RESEARCH ARTICLES

Perceptions of the therapeutic relationship from caring professionals in therapeutic communities

Maria Bruna Espinoza Fernández^I ; Margarita Antonia Villar Luis^II

^INurse. Assistant Professor at the University of Valparaíso, Chile. E-mail: bef_58@yahoo.es
^IIProfessor in the Department of Psychiatric Nursing and Human Sciences of the University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: margarit@eerp.usp.br
^IIIWe would like to thank the National Department for Policies on Drugs of the Ministry of Health/Brazil and University of São Paulo at Ribeirão Preto College of Nursing.

ABSTRACT

This exploratory qualitative research aims to describe the role that the professional nurse plays in therapeutic communities according to the perception of its participants in the Region of Valparaiso in Chile. The gathering of the data was done through semi-structured interviews to rehabilitation and treatment technicians, since there were no professional nurses in the therapeutic communities in January/2012. The methodology used for the data analysis was content analysis. It focused on the identification of the main themes that surrounded the meaning that participants give to their work as well as the perception of the therapeutic relationship they develop. The methodological framework used was therapeutic relationship. The findings show that the working with addicts in an interactional basis is hard and frustrating, but at the same time, rewarding. The technician takes care of the person and his/her family in a collaborative work centred on motivations and support with a multi-professional team. Keywords: Therapeutic relationship; nursing care; drug addiction; therapeutic community.

Keywords: Therapeutic relationship; nursing care; drug addiction; therapeutic community.

INTRODUCTION

In Chile, the problems associated with drug and alcohol abuse^III are the leading cause of death and disability in men under age 45 in the country, and dependence on these substances is one of the ten main causes of years of healthy life lost due to disability or premature death (AVISA) in the entire population^1,2.

The problem with psychoactive drug and alcohol use in Chile is not generic or across the board for all existing drugs, or for all age groups and socioeconomic levels, but entails a high level of alcohol and marijuana use among adolescents, the problematic use of freebase and cocaine among the vulnerable population and high risk consumption of alcohol among the whole population³.

The National Service for Drug and Alcohol Prevention and Rehabilitation (SENDA, as per its acronym in Portuguese) is a public agency under the Ministry of the Interior of the Government of Chile, responsible for formulating drug and alcohol prevention polices, as well as the treatment, rehabilitation and social reintegration of persons affected by these substances, in an inter-sectoral strategy in coordination with the Ministry of Health, Ministry of Justice and Ministry of Education³.

The treatment and rehabilitation program for people suffering from alcohol or drug abuse is one of the intervention priorities implemented by SENDA. This program has been applied in all the country's health services since 2001, including the primary health care network, mental health community centers, general hospitals and those with psychiatric specialties, as well as therapeutic communities³.

Therapeutic communities are non-governmental organizations (NGOs), which use a psychotherapeutic approach aimed at the total rehabilitation of individuals suffering from alcohol and drug abuse. Adaptive standards are developed within their structure to help patients assume roles that will facilitate their reintegration into society and retrain them in a new lifestyle. People who agree to undergo this therapeutic strategy may do so in residential treatment centers or on an outpatient basis, according to the physical and psychological conditions resulting from their addiction^4,5. These institutions have specialized multidisciplinary teams, but nursing professionals do not operate in this area.

In the legal framework of the Chilean Health System⁶, the role of this professional falls under nursing care management, which includes professional services for promotion, prevention, treatment and rehabilitation, all of which activities can be found in the work carried out by health care teams in therapeutic communities.

Chilean law recognizes nurses not only as professionals in terms of medical collaboration, but also identifies an autonomous role in the integral care of people⁷.

In observing nursing tasks in the field of mental health, it would appear that this professional is more linked to the role of resource manager as opposed to being a caregiver involved in the therapeutic relationship process for assisting patients and their families⁸.

Latin American studies support this finding, which describe the stereotyped image of the nursing role and refer to problems involving visibility of the nursing operation, absence of actual records, lack of definition of nursing roles at an autonomous level and lack of specificity in the care of people with addictions^8-10.

Based on two research studies, conducted in Spain and Colombia, the authors, using two frames of reference, Gordon's functional health patterns ¹¹ and the North American Nursing Diagnosis Association (NANDA)¹², establishing the need for care, diagnosis and nursing activities, defined the social and clinical profile, assessed the health status of the participants and used a NANDA-based instrument.

The goal of this study is determine the role of the nursing professional in therapeutic communities as perceived by the participants.

Theoretical and methodological framework

For the purpose of this study, a theoretical framework will be used that prioritizes interpersonal relationships. The theorists who support these principles have focused their interest on interaction processes and define care as a humanitarian activity, drawing their inspiration from phenomenology and existentialism¹³.

The pioneer of the interpersonal process is Hildegard Peplau, who defines people as spiritual biopsychosocial beings who are in constant development and have the ability to understand their situation, allowing them to be potential agents in the recovery of their health and the transformation of their anxiety into positive energy, which will enable them to respond to their needs^11,14.

