ORIGINAL ARTICLES

Adherence to treatment by the staff of a mental health service: an exploratory study

Cilene Despontin Malvezzi¹, Helena Cavaleri Gerhardinger², Luís Felipe Pereira Santos², Vanessa Pellegrino Toledo², Ana Paula Rigon Francischetti Garcia²

¹Campinas Municipal Bureau of Health
²Campinas State University

ABSTRACT
Aims: To understand how the multidisciplinary team conceives adherence to the treatment of users inserted in CAPS AD.
Methodology: This is a descriptive and exploratory study, using a qualitative approach conducted with professionals from a mental health service through semi-structured interviews and subsequent thematic analysis.
Results: Two categories have emerged - the conception of adherence to treatment which highlighted the link, the recognition of the will to treat on the part of the person and understanding in terms of abstinence; and how the team takes care of the users and the service, which emphasized the multidisciplinary work, organization of the work process, flexibility of schedules, active search for the absent persons, individual therapeutic project, and attention to the care needs of the person undergoing treatment.
Conclusion: It highlighted the importance of welcoming attitudes to strengthen the bond, permeating the understanding in terms of adhesion and influence over the multi-professional teamwork process.
Descriptors: Patient Compliance; Substance-Related Disorders; Drug Users; Substance Abuse Treatment Centers.

INTRODUCTION

Drug use is an ancient and universal practice that is part of different cultures, contexts and purposes. It has gone from the ritualistic form, consumed in small quantities, to abuse and dependence, characterized as a serious public health problem. Classified as a mental disorder, it can lead to the destructuration of individuals, their physical and mental well-being, and their relationship with their families, work and community^(1,2).

It is estimated that in the US, about 246 million people (or 1 in 20), between 15 and 64 years of age, had used illicit substances at least once in 2013, corresponding to 6.6% of the world population in this age group⁽³⁾. In Brazil, a study involving the 108 largest cities in the country showed 22.8% of the population aged between 12 and 65 years have used any psychotropic drug (except alcohol and tobacco) during their lives, which corresponds to almost 12 million people⁽⁴⁾. Still in the Brazilian scenario, alcohol is the psychoactive substance most commonly used during the course of life, followed by tobacco, and cannabis⁽⁴). Concerns related to the damage to people and society by drug abuse led to the development of public policies that consider regional socioeconomic characteristics^(4,5).

Most treatment services for problems arising from the use of drugs in Brazil belong to the public health system, ruled by the principles of the Sistema Único de Saúde (SUS) (Unified Health System), and the model of care to users of alcohol and other drugs. It presupposes universal, comprehensive, and equitable care, and care-network consolidation on a regional, hierarchical, and integrated basis. It also defines that, in mental health care, the rehabilitation and social reintegration of a person should be provided based on the provision of care in non-hospital services articulated with the health network⁽⁵⁾.

The Centro de Atenção Psicossocial Álcool e Drogas (CAPS AD) (Drug and Alcohol Psychosocial Care Center) is the service that includes care from the assumptions of the current health policy and it replaces the old hospital-centered care model. It should work with natural and flexible therapeutic projects, respecting the harm-reduction policy and be backed by psychiatric beds in general hospitals as well as strategies that encourage adherence to treatment, characterized by considering the patient's perspective as a free person, able to accept or ignore the recommendations of the multidisciplinary team concerning their treatment^(5,6).

We emphasize the need for an approach by professionals, services, and society that is consistent with the challenges that occur in terms of giving assistance to drug users. One has to consider that these substances can produce side effects, such as compulsive behavior, and physical and psychological abstinence symptoms, which can lead to frequent relapses and consumption maintained during treatment. The position of professionals when associated with the search for a "magic formula" for sobriety, can hinder adherence to treatment⁽⁶⁾.

Non-adherence to therapy is described in the literature as an "independent universal phenomenon of social class, ethnicity, education level or severity of the disease"⁽⁷⁾. Among the drug addicts, up to 50% of indicated noncompliance with their treatment, suggesting a worrying and costly framework for the health system. There is a tendency to blame the dependents of non-compliance, without considering the expectations, knowledge, and individual characteristics that could lead to more skilled care by the health team^(8,9).

