ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.smad.2019.000415

 

Adherence to treatment: perception of adolescents in chemical dependency*

 

Adhesión al tratamiento: percepción de adolescentes dependientes químicos

 

 

Jurema Ribeiro Luiz Gonçalves^I; Lívia Wazir Canassa^I; Lilian Cristina da Cruz^I; Andrea Ruzzi Pereira^I; Daniela Mendes dos Santos^I; Amanda Ribeiro Gonçalves^I

^IUniversidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil

 

 

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ABSTRACT

OBJECTIVE: the objective of this study was to describe the adolescents’ perception about adherence to the chemical dependency treatment.
METHOD: descriptive, exploratory study with a qualitative approach. Eleven adolescents attended the Psychosocial Care Center for Alcohol and Drugs (CAPS ad) in the interior of Minas Gerais. Data were collected through interviews, using a semi-structured instrument and then analyzed through the content analysis technique.
RESULTS: it was found that the established links, the activities developed, the family support facilitates the adherence to the treatment and the court order assists in the frequency of service.
CONCLUSION: it is concluded that the identification and understanding of the factors that interfere in the process of adherence to treatment allow the elaboration of adequate and effective therapeutic programs and approaches, based on the needs of adolescents.

Descriptors: Adolescent; Drug Users; Substance Abuse Treatment Centers.

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RESUMEN

OBJETIVO: el trabajo tuvo se objetivó describir la percepción de adolescentes sobre la adhesión al tratamiento de la dependencia química.
MÉTODO: se trata de un estudio descriptivo, exploratorio, con abordaje cualitativo. Participaron del estudio once adolescentes atendidos en el grupo psicoterapéutico en el Centro de Atención Psicosocial Alcohol y Drogas (CAPS ad) en el interior de Minas Gerais.
RESULTADOS: los datos fueron recolectados por medio de entrevistas, utilizando un instrumento semiestructurado y después de analizadas a través de la técnica de análisis de contenido. Se constató que los vínculos establecidos, las actividades desarrolladas, el apoyo familiar facilitan la adhesión al tratamiento y el orden judicial auxilia en la frecuencia al servicio.
CONCLUSIÓN: se concluye que la identificación y la comprensión de los factores posibilitan la elaboración de programas y enfoques terapéuticos adecuados y eficaces.

Descriptores: Adolescente; Consumidores de Drogas; Centros de Tratamiento de Abuso de Sustancias.

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Introduction

Adolescence is a unique period for every human being. It is characterized by biopsychosocial changes and notorious adaptations that the individual experiences in the process of changing into adult life⁽¹⁾. According to the Child and Adolescent Status (ECA), it is the period between 12 and 18 years old⁽²⁾. It is highlighted by the awakening of new personal and interpersonal skills and abilities, discoveries, experiences, search for an identity and choices that can be decisive and permanent in their life⁽³⁾.

This transition is considered critical because, together with other factors, especially environmental factors, they may induce drug use/abuse⁽⁴⁾. In the process of adolescence, chemical dependency can influence school drop-out, intensify difficulties in family and professional relationships, resulting in a great social impact⁽⁵⁾.

In this context, the importance of understanding the singularities of adolescence, the reference of chemical dependency, psychodynamic functioning, interpersonal relationships and support of the family as behavior influencers, professional link to the patient, personal motivation for the change of behavior are important factors contributing to better adherence to the therapeutic plan^(4-6).

From the understanding of these different factors and the relationship established between them, it is possible to observe possibilities of assistance and to articulate the approach, guaranteeing the effectiveness of the actions, since adolescents are cited in the literature as a group that manifests hostility, distrust and other forms resistance, and low motivation for adherence to treatment⁽⁷⁾.

To discuss the issue of adherence of adolescents to the treatment of chemical dependency, this paper aims to describe the adolescents’ perception of adherence to the treatment of chemical dependency.

 

Method

This is a descriptive, exploratory study with a qualitative approach to the data, aiming to deepen into the complexity of the phenomenon and the approximation of reality in the social context with its peculiarities and meanings⁽⁸⁾. The research was carried out in a Psychosocial Alcohol and Drug Attention Center (CAPS ad) in the interior of the state of Minas Gerais.

Eleven adolescents who attended the institution during the data collection period and who met the following inclusion criteria participated in the study: 18 years old or less; be inserted in the therapeutic plan for adolescents; and agree to participate voluntarily in the study.

Data were collected by two researchers, who received previous training. The semi-structured interview was used as the collection technique with guiding questions focused on the adherence to the treatment. The answers were recorded on a tape recorder and transcribed in full, for further analysis. Respondents received fictitious identification (eg, E1, E2, E3...), according to the order in which they were addressed, for identity preservation. The information obtained in the interviews was analyzed and categorized through the content analysis technique, including three steps: pre-analysis, material exploration, and treatment of the results obtained⁽⁹⁾.

