FAMILY MEMBER WITH CHEMICAL DEPENDENCE AND CONSEQUENT OVERBURDEN SUFFERED BY FAMILY: DESCRIPTIVE RESEARCH
Elias Barbosa Oliveira1, Jovana Lucia Schettini Medonça2
1 State University of Rio de Janeiro;2 Health Department of the Municipality of Rio de Janeiro
ABSTRACT
Problem: health professionals should provide support to the family of drugs addicts due to the overload experienced in this process. Objective: The objective was to analyze the difficulties faced by the family in the treatment of the chemically dependent family member. Method: Qualitative descriptive study. We used a semi-structured interview by means of a script and treatment analysis of the data content. 05 families took part in the study at a public psychiatric hospital located in the city of Rio de Janeiro (Brazil) in 2007. Results: families reported as difficulties the abandonment of treatment by the patient and his regression, the emotional burden and the non- forwarding to services outside the hospital by the health team. Conclusions: It was concluded that there is a need for greater coordination of services for primary and secondary care in Mental Health, so as to minimize the difficulties faced by the family. The family that takes care of chemically dependent has an important and indispensable social role to the consolidation of the psychiatric reform in the country.
Keywords: family relation; substance-related disorders; mental health.
INTRODUCTION
This article arose from reflections on the problem of hospitalization of patients with a diagnosis of substance abuse in psychiatric hospital. In our experience as nurses working in a psychiatric hospital, we have noticed that because the service does not offer a private area for the drug addict, family would become discontent and questioning because the patient, during hospitalization, would stay with patients with severe psychiatric conditions, which, in the perception of the family, could contribute to patient isolation and treatment noncompliance. We may add that some patients, after hospital discharge, would relapse, resulting in the the family nucleus emotional, social and financial overload(1) due to conflicts in the family and because of search for care in psychiatric units in the city, considering that the unit had no psychiatric emergency service.
Although the law 10.216/2002 legitimizes the right to service users and those who suffer from problems caused by alcohol and other drugs, universal access and care in specialized units(2), the users themselves resent the difficulty of access to services outside the hospital due to geographical distance and even the absence of such services in some municipalities.
Therefore, it is essential to expand the ambulatory network and the strengthening of initiatives for the creation of intensive and intermediate equipment between outpatient treatment and hospitalization, with emphasis on the actions of psychosocial rehabilitation of individuals diagnosed with chemical dependency that should be treated in Psychosocial Care Centers (PCCS), including the Alcohol and Drugs Psychosocial Care Centers (PCCS-ad), with a view toward primary care in the community with family participation.
Generally, addicts have difficulty keeping family structures working due to problems related to regulation of relationships and emotions, hence the role of the family, both in the creation of conditions related to the use and / or drug abuse as in the construction of protective factors as the families spend their values and beliefs through generations, being the primary source of care for their members. For being co-responsible for the training of individuals, the family is directly involved in the healthy or ill development of its members(3).
There are situations in which the family may be a complicating factor in the recovery of the patient due to the organization and the roles played by its members. It is important that professionals understand the arrangements and conditions for each group in order to build bonds and ties of solidarity, in a private space, and uncomfortable for mental health workers who have no ready answers to offer. The intervention in the family not only aims to instrumentalize them as caregivers, but as people who also need to be cared for in order to minimize the emotional burden by offering cozy and facilitating spaces of action and exchange of caring experiences(4).
Based on this, there is the need to expand the provisions to mental health care that enable the reception of users and their relatives by the nursing staff and other mental health professionals faced with the emotional, financial and social overload status brought about by substance abuse in order to maximize patient's adherence to therapeutic regimens and to strengthen ties.
The aim of this study was to analyze the difficulties faced by the family in the welcome of the addicted family member.
METHOD
Qualitative and descriptive field research, which sought to understand a problem from the perspective of the subject who experienced it, I mean, it started in his everyday life, his satisfactions, disappointments, surprises, and other emotions(5). The study included 05 families of patients in regimen of internment, being adopted as an inclusion criterion the fact that they have already experienced other hospitalizations due to relapse of chemical dependents.