Thus, this study is justified when considering the preparation of health staff to deal with the idiosyncrasies concerning the treatment of this population, recognizing the lack of compliance as part of the therapeutic process, and expanding the reading of this phenomenon so that the attention the health of the drug user can be qualified^(8,9). To this end, the goal is to understand how the multidisciplinary team conceives adherence of users inserted in CAPS AD to treatment.

METHOD

This is descriptive and exploratory research that uses a qualitative approach, which aims to reveal the many meanings, motives, beliefs, and values of the professionals interviewed, related to the concept of adherence to treatment⁽¹⁰⁾.

Data collection was performed in the CAPS AD responsible for the health care of the people of the North Health District and east of the city of Campinas, SP.

The inclusion criteria were: working in the service in question for more than a year, being a member of the multidisciplinary team, and taking part in the study by signing the free and informed consent. The excluded subjects were individuals who did not meet one or more criteria for inclusion. Eight professionals from the multidisciplinary team were considered subjects of this research, covering the following categories: psychiatrist, nurse, psychologist, occupational therapist, nurse technician, pharmacy technician, and harm reduction agents.

The interviews were semi-structured, recorded, and transcribed verbatim. They were carried out in July 2013 and had the following question: how is the adherence to the treatment of users in CAPS AD in your opinion?
A thematic analysis was carried out, focusing on the following steps:

1. Pre-analysis: this included the performance of the initial reading of the interviews, the constitution of the corpus, and the formulation of hypotheses and objectives. At this stage, the registration units, the cutouts, the form of categorization, the codification, and the general theoretical concepts that guide the analysis are determined;
2. Material exploration: transformation of raw data in order to reach the core understanding of the text;

3. Results and interpretation Treatment: has allowed the highlight of the information obtained, linking it to the theoretical understanding, which, in this study, was developed from concepts that underline the theoretical framework of Carl Rogers^(10,11). Thus, the discussion is anchored in the concept of empathy, characterized by a technique that contributes to the development of a supportive climate, favoring the formation of the bond, the unconditional acceptance, authenticity and warm attitude, and giving substantiated reasons on how professionals understand users’ reality by putting themselves in their places⁽¹¹⁾.

The ethical aspects were respected, according to Resolution no. 466/2012 of the National Health Council. The study was approved by the Research Ethics Committee of the Faculty of Medical Sciences, State University of Campinas, in Opinion No. 294 918 of June 6, 2013.

RESULTS

The understanding of the multidisciplinary team on the concept of the adherence to treatment of CAPS AD users was gained from what the participants said and was then then divided into two categories: the concept of adherence to treatment and how the team takes care of the users and the service.

The conception of treatment adherence
The link established between the user and the professional was cited as an important criterion for good adherence to treatment.
If you cannot form a bond, you also can't achieve patient compliance. (E-6)
Building a good relationship with the professional favors adhesion. (E-7)
Having a bond with them, I think, helps a lot in the treatment. (E-1)

The way in which the staff welcomes users, talks to them, and explains how the service works was cited as critical by the respondents for compliance.
When patients come to the CAPS for the first time, or are sent, or come by spontaneous demand, I think that the way care is provided, the way they are welcomed [...] depending on the way you talk, or explain service, it can be positive or not for membership [...] (E-6)
It may be a street patient, a street beggar. If they come here, we treat them well. So it is decisive. This welcome makes a difference for them. (E-4)

The willingness to adhere to treatment by the users, and the realization that they need help, are related to better adherence to treatment.
So, in relation to adhesion ... I think they must have the desire to want treatment. (E-1)
When they say, "yes, I will" and "I made the decision, I need help," I think it's a big step. I consider it an adhesion. (E-3)