According to the regulations of research developed with human beings, the project was submitted to the Research Ethics Committee (CEP) of the Federal University of the Triângulo Mineiro (UFTM), receiving a favorable opinion with protocol 2204. After appreciation and approval of the project, the committee began collecting data. For each volunteer and responsible, the Term of Free and Informed Consent was given, according to Resolution 466/12, and elucidated the purpose of the study, as well as the guarantee of anonymity and the volunteer’s total freedom to give up the research at any time.

 

Results and Discussion

The sociodemographic data obtained in the interviews showed that the patients were between 15 and 18 years old, ten were male and one was female. All of them were singles, with only one living with his girlfriend and having children. No adolescent had finished high school and eight of them reported dropping out because they had recently been admitted to rehabilitation institutions or the Center for Attention and Social Re-education of Adolescents and Minor Offenders (CARESAMI). Ten adolescents attend the Specialized Referral Center of Social Assistance (CREAS) as a fulfillment of the socio-educative measure of assisted freedom and community service, so they attend the CAPS ad rehabilitation service by a court order, with only one patient attending CAPS ad by family orientation. Five of them work, but none of them have formalized employment. As for the family arrangement, the adolescents reported living with their parents, with uncles, sisters, girlfriend, and nephews.

After reading and analyzing the interviews, the following categories emerged: I- Links; II- Activities developed in group; III- Family support; IV- Frequency of service: court order; V: Afraid to evaluate the service.

Category I: Links

This category indicates the established friendship and the creation of bonds with the other participating adolescents and with professionals of the institution as the main factor for the adherence to the treatment. It was identified that the relationship with the other members was possible because they were of the same age group and identified with the problems of each other. This can be evidenced by the following reports:

Young people of my age, the same age, this is cool. (E6)

What I like the most is talking to [...] the professionals. (E1)

One thing I enjoyed is friendships, meeting lots of people, the conversations are good. It helps a lot, it’s just make me think about friends that everything improves, everything gets easier. (E10)

The literature highlights how favorable to adherence to treatment in the frequent attendance at CAPS ad, the constitution of a new network of relationships among patients, especially those of the same age group, good relationship with professionals of the specialized service, who have affinity with the chemical dependency work to offer a welcoming and qualified assistance, developing friendly relationships, focused on the individualized therapeutic plan and the formation of a solid social network^{(3, 6, 10)}.

In this sense, the bond allows a more effective approach between the patients and the professional, enabling to establish relationships based on listening, dialogue and respect, which contributes to the success of the treatment. The patient feels safer because he/she perceives accepted and closed to the professionals and establishes a relation of confidence, increasing possibilities of solving the problems presented in the context of the use of drugs. However, it should be emphasized that the bond cannot become a dependency, since the professional helps the patient to reach his autonomy and independence, hindering to establish a dependent relationship^(6,11).

Thus, the social support network suggested by the psychiatric reform aims to support individuals, promoting health and creating new links, and strengthening the access to other social networks within the community⁽¹²⁾.

In this way, the established bonds provide a sense of welcome, support, and contribute to the adolescent feeling safe and protected, conditions that the family context often does not provide.

Category II: Activities developed in group

According to the adolescents´ perception, the activities developed in CAPS ad emphasized the therapeutic groups mediated by the psychologist, highlighting to facilitate factors for adherence. This can be proved by the following reports:

I like to come here and join the group. That’s what I like the most. (E5)

What I like the most is the activities, when we gather everyone to talk, talk about things. [...] (E11)

I like the activities we do together. (E7)

In general, the activities carried out in the CAPS ad include visits and home visits, family care, community activities focused on the integration of the chemical dependency in the community and their family and social insertion, as well as detoxification care⁽¹³⁾, with emphasis on the group visits, for their contributions in the rehabilitation of the patients⁽¹⁴⁾. Groups are spaces created to work in vulnerable areas, sharing experiences and feelings, leading to reflection and reformulation of concepts⁽¹⁵⁾. Thus, the welcoming environment gives individuals the opportunity to discuss their problems and share experiences, aiming at social insertion, helping patients to assume their roles in society, increasing their potential for behavior change⁽¹²⁾.

The inclusion of groups for adolescent care is an effective tool and good results. Groups of leisure activities, pleasurable and inherent to the daily life of adolescents enable the leisure experience with a therapeutic approach of rehabilitation.

Category III: Family support

The support received by the family favors the adolescent’s adherence to treatment in CAPS ad, since the patients report the support and encouragement received from the family members at different moments. Also, it is evident that regularly attending CAPS ad represents a form of response to a debt with their relatives. The support received can be demonstrated by the following reports:

They support me to come here, otherwise, I will not come. (E3)

I come with my mother when she calls me. (E7)

My mother supports comes here in community participation, my mother who takes care of me. (E10)

Family work plays a wide influence on the conditions and decisions of the adolescent chemical dependent, becoming relevant to the treatment adherence when providing support, harmonious family coexistence, dialogue, orientation and effective interaction in the rehabilitation process^(16-17).

Thus, the family approach is critical in the treatment of chemical dependency, especially with adolescents. Different studies point to better results for treatments in which the family is involved in the process and stimulated to offer support, compared with those that are patient-centered, evidencing the importance of family support in adherence to treatment^(3,18).