Data collection occurred in the second half of 2007 in a public psychiatric hospital located in the city of Rio de Janeiro. We used the technique of semi-structured interview, through the application of a script containing questions that enabled the family to speak about the difficulties of the addiction of their family member. The statements were recorded on mp3 files and transcribed in its entirety for further analysis.
The interviews were conducted individually at the inpatient unit. They were scheduled in advance and started after family members became aware of the opinion delivered by the Research Ethics Committee (CEP / HUPE / UERJ - 1704) and signed the consent form, according to Resolution 196/96 of the National Health Council. We ensured participants' anonymity and confirmed that they could withdraw from the research at any stage. We explained that the study results would be presented in events and published in scientific journals. In the construction of the corpus of the text the following conventions were adopted: interviewee (F) followed by a number according to the order of entry in the text.
The categories of the study resulted from the application of the analysis technique of thematic content(5), in which we focused in the production conditions of the text by reading the material exhaustively and identificating the frequency of presence, homogeneity or items of meaning. After analyzing the testimony, the words of meaning or registration units were grouped together and formed thematic units, which together permeated the experiences of the family who mentioned the difficulties faced regarding the treatment of dependent and his participation. The results are presented in the following order: family's perception of addiction, non-adherence to the treatment by the chemically dependent, the unfamiliarity of extra-hospital services: caps-ad, the suffering of the family: the chemically dependent's relapses, the vision of the family on the home visit.
RESULTS
Family's perception of drug addiction
Although changes in Brazilian family structure are constant(6), especially in the last decade, and even with myths, values and taboos about family structures that diverge from the traditional model (nuclear family), the drug abuse in the family is not directly related(3) to the type of structure that the family presents. Thus, it appears that the role of the family is more important from the perspective of prevention and treatment of chemical dependency, than to assign to the family structure a causal relationship.
Therefore, it is important to identify the perception of the family about chemical dependency in its nucleus and management mechanisms adopted before the emotional, social and economic overload in order to accommodate the group in its suffering.
[...] I would want my son to return home without that need to use drugs, but I know it is not easy. This is a disease, an addiction, and does not get cured overnight. It depends a lot on his will. He has to want it. (F1)
[...] Her issue with drugs is also closely linked to influences. Her boyfriend also uses drugs and it is no use to tell her not to date him. But I also know that problems with drugs are not so easy to deal with. It depends a lot on her and her willpower. (F2)
I wish he (patient) became aware of your problem and had the strength to stop drinking. It is a matter that depends on him more than anyone else. The doctor can not do it for him. I cannot. Only he can, and stop drinking is very difficult. (F5)
[...] He was always like that. He moves around the house, quiet, does not talk much, has no interest in doing anything. I just wanted him to stop with drugs and booze. I wish he got a job, but I know he can't. (F4)
In the perception of the family addiction is tied to the biological model (illness), lack of determination of the individual to stop using drugs (moral) and the influence of people who are also part of his conviviality. In these circumstances, conflicts may arise between members, as the family projects on the dependent their uncertainties, anxieties and feelings of helplessness, without considering that the individual, even sober, may vary from wanting to stop and willing to use some drug, which is a condition of the disease, but considering the relapse an expected event.
The unfamiliarity of the extra-hospital services: ad-caps
The hospitalization of patients with a diagnosis of chemical dependency should be performed in a specialized unit, provided with structure and personnel properly trained for effective treatment, having the Therapeutic Community as a model. In order to promote adherence to therapeutic regimens, hospitalization should be voluntary and it is up to the staff to develop an individualized treatment plan, containing the activities to be undertaken by the patient, their rights and duties that must be explained in detail.
Depending on participation and responses (adhesion) of the patient to the treatment plan, instituted during hospitalization, the team may decide to discharge the patient, which should be oriented along with the family about the continuity of the treatment. The preparation for hospital discharge is a moment for reflection and should be performed by the team and with the participation of the family who, by feeling welcome, can clarify doubts about its role and know in advance that it can request help in crisis situations. On the other hand, even if the service is not prepared for the effective support to family members regarding family therapy, the team should refer the patient and family to the ad-CAPS closer to their residence, which was not evident in the statements.