The identification of the increased frequency of the service users is directly related to the increase of health problems, contributing to increased membership.
] He hasn’t eaten for three days, used drugs, vomited, and had his diabetes altered; he was totally debilitated... Then he went to bed and got stabilized... This is the patient who adhered. (E-2)
] During the adhesion, when they already have their health compromised, among other comorbidities [...] when they are really bad, debilitated, they end up attending services more often. (E-7)

The team has differing views on the understanding of abstinence. Some understand that it is not the central aim of treatment. They accept relapsing as a peculiar way for users transitioning the service, consistent with the drug addiction phenomenon. They call it a floating or unstable membership.
] If the patient is here, he doesn't need to be abstinent. Abstinence is not the main target of the process. You can live with the moments of intoxication, with these fluctuations of sobriety and it seems to me more consistent with the clinical reality. [...] So, his adhesion is fluctuating and unstable. (E-5)
I think I have a little group that adheres bly to the treatment. They know that they certainly will relapse, because that's how it has to be. (E-1) A patient acceded to CAPS is a patient who often attends treatment, who undergoes a therapy [...] who has his relapses, [...] and has his ups and downs. (E-2)

Other professionals have negative feelings regarding relapses, understanding that the adhesion occurs when users come detoxified to the service, participate in groups, and comply with the rules.
We understand that this patient who often comes detoxified is adhered to treatment. (E-4)
He has good adhesion [...] He participates in groups correctly; he tries to avoid coming to CAPS intoxicated; he tries to arrive on time. When he doesn’t come, he calls to let us know. (E-3)

How the team takes care of users and service
The group values its multidisciplinary character and organizes their work process by distributing the workload of professionals throughout the week, with flexible schedules for fittings and actively searches for the absent individuals.

It is very nice to work in a multidisciplinary team because we think together about what we will do with the different types of membership. (E-6)
I think the worker of the AD area must have a 36h bond. You can't have a 20h bond. You can't work as in an ambulatory. [...] I need to be here every day, morning and afternoon. (E-5)
Here, I make an active search. [...] Today, four patients were absent. They know I'm here, [...] some call and we reschedule it. (E-5)

They emphasize the importance of individual therapeutic projects, understanding the differences and uniqueness of users in order to facilitate adherence to treatment.
Here at CAPS, we work with individual therapeutic projects [....] and it is very cool because every patient is different [....] they are not all the same! [...] And this flexibility in the therapeutic project is something that greatly facilitates patient compliance. (E-6)
Each patient has an individual therapeutic project. It will depend on whether he is working, if he has availability to come every day or not... So, according to the patient's needs, we make a bespoke therapeutic project [...] And that facilitates adhesion. (E-7)

The needs brought by users in relation to transportation, housing, social benefits, food, and clothing rely on the care team, which is organized with its own resources or partnerships to structure these offerings of care. Professionals believe that in this way they facilitate adhesion to treatment.

They come with an expectation that services can solve that housing problem: "I have no home, I don't have it, I'm hungry." (E-1)
We realize that many patients come for the food. (E-4)
I think this partnership with Associação das Empresas de Transporte Coletivo Urbano de Campinas Transurc (Association of Public Urban Transport Companies of Campinas) facilitates adherence to treatment, because with the bus pass he can come to the treatment [...] (E-6)
He seeks the CAPS because he knows that here he receives treatment; he knows that here he will receive medication, clothes, everything. [...] The social service helps with the documents and there are patients who managed to get retirement. (E-2)

DISCUSSION

The conception of users’ treatment compliance in CAPS AD, mentioned by the subjects of this study, is directly related to the ability to build a good relationship between the user and the provider. The link is defined as a close and lasting personal relationship between health professionals and the people under treatment, allowing these individuals to recognize the service as capable of satisfying their needs, supported by professionals interested in the life of those who demand care, and not only in their pathology⁽¹²⁾.

It was evident that some family ties are broken due to the changes caused by the process of psychoactive substance dependence. Individuals who still retain some link with family members live with relationships permeated by ambiguity, stress, and emotional distress. In the relationship with friends who share the use of alcohol or drugs, the bonds were not considered significant, since they refer to the continued use of substances, pushing them away from treatment⁽¹²⁾.

