RESEARCH ARTICLES

Psychosocial rehabilitation: process of reconstructing drug users' subjectivities

Gustavo Costa de Oliveira^I; Cíntia Nasi^II; Annie Jeanninne Bisso Lacchini^III ; Marcio Wagner Camatta^IV; Carolina Maltz^V; Jacó Fernando Schneider^VI

^I Master in Nursing. PhD student in nursing at the Postgraduate Nursing Program of the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brazil. E-mail: gustavoenfufrgs@gmail.com
^II PhD in nursing. Adjunct Professor of the Nursing Course of Federal University of Health Sciences of Porto Alegre. Rio Grande do Sul, Brazil. E-mail: cintianasi@yahoo.com.br
^III PhD in nursing. Adjunct Professor of the Nursing Course of Federal University of Health Sciences of Porto Alegre. Rio Grande do Sul, Brazil. E-mail: anniejbl@hotmail.com
^IV PhD in Nursing. Assistant professor at the School of Nursing of the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brazil. E-mail: mcamatta@gmail.com
^V Nurse. Graduated by the Nursing course of the Federal University of Health Sciences of Porto Alegre. Rio Grande do Sul, Brazil. E-mail: carol.maltz@hotmail.com
^VI PhD in Nursing. Full Professor at the School of Nursing and the Postgraduate Program in Nursing of the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brazil. E-mail: jaco_schneider@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.11742

ABSTRACT

The study aimed to understand psychosocial rehabilitation the reconstruction of drug users' subjectivities in a process informed by the phenomenological sociology of Alfred Schutz. This qualitative, phenomenological study of 12 health workers at a psychosocial care center (CAPSad), focused on alcohol and drug rehabilitation in Porto Alegre, Rio Grande do Sul State, Brazil. Data was collected by phenomenological interviews and analyzed using 'comprehending interpretation'. The CAPSad was found to be important to establishing psychosocial rehabilitation as a process to reconstruct drug users' subjectivities. The study showed that drug users' everyday worlds should be explored and contexts visualized as through their eyes in order to understand these individuals in their singularity and individuality and thus introduce mental health actions to integrate, potentiate and permit psychosocial rehabilitation.

Keywords: Nursing; mental health; psychosocial; philosophy.

INTRODUCTION

Mental health care, including attention to drug users, has been diverted in recent years toward a model that favours the community setting. This perspective comes hand-in-hand with the psychiatric reform in which attention to mental health inserted in a network of community services is recommended. Psychosocial Care Centers (CAPS) have a strategic role in the promotion of mental health focused on the social, where treatment does not isolate the user from society, but rather seeks to act in liaison with the other resources of the health system, aimed at psychosocial rehabilitation of this user ^1-3.

Psychosocial rehabilitation corresponds to a process that facilitates the opportunity of people going through psychological distress to reach a more independent functioning in the community. Because psychosocial rehabilitation aims at reducing the stigma and prejudice and, at the same time, improving health, its proponents are engaged in self-help, organization and family support, and promotion of efforts to strengthen services and develop existing networks and systems⁴.

Psychosocial rehabilitation of people going through psychological suffering can be characterized as a reconstruction process of their subjectivity, considering their habitat, social and labor network, needed to (re)adapt to the world⁵.

In the logic of the institution of psychosocial rehabilitation in the therapy drug users, actions in mental health developed in the CAPS alcohol and drugs (CAPSad) aim to strengthen this subject, since the therapeutic process must have tools for individual (re)organization and (re)integration in the family and in society.

This study is justified by the importance of understanding the psychosocial rehabilitation as process of rebuilding of drug users' subjectivity, giving them greater visibility. In this research, the theoretical-methodological framework of the phenomenological sociology of Alfred Schutz was used to give voice to workers of a CAPSad as to their understanding of the process of psychosocial rehabilitation of users. According to this phenomenological reference, subjects gain voice, immersing themselves in their subjectivity and social relations, in order to unveil the phenomenon through the experiences of individuals^6,7.

The study aimed to understand the intentions of workers with respect to the psychosocial rehabilitation of the treatment of users of a CAPSad.