[...] When I left, they recommended me the CSRAD (Center for Studies and Research in Attention to Drug use), but we did not look for it. We didn't have enough time. In a week it started all over again. (F1)
[...] The recommendation we received was that we could be looking for these groups for addicts which I don't even remember the name. Go through a more specific treatment, since this is her problem. (F2)
[...] He was hospitalized for, let me see, I think a month. They told me he had to continue treatment and that the voices could be from the drugs, but he refused to go to the doctor or take medicine.(F4)
Although the law 10.216/2002 (2) has in its core guidelines and actions that legitimize the creation and maintenance in the services of secondary care, strategies of articulation with extra-hospital devices, it became clear in the statements that the family did not receive relevant and clear guidelines about the referral and continuity of treatment of chemically dependent. Given this reality, the family can see the patient's hospitalization in a psychiatric hospital the only solution to the problems resulting from relapse.
The suffering of the family: the addict's relapse
Given the difficulties of access and lack of specialized professionals for continuity of care outside the hospital of the chemical dependent egress from psychiatric hospitals, nurses and staff must work in the perspective of a mental health care network in order to strengthen ties, to continue therapeutic regimens and intervene promptly in crisis situations, in view of the emotional burden mentioned by the family regarding the relapse.
[...] He returned home peacefully, less aggressive. But a week he after he went back to drugs again and because of it, he became aggressive again. He would come home willing to break everything. He would threaten me physically. It was horrible. There was a point in which we could no longer keep him at home. (F1)
[...] He returned well. He did not hear many voices, but as he stopped going to the hospital, he soon went back to using drugs too. He would do small jobs and with the little money he earned, he'd spend it all buying drugs. (F5)
[...] Because there are times when you want to give everything up. I get nervous and end up fighting with her. This makes everything worse. I know, but I'm so tired I cannot control myself. (F2)
The relapse of the chemically dependent after hospital discharge - analyzed as an expected event - generates frustrated expectations by the family in relation to treatment and the commitment made by the patient in his treatment plan. Added to the emotional burden due to conflicts entailed in the nucleus in which the family feels helpless, hopeless and worn.
Progress achieved in neuroscience have shown that drug addiction is a chronic disorder, recurrent, with a biological and genetic basis and not a simple lack of will or desire to be freed. There are effective treatments and interventions that imply behavioral and pharmacological therapies(7) that provide opportunity to clarify and eliminate harmful and inaccurate stereotypes, because the bias associated with the consumption and dependence may hamper treatment, as well as the implementation of appropriate policies by professionals.
Inserted in this context, the nurse sees himself in the confluence of a care characterized by polarization. On one hand, the positioning of the chemically dependent who at times refuses to get treated, although he recognizes, even minimally, that his condition requires treatment. On the other, the positioning of the family, no less anxiogenic and defensive, seeking support and solution to the difficulties of this process(6).
The individual's perception of his physical weakness, fear of death or becoming incapable of taking care of himself due to organic complications arising from the use of drugs, are highly significant factors for the acceptance of addiction as a disease that needs to be treated and the decision taking in search for specialized treatment. The clear and precise intervention by the health professional to point out the losses and risks of continued use of the substance, are considered important by the dependent and motivating for the search for specialized treatment(8).
Thus, the hospitalization can be seen by the addict as a safe way to protect himself of what he is not able to control. The temporary detachment of the territory, through planned and structured treatment, may contribute so that the individual may rethink his life and issues that concern the family, work and friends, since probably all areas of his existence are affected by addiction(9).
Considering that the information provided in meetings between professional and family not always meets the expectations of the group, the nurse(6) should consider the inclusion of the family of addicts in his interventions, by approaching its members through educational activities and home visits, given that social support promotes autonomy of the subjects regarding the proceedings on his health. The family needs support at all stages of treatment, especially after discharge of the family member, when the addict may be vulnerable to remain in a state of abstinence.
The return of the patient to his family is experienced by its members with great expectation of cure and that the individual keeps himself sober, restructure his life and resume his daily activities with greater autonomy. However, with the relapse of the drug addict, the family may assume a position that ranges from denial to disorganization, seeing the psychiatric hospital as the only solution to face the problem due to the conflicts generated in its core and for feeling incapable of giving an effective response given the problem.