In this context, the interaction of the family with the patient during the treatment is fundamental, seeking participation in joint activities⁽¹⁹⁾, being present at this stage of the intervention constitutes a factor of support and security for their social reinsertion⁽²⁰⁾.

Category IV: Frequency of service: Judicial order

An important factor for attendance at the chemical dependency treatment service is related to the court order to attend CAPS ad aiming to effective participation in the service as a form of dependency treatment and relapse prevention. Although this measure has a authoritative character, it contributes directly to attendance, being reported by ten of the study participants. This can be demonstrated by the following reports:

I came by the court order. (E3)

I come here because they sent me. They told me to come and finish my treatment here. (E5)

I am obliged to come. (E7)

I came because of the judge, he told me. (E8)

For the adolescent who commits an infraction, it is the responsibility of the Judiciary to apply orders of legal measures for the protection of rights and socio-educational, provided in the ECA, for resolving and coping with the legal cases that are presented. Thus, the beginning of specialized treatment usually occurs through judicial referrals associated with infractions or follow-up by the Guardianship Council^(21-22).

Thus, the court order is pointed out in the literature as elementary in the process of seeking help, assiduity to CAPS ad and, therefore, better adherence to treatment^(3,23). However, there is a question of not expressing a desire to seek help from patients, and judicial imposition is necessary. This may interfere with the success of long-term treatment due to lack of motivation and interest in change. However, coercive measures influence adherence to treatment by subjecting the patient to different types of intimidation for behavioral change⁽⁷⁾.

Given this, it is evident the need for an effective and constant work by CAPS ad professionals to sensitize adolescents to attending treatment service, not only as a form of compliance with previously established orders but based on awareness raising and understanding of the need to rehabilitate their social functions by adhering to the therapeutic plan.

Category V: Afraid to evaluate the service

Regarding to the perception about the care service for adherence to the treatment of chemical dependency, the adolescents were afraid to say it. While being clear about the objectives of the work, guaranteeing secrecy and certifying that the information would have no risk to them, they chose not to answer clearly to the questions about the impediments of adherence, especially issues related to negative aspects of the place or suggestion of changes in activities of the institution, believing that pointing out possible inadequacies in the service or exposing complaints of dissatisfaction could subsequently be harmed in some way.

It is highlighted that this fear presented by all the participants is an implicit feeling of self-protection and caution not to compromise. Some of them suggested in their testimonies that they felt insecure to tell about the subject since they were inserted in the service not long ago and they feared that to make critics/suggestions of the service could represent risk of harming them. Through verbal reports and observation of body language, this fear is evident:

That question there, that crazy talking, skips it [...] I have nothing to declare on that question. (E10)

I have no idea. (E12)

What do I least like here? I do not know how to explain it to you. [...] (E3)

There’s nothing, there’s nothing I do not like. (E5)

Nothing, there are none, I think. [...] (E8)

Length of stay, coexistence with service professionals and gradually established links can minimize this behavior. The presence of a qualified multi-professional team, with availability to host, that allows the construction of an effective relationship capable of generating interaction are factors considered as facilitators for adherence to treatment⁽³⁾.

However, adherence to treatment in chemical dependency presents several challenges and there is no evidence to categorize the different interventions in terms of greater or lesser effectiveness^(24-25).

 

Conclusion

Thus, it is possible to consider that adherence to the treatment of chemical dependency by adolescents is a complex and multifactorial process. However, relevant aspects in this context are highlighted in this study. The reception offered in the adolescent’s admission to the service is decisive in adherence to the treatment, because even if the initiative to attend CAPS ad is by judicial imposition, the initial approach performed by the service can result in adherence, when providing the establishment of relationships of respect and mutual acceptance as well as the creation of links not only in adolescents but also between service patients and professional staff.

It is worth noting the development of activities of interest to adolescents, so they are concomitantly pleasurable and capable of sensitizing behavior change, so the frequency in the service is not only for the fulfillment of a judicial order but for the adolescent’s own interest. The presence of the family offering support and encouragement as relevant factors in this process is also worth mentioning.

Thus, the identification and understanding of the factors that interfere in the process of adherence to the treatment allow the elaboration of adequate and effective therapeutic programs and approaches to enable strategies that help adolescents to cope with chemical dependency, in the real needs manifested by them, exempting concepts and mistaken interventions that occur in practice and that in several cases they harm the adherence to the service.

As a limitation of the study, there were the adolescents who did not express regarding the perception of the service about characteristics of the service and the team that they could judge relevant in this process. The thematic of this study was presented in a challenging way for the researchers, who did not intend to exhaust the thematic approach with this research. Therefore, it is important to emphasize the need for research in other services, and this work has the role of initiating a long search for knowledge about adherence to the treatment of dependent adolescents.

 

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Received: Aug 31^st 2017
Accepted: July 31^st 2018

Corresponding author:
E-mail: juremaluiz@hotmail.com.br
 https://orcid.org/0000-0002-6971-5296

 

 

* Supported by Ministério da Saúde, Brazil.