LITERATURE REVIEW

In Brazil, assistance to people under psychological distress and their families was guided in the hospital-centered model, centered in the care offered in the nursing home, with controlling and repressive treatment also performed by the nursing team⁸. In the 1970s, a process of change in this model was initiated, called the Brazilian psychiatric reform.

The psychiatric reform is configured as the historical process of critical and practical formulation that has as objectives and strategies the questioning and development of proposals for the transformation of the classical model and the paradigm of psychiatry.

The principles, objectives and assumptions of psychiatric reform guide the actions in the health network⁴. One can think of psychosocial rehabilitation of people under psychological suffering as a proposal to introduce these subjects into community networks, which would facilitate the insertion in their social environment, implying the possibility for them to reconstruct the sense of their everyday life⁹.

Psychosocial rehabilitation of users of alcohol and other drugs can be brought about in health care services through therapeutic workshops, in external activities and/or partnerships for service, producing more social forms of treatment and allowing the movement of users throughout the city. Psychosocial rehabilitation of users of psychoactive substance is still a complex process that involves several dimensions, from the micro level (individual/familiar/institutional) to the macro level (community, society and mental health policies) and, in order to really accomplish it, services must be committed with the transformation of the living conditions of these subjects¹⁰.

The concept of psychosocial rehabilitation refers not only to support received from the social network of the user, but involves a more comprehensive concept, related to the transformation of the subject from their condition of sick persons to their role as citizens. In the context of the Psychiatric Reform, psychosocial rehabilitation should seek to restore the subjectivity to the individual, allowing the recovery of the power of contractually, to develop effective strategies and intra-sectoral and inter-sectoral actions, in order to enable the individuals to assume the condition of a social subject ¹¹.

In the present scenario, the alternative services emerge as services that seek to consolidate the psychosocial care mode, operating with other theoretical connotation different from the clinical psychiatry. Its assumptions highlight the service to individuals under psychological distress, as well as psychosocial rehabilitation, aiming to promote citizenship and social interaction¹².

THEORETICAL-METHODOLOGICAL REFERENCE

This is a qualitative study with phenomenological approach and theoretical and methodological framework of the phenomenological sociology of Alfred Schutz.

The setting of this study was CAPSad III connected to Conceição Hospital Group (GHC) located in the municipality of Porto Alegre, Rio Grande do Sul, Brazil.

Study subjects were 12 workers of the CAPSad, from different professional categories and from three shifts of service. As inclusion criteria, workers needed to be part of the functional service framework, be of age and be acting in the service for at least three months.

Data collection was performed by means of phenomenological interview in the CAPS, from September 2013 to February 2014. The interviews had the following guiding questions: What is your conception of attention to drug users; Tell me what actions you develop in CAPS; and What do you have in mind with these actions?.

The information obtained was submitted to phenomenological analysis in line with the benchmark of Alfred Schutz. To unveil the experiences expressed in the statements of workers about the meaning of mental health care, the lines were analyzed as indicated by researchers of social phenomenology:^13,14 : Make reading and rereading the content of speeches aiming to get the essence of the meaning of the actions of workers; identify portions of the statements that express the meaning of the action of offering assistance at the CAPS AD; group the common features of the units of meaning, that is, the convergences that enable the emergence of concrete categories about the actions established between workers in the CAPS.

After collecting the data, we sought the convergence of information provided in the interviews, submitting them to the phenomenological analysis.

In order to ensure the anonymity of the interviewed subjects, workers of the team were identified by the acronym "I" with the number corresponding to the order of interviews (I1 to I12).

Ethical aspects necessary to develop research involving human beings were respected, according to Resolution nº 466/2012 of the National Council of Health of the Ministry of Health¹⁵. Thus, an informed consent was previously distributed among participants in two copies, leaving one with the participant and the other was kept with the researcher.

The research project was submitted to the Platform Brazil and was approved by the Research Ethics Committee of the Federal University of Health Sciences of Porto Alegre, according to Opinion nº 296.058; and was approved by the Research Ethics Committee of the GHC, under Opinion nº 371.804.