We may also add the emotional atmosphere1 with a feeling of stress, anger, insecurity and loneliness experienced by the family for not knowing how to deal with some behavior displayed by the person in psychological distress such as excessive silence, episodes of turmoil and aggressiveness.
It is important that the nurse works on the emotions expressed by the family related to the non-adherence of the patient to treatment, which have been identified as factors influencing relapse and have three components: critical observations, hostility and emotional over involvement. The family deals with the patient's symptoms as if they were the individual's personality traits and so they begin to deal with the symptoms and not with the individual who brings these symptoms(4).
Thus, the family must be seen as a group that needs support and guidance in dealing with the impact generated by long-term psychological distress in its family nucleus, which undoubtedly leads to changes in daily activities and the family budget. Without these resources, the family will probably continue feeling helpless and unattended, having no conditions of taking care of the critically ill patient in the family environment and making it unbearable to keep the patient at home(10).
It was evident that the family sees addiction as a disease that needs treatment in psychiatric hospitals, not mentioning the extra-hospital services such as ad-CAPS in so far as it has not received from professionals clear and relevant information about the access and the importance of these services in relation to the continuity of treatment and relapse prevention. Therefore, nurses must help the family in the perspective of maintaining the patient in his territory in order to help him manage the resumption of his activities after discharge and the continuity of treatment in an ad-CAPS closer to the territory.
REFERENCES
1. Pegoraro RF, Caldanha RHL. Sobrecarga de familiares de usuários de um centro de atenção psicossocial. Psicol. Estud. [serial on internet]. 2006, [cited 2010-06-17]; 11(3): 569-77. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-73722006000300013&lng=en&nrm=iso.
2. Ministério da Saúde (BR). A Política do Ministério da Saúde para a Atenção Integral aos Usuários de Álcool e outras Drogas. Brasília: Ministério da Saúde; 2003.
3. Schenkerl M, Minayo MCS. A implicação da família no uso abusivo de drogas: uma revisão crítica. Rev. Ciência & Saúde Coletiva 2003; v 8: 299-06.
4. Soares C, Munari D. Consideration about the overburden in families of mentally ill individuals. Ciência, Cuidado E Saúde, [serial on the internet]. 2005 [cited 2010 september 30]; 6(3):357-62. Available from: http://periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/4024/2717
5. Minayo MCS, Deslandes SF. Gomes, R. Pesquisa Social: Teoria, Método e Criatividade.19ª ed. Petrópolis (RJ): 2001.
6. Lima H.Braga V.Gubert F. Interface between gender and mental health in the voice of alcoholics: qualitative study Online Brazilian Journal of Nursing [serial on the Internet]. 2010 August 20; [Cited 2011 July 21]; 9(2):[about ## p.]. Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/j.1676-4285.2010.2907/665. Date accessed: 21 Jul. 2011.
7. Organização Mundial de Saúde. WHO Library Cataloguing-in-Publication Data (Genebra). Neurociência: consumo e dependência de substâncias psicoativas. [serial on the internet]. 2004 [cited 2010 june 14]; 34p. Available from: http://www.who.int/substance_abuse/publications/en/Neuroscience_P.pdf
8. Taveira MC, Luis MAV. A motivação inicial para a busca do tratamento da dependência química. In: Luis MAV, Pillon SC. Pesquisas sobre a prática da assistência a usuários de álcool e drogas no Estado de São Paulo. Ribeirão Preto (SP). Fundação Instituto de Enfermagem de Ribeirão Preto; 2004. p.263-68.
9. Ferreira FGKY, Luz JÁ, Obrzut-neto L, Santos KA. Uma visão multiprofissional humanizada da pessoa com dependência química em enfermaria psiquiátrica de um Hospital Geral no Paraná. Rev Cogitaire Enferm [serial on the internet]. 2005 [cited 2010 november 3]; 10:54-2. Available from: http://ojs.c3sl.ufpr.br/ojs2/index.php/cogitare/article/viewFile/5009/3787
10. Mello R. A construção do cuidado à família e a consolidação da reforma psiquiátrica. Rev. Enfermagem UERJ 2005; 13:390-5.
Approved: 21/07/2011
Received: 27/12/2011