of the people living on the streets, most of them consuming crack, presented with serious physical and emotional damage as a result of the risks they were exposed to. Considering the changes that occurred in the last fifteen years, it appears that, despite crack use has become popular and spread across different social groups, the most excluded and marginalized individuals, such as the homeless, continue to be the most affected, both from the abusive use of crack and from poverty and social abandonment⁽¹⁸⁾.

In this regard, it must be considered that there is an increasing number of people in the general population on the margins of conventional structures of society, resulting in the compromising of their physical and psychological health and, consequently, their survival. It is in the streets context that many of these people seek help, while at the same time they are faced with situations and risk behaviors, including drug use⁽¹⁹⁾. In addition to social exclusion there is a constant risk of death due to poverty, violence and insecurity and marginality, which are compounded by the illegal sale and consumption of crack cocaine⁽²⁰⁾.

This condition portrays a context of needs, faults and abuses. However, devices such as the Street Office, for example, appear as social support, affection and a perspective of change for those who are in a "street situation". The results of the study demonstrated that this service is evaluated positively by users, who aim to receive support and, in some cases, opportunities to change their lives. In addition, they highlighted facilitation of access to health services, commitment of the team, and respectful relationships established with users.

To address these multiple needs, researchers^(19-22) argue that therapeutic approaches should take into account the pharmacological and clinical characteristics involved in harmful use, but overcome the focus solely on the product and its consequences, so as to consider the excluding living conditions in which a large proportion of people who use drugs in harmful ways are, especially in urban contexts. They call attention to the importance of social and family structures in supporting the attempts of self-control and facing the difficulties of interrupting drug use^(19-22).

The national survey on crack use⁽²¹⁾, conducted in Brazil in 2014, indicated low access to equipment available to attend to the needs arising from the use of alcohol and other drugs, although a large number of users stated that they wished to undergo treatment for drug use. This would justify interviewees’ gratitude for being admitted to the service, commonly expressed in their talks.

However, with a policy of deinstitutionalization, one does not see any significant evaluation of distress and care of people living on the streets, whose number has grown significantly in the last decades. These people suffer from social stigmas and labels as a result of drug use and street walking, sometimes committing crimes to maintain consumption⁽²²⁾.

However, this study shows the potential of Night Admission to bring about changes in the course of people in harmful drug use, as it is recognized by these as a possible way out to regain what was lost. Of course, because of its transitory nature, the service alone is not enough to overcome the loss of control, chemical dependency and social vulnerability of those seeking CAPSad.

However, as users and other RAPS practitioners view it as a solution to the problem, it can work as a device for change, articulating with other network services and social institutions. This research design has specific characteristics that do not allow generalizations, so it cannot be said that subjects’ reports are representative of a larger group or other social contexts. It is also noteworthy that the understanding of the phenomenon is not exhausted in the talks of the subjects interviewed.

 

Conclusion

Faced with the harms caused by the use of psychoactive substances, some of the interviewees were taken to situations of extreme vulnerability, such as living on the streets. Although the search for night admission to CAPSad 24h occurred of their own free will, family proved to be an important motivational resource, as well as the action of network professionals.

In the context of vulnerability, individuals with harmful drug use perceived the need to seek the service as arising from the loss of control over substance use, which commonly led to addiction and physical, material and emotional losses. While this situation deepened distress and loss of life’s meaning, it also promoted the search for a solution and the will to overcome the problem in the people interviewed.

Studies carried out in other scenarios indicated that the findings reported here also reflect the needs of users living in other Brazilian regions, with similar circumstances regarding the challenge of dealing with problems caused by harmful use of drugs.

In this sense, considering the potential of night admission to trigger changes in lives devastated by drug use, expansion of the provision of this service elsewhere in RAPS is important and necessary. For in the struggle for life, this service was perceived as a concrete possibility of regaining the will to live in people who are in distress due to drug addiction and in situations of extreme social vulnerability.

 

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Received: Mar 26^th 2017
Accepted: Sep 11^th 2018

Corresponding author:
Thyara Maia Brandão
E-mail: thyara.maia@hotmail.com
 https://orcid.org/0000-0003-4630-6956

 

 

* Paper extracted from master’s thesis "A vivência do acolhimento noturno em Centro de Atenção Psicossocial para álcool e outras drogas 24 horas", presented to Escola de Enfermagem e Farmácia, Universidade Federal de Alagoas, Maceió, AL, Brazil.