RESULTS AND DISCUSSION

Based on the analysis of the statements in light of the social phenomenology framework of Alfred Schutz, the concrete category is presented: Psychosocial rehabilitation in the CAPSad.

Psychosocial rehabilitation in the CAPS ad

Understanding the human being is a complex task, since there are subjective, biological, psychological and social issues⁷. In addition, understanding represents the experiential form of knowledge that common sense has about things⁶. From this perspective, the sociological understanding is the result of subjective interpretation of the phenomenological researcher about the human behaviour phenomenon that this studies ⁹.

Motives for the action

However, in order to this researcher understand the action of another person, it is necessary to know the reasons of the action, recognizing that social action involves attitudes and acting of people, oriented to the act of another⁷.

Thus, the reasons leading to the action of the social actor may have a subjective meaning (reasons to) and other objective meaning ( reasons why)⁷, and the reasons to outlined in this research, the interpretation of the social actions of individuals in the world of everyday life.

It was initially observed in the speeches of health workers of the CAPSad, that they:

The objective you always sees that it is an improvement of the patient. (I6)

Be able to collaborate with him, for him to improve his life. (I10)

The statements show that the therapeutic process in CAPSad, in the perspective of the professionals, has the purpose of improving the user's health situation. Mental health practices seek to contribute to the improvement of the user's life, what may mean health interventions that run through the walls of the health service.

Another element present in the narrative of health workers is the expectation of improvement of users. In the following lines, professionals report their desire that the treatment promotes the improvement of the health status of these users:

We expect the patient to get well [...] we are glad to know that our patients who began treatment, are now well. (I5)

I hope the user get well like this, independent of the choice he does, whether it will be use, or whether it will be abstinence, the interruption of such use. (I11)

I keep hoping they improve. (I12)

Based on the speeches, a connection between the actions of mental health developed in CAPSad and the expectations of health workers as to the user prognosis is evident. Thus, the health service can provide a health care turned toward the user, valuing the subjectivities, featuring this user as a social subject, endowed with values ​​and beliefs, which can influence the therapy.

Customers' autonomy

This health care could provide an understanding of the human being situated in his world of life, starting from the concrete reality, that is, their life experiences. The world of life is the social world that is shared, experienced and interpreted by all actors, and that's where they coexist similarly to whom they establish different social relations, being able to produce subject citizens who may be responsible in managing their lives⁷.

Some health workers expressed the need to build health actions that promote autonomy to users, as is displayed in the following lines:

Working autonomy so that he can rearrange his life not without the need to depend on services neither on substance abuse. (I3)

Offer care to that user, but that this care may not be restricted to the health service, but that this care may also go out. (I7)

Strengthen this autonomy in them, strengthen them as persons [...] Think together what we will do, what he will do, and [...] trying to make him to build the exit to get out of this. (I10)

The autonomy of users established throughout the therapeutic process can promote the (re) construction of the lives of these users, strengthening them in the world of everyday life. Based on the speeches, it is clear that autonomy is linked to health actions that help users in their own choices in daily life and in the organization of their lives.

In this sense, creating tools that enhance the subject to produce life projects, in the sense of therapeutic independence, is an implication of for the construction of a psychosocial approach focused on the autonomy of users. Thus, mental health practices should be linked to the social context of the individual, in which skills can be leveraged and thereby also may contribute to the recognition of the autonomy of the social actor¹⁶.

Other workers put, as intentions, the construction of the autonomy of users from health actions in order to strengthen skills and capabilities as well as assist in the decision making process of these individuals, as the following lines show:

[...] to see more issues of skills and capabilities. (I11)

[...] I try to occupy these spaces causing him to develop [...] cognitive abilities, [...] so that later when he returns to his home or to society he may be able to take anything. (I1)

Try to organize them so that they can live out there, [...] and try to show them that they can indeed make good choices, choices that will lead them to have a different life, better than theirs had been. (I2)

Social re-integration

By analysing the statements, it is noted that workers seek, through health actions, assess skills and capabilities of users in order to develop means for society to understand these users, as well as to take responsibility for the process of social re-integration.