It can be considered that users who require longer care time, such as sufferers of chronic diseases, require a friendly relationship, based on respect and trust. This relationship should be sustained by a constant dialogue throughout the treatment process⁽¹³⁾.

The construction of the link begins at the arrival of the user to the service through the welcoming attitude of the staff. The act of receiving must have the intention to solve the health problems of the people seeking the service, and it is based on listening and on the production of bonds as therapeutic actions, aimed at identifying the risks and vulnerability of the patient. The service welcomes fears and takes responsibility for a response to the brought demand^(12,13).
The welcoming attitude, referred to by professionals in this study, can be an enabling condition of personal growth, requiring the unconditional acceptance of individuals from the trust and understanding of their experiences, their personalities and whatever they are at that moment⁽¹¹⁾.

The user's motivation for seeking help, understood as a state of readiness to change that may fluctuate depending on the situation or moment people find themselves, has become a relevant factor with regard to the understanding of treatment adherence, according to the professionals⁽¹⁴⁾. It is noteworthy that the motivation is influenced by external and internal factors; such recognition may favor professional action when they identify motivational aspects through a welcoming attitude and use them to organize therapeutic approaches that could strengthen the bond and, therefore, the adherence to treatment.

It is also important that the development of an environment capable of facilitating psychological attitudes, such as authenticity, sincerity, unconditional acceptance, concern for others, and empathy in the person-to-person relation favors the activation of the bond. This allows the person to use resources for self-understanding and for the modification of their concepts⁽¹¹⁾. Thus, the development of a therapeutic relationship can become an alternative to both the treatment and to the effectiveness of the adhesion, and it responds to requests guided by the comprehensive care of conception. Therefore, it is important that this answer is offered by a multidisciplinary team, for this dimension favors the recognition of different factors that can contribute to the understanding of the application and diversify the possibilities of response, which may promote the installation of natural and lasting links.

To facilitate the search for treatment, according to respondents, users need to recognize the physical, emotional, social, and professional damage that affect them over time. When they are weak, frail, and sick, they tend to increase the frequency of their visits to the institution and, therefore, treatment compliance.

The desire to recover the family, the fear of losing spouses, children, material goods, and employment, an the recognition of powerlessness over addiction, evidenced mainly in undesirable physical symptoms, are factors that lead drug users to search for treatment^(15,16).

However, self-recognition does not happen solely from the presentation of the difficulties. It is developed to the extent that health professionals are able to establish a therapeutic relationship that must be conducted from the bond and empathy that are supported by their welcoming attitude; they should also link it to the understanding of the social determinants that lead people to establish a relationship with psychoactive substances⁽¹¹⁾.

Thus, to sustain attitudes favoring membership, the importance of care policies that emphasize the uniqueness of the users should be recognized, since the relationship that each person establishes with substances use can determine his/her behavior before treatment⁽¹⁴⁾.

The findings indicate the differing views of the staff regarding abstinence: some believe it is the adhesion, such as detoxification, and compliance with the rules of the institution; others accept relapse as a peculiar way for users to deal with treatment, naming it a floating or unstable condition, compatible with the unique ways in which psychoactive substances are used. Both positions indicate that adherence is guided by abstinence; even when professionals mention a floating mode and unstable user traffic in the service, they are guided by the expectation of abstinence. This design may indicate a weak reading in terms of the comprehension of the team on compliance, as it is important to recognize the movements that users of psychoactive substances make. Such movement is influenced by relational factors that these people develop to walk in life and seek solutions to their problems^(11,14).

To understand the recognition of adhesion as abstinence, an alternative for professionals is to use relational techniques, such as authenticity, recognition of their professional and personal barriers, empathy and congruence that, as already indicated, underpin the welcoming attitude. Thus, professionals can pave the way for users to change and grow in a constructive way and, for that, it is necessary to believe in the potential of each patient, which is a challenge considering the stigma that drug users carry in our society^(1,2,11).