Autonomy seems to identify with the social relations, being possible to inserted socially segregated individuals by minimizing the effects of psychological distress and encouraging users to face their problems¹⁷. This, however, must be based on their social, economic and cultural conditions, rescuing their citizenship to their own reintegration into society¹⁸.

When considering the context in which this user is inserted, paying attention to the world of everyday life of each individual, it is possible to favour the transcendence of values, the inter-subjectivity and the social interaction throughout the process^6,7. Thus, social reintegration of the user becomes essential for him to share the world of everyday life with his fellows, rebuilding relationships and reflecting on every day to organize their choices, as it is observed in the following lines:

Reintegrate him into society, [...] provide that space so that he may reflect on all that he did, [...] and what he wants of his life. (I1)

Here would be a space where people can recycle, [...] can rebuild ties [...], you can return to live in society. [...] Here is a preparation for our clientele to return to society. (I2)

The main objective is [...] that he may be able to be reintegrated to society. (I6)

It is notable that the health work in CAPSad proposes the construction of spaces for social inclusion of users, in which reflection, health education and reducing the use of psychoactive substances are encouraged. With this, from the workers' perspective, it is possible to prepare these users to reintegrate into society.

The social world appears as an intersubjective environment covering all walks of life experiences and everyday experiences, whereby subjects, by their intentions, develop relationships with their neighbours, design actions and conceive plans. It is in the world of life that the experience is organized from the present and is directed to the past and the future, and that there is the sharing of meanings in social interactions⁷.

For this reason, the closeness between health service and user is considered crucial, based on an essentially interdisciplinary health work, enabling a therapeutic process that meets all interests¹⁹. In addition, this health work can allow the user to get adapted to the development of daily activities such as work, study, tourism, ie, that the individual may be able to manage his life, as disclosed in the reports:

That he returns to his routine, returns to work, comes back to their families. (I5)

She get a job, have a good life of relationship with their family, with the wife, with their children. (I12)

I hope that he be able [...] to work, that may manage his money in order to provide conditions for the family. (I6)

It is important to understand that the social reintegration embodied in the therapeutic process and the social relations among all actors may strengthen the social ballast of actions in health services. Within this understanding, social inclusion becomes the locus for the world's reflection of everyday life of users, being one of the mechanisms to conduct practices that can promote the transformation of social reality.

Care mechanisms in mental health are cross cutting in CAPS daily life, particularly in social interactions built up throughout the therapeutic process ¹⁸. In this scenario, the psychosocial rehabilitation is emphasized. This may request from the actors involved a greater capacity to articulate with the possibility of mental health care in the health service²⁰ and with the own demands that constitue the subjective context of each user, family and work.

Thus, it is emphasized that the actions of mental health developed in CAPSad proposes building a therapeutic aimed at improving the user's state of health; autonomy of the user; and social reintegration. With this, the health work can assist in the establishment of psychosocial rehabilitation of users, where they can actively participate in mental health care, and may be protagonists of their world of everyday life.

CONCLUSION

It was observed in this research, from the analysis of the speeches of workers in a CAPSad, that the institution of actions in mental health in this space, which yearn for psychosocial rehabilitation in the therapeutic process. It was perceived that social relationship between the health professional and the user becomes paramount in this care, which may allow the strengthening of the bond and understanding of the social context of the drug user, working to psychosocial rehabilitation as a process of reconstruction of the subjectivity of this subject.

The results of this study showed that the therapeutic process is presented with the purpose of improving the user's health conditions; to stimulate the autonomy of users to promote better choices and organization in daily life; to prepare drug users for life in society through ascertainment of skills; and connected to the expectations of professionals. However, one should reflect on these therapy features in CAPSad, valuing such proposals of assistance for drug users, and especially evaluating whether there are difficulties in structuring and executing them.

The search by CAPSad health professionals for care organization in mental health with a view to psychosocial rehabilitation, based on the approximation to the social context of each drug user, contributes to this perspective. Therefore, it is essential to explore the user's world of everyday life and view contexts, making possible to understand this individual in its uniqueness and individuality and, consequently, institute actions in mental health that integrate, enhance and make possible the reconstruction process of the subjectivity of the drug user, that is, the psychosocial rehabilitation.

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