To encourage the shift in management, it is interesting to support the work in a care model centered on the user with certain actions that can produce a permanent commitment to the task of hosting, accountability, and promotion of the autonomy of the actors involved, featuring live work⁽¹⁷⁾. For by having a focus on complex situations of social and individual vulnerabilities, this work becomes a living labor to the extent that the exchange of knowledge occurs between users and professionals which, in the context of working as a team, may condition self-knowledge, a determining factor for the accountability of subjects and consequent increase in treatment adherence.

Thus, it is important that the management of services for the treatment of chemical dependency considers the internal structure and its place in the local care network, and also understands its possibilities and limitations. This helps the process of adaptation to the individual needs of those seeking treatment⁽¹⁸⁾.

Thus, it is observed in this study that the distribution of the working hours of professionals throughout the week, the flexibility of schedules, fittings, and the search for absent individuals showed the concern of the staff, in terms of adapting their work process to the individual needs of users. Unconditional acceptance and interest in the person, together with the assumption of living labor, can remove the institutional barriers, rules, judgments, and external frameworks, and help to look at the overall experience of the person^(11,17,18). Yet, at the same time, the studied professionals recognize the need to remove bureaucratic barriers of care. They also conceive treatment adherence and compliance with the institutional rules already established; thus, causing contradiction and making the evaluation of adhesion difficult.

Another factor to be considered in the care of these users, and therefore the adherence to treatment, is the importance of building the therapeutic project from intersectional actions. However, one must consider that what the CAPS offers to users means to rebuild and strengthen their relationships and social bonds.

In this perspective, a service whose internal structure is organized from the construction of individual therapeutic projects, in which the multidisciplinary team can cast different assessments on the health of these users, has the effect of reading the diversity of factors that lead to the use of alcohol and drugs. This service could usher care pacts in a dimension of responsibility, resulting in tightening the bond and the trust established in the therapeutic relationship and promote adherence to treatment.

It is important that the multidisciplinary team also considers that their care strategies should not be exclusive, because then there is the risk of users becoming dependent on this single type of service. Thus, the establishment of teamwork can promote the circulation of these users, enabling health care to be covered by the access to various community spaces, which strengthens the care network⁽¹⁹⁾.

It is interesting to note the adherence to treatment dimensions offered by the global experience of people whose aim is to strengthen their autonomy. In this sense, the therapeutic ratio may encourage the focus displacement for identifying the capabilities and users' abilities, to the detriment of interventions that reduce life-long addiction. Therefore, comprehensive care becomes an important guideline for the organization of multidisciplinary actions.

CONCLUSION

The Understanding of the multidisciplinary team on adherence to treatment of the users of CAPS AD is developed from the construction of the link, which is based on how the users are received in the institution, especially by the staff’s welcoming attitude. This understanding can contribute to opening the possibility of building a treatment proposal supported by therapeutic relationships, which facilitate the recognition of individual needs by placing the user as the central focus of action.

Linked to this issue was motivation, understood as a desire to undergo treatment on the part of the user, whose counterpart by the team is characterized by empathy. This favors the recognition of health problems and increases the understanding of the social determinants involved in the person's relationship with psychoactive substances.

The search for solutions for the problems arising from the use of psychoactive substances is related to relational factors that users develop to route their lives. Such factors may be treated more efficiently in a multi-professional perspective. This favors the diversity of readings that translate the movement that marks how these users adhere to treatment and thus increases the likelihood of responses to the demands brought by them. Yet, as far as the staff goes, there is the expectation of abstinence, which weakens and interferes with the evaluation of adherence as it dismisses the idea that such users are to use the drug.

In this context, this study also makes a contribution by emphasizing the importance of recognizing uniqueness in the treatment of these users. This is considered in the context of health policy consolidation to enable management methods that prioritize models centered on users, such as the construction of the mental health network that aims for the recognition of the overall experience of the person through a comprehensive care, developed from multidisciplinary actions.

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Received: 04/08/2015
Revised: 04/28/2016
Approved: 04/29/2016