Peplau believes that sickness constitutes a potential learning experience where through a meaningful nurse-patient relationship both sides can develop, learn and grow further as people^11,14.

The therapeutic relationship can be considered an outgrowth of knowledge built through nursing practices and could represent a specific contribution from the field in terms of formulating therapeutic projects in mental health institutions as well as therapeutic plans for people with alcohol psychoactive drug abuse problems.

The definition of the research problem-question is as follows: Are the essential suppositions of the therapeutic relationship found in the nursing care provided in therapeutic communities?

METHODOLOGY

This is an exploratory study of a qualitative nature, since it represents a research method for guiding the understanding of a reality that cannot be quantified, and works with meanings, attitudes, values ​​and beliefs corresponding to a deeper realm of processes or phenomena. The qualitative approach seeks to delve into the world of meanings and relationships¹⁵.

Qualitative researchers take into account the participation of the subject – the focus of their study –as one of the elements of their scientific work, thus emphasizing their relationship with the person providing information¹⁵.

The research was carried out in four therapeutic communities located in the V Region of Valparaiso, Chile, referred to as therapeutic communities A, B, C and D to ensure the anonymity of the institutions, and were chosen based on ease of access and previous links.

There is no provision for nursing professionals to work in these therapeutic communities, for which reason they chose to work with drug treatment and rehabilitation staff who exercised the duties included in the nursing role. For this study, the participants were four staff members (SM) who were assigned numbers from 1-4 in their interviews, to ensure the anonymity of the subjects. One participant was chosen from each community, based on the criterion of greater experience and seniority. These people studied for two years in institutions of higher education.

In November 2011, the authorities of each institution were informally approached to assess the possibility of carrying out the research. Written authorization was then requested from the director of each organization, after which the project, together with this document, was sent to the Health Service Ethics Committee which, in turn, gave written approval for the research.

Procedure

The selected participants were contacted to set up the interviews. The study was conducted in accordance with the ethical principles and conditions for research involving human subjects, as laid down in the Declaration of Helsinki (1989) and the Code of Ethics established by the State of Chile. All signed an informed consent form.

Due to the exploratory nature of the research, the most appropriate format was to collect data through semi-structured interviews, based on two open questions regarding the professional relationship and the meaning that participants attribute to that relationship. This technique enabled data of interest to the researcher to be collected and at the same time allowed for free and spontaneous expression on the part of participants¹⁵. The data was collected during the month of January, 2012.

The interviews, which were conducted in the facilities of the therapeutic communities, were recorded and lasted no longer than 45 minutes.

The recordings of the interviews were transcribed and each one was read in depth, in order to have a general and comprehensive understanding of their contents. Afterwards, the conversations were organized by selecting out the topics which emerged during the interviews and organizing them in thematic categories – in terms of the meaning participants attribute to their work and perceptions of the interactional work that is developed.

The theoretical and methodological perspective used to analyze the content is linked to the theoretical concept developed by Peplau, in reference to interpersonal relationships.

RESULTS AND DISCUSSION

In regards to the general traits of the participants, they had, on average, been working with substance abusers for six years, work 12 and 24 hour shifts and two of them were former drug users.

The content provided by the participants underscores the meaning and perception they attribute to their work with users. The discussion of the categories is grouped into components presented as follows:

Meaning that participants attribute to their work

Two subjects come to the fore when analyzing the participants' interviews: one is satisfaction and meaning in life whenever positive results occur and the other is the power of intellectual and emotional commitment when dealing with frustrating and complex realities.

Meaning of life and satisfaction

In her theory, Peplau views sickness as a potential learning experience where through a meaningful health worker-patient relationship both sides can learn, develop and grow^11,14, as confirmed by the interviewees in the following statements:

If there's something this work provides it's a sense of meaning in life [...], I got started in this in 98, working with the most vulnerable sectors [...] and I found a sense of meaning there [...] the power to help, guide, support, motivate others [...] and it has borne plenty of fruit . Living with the boys has given me this satisfaction [...] I see them in the square, with their mates, I see them recovered, more or less made whole [...] it's priceless [...] (SMA1).

[…]I'd screwed up in my life and with my family and then I got into this [...] I've already been doing it for five years and it's changed my life […] (SMD4).

The learning and experience from day-to-day work impart positive meaning to their lives and they feel a sense of satisfaction with the work accomplished. Peplau says that to provide quality care, nurses need to develop and mature as people, so that patients can identify more with their health problems and put forth the means to solve or overcome them^11,14.

[...] I can say now after two years, well... some realities deeply sadden me but there are many others that make me happy [...] the boys come to tell me they're working and their mothers come to thank me because the treatment worked [...] then those things give you a boost to keep on going […] (SMB2)

The cases that end well are encouraging experiences that spur staff members on, generate commitment and provide satisfaction for the care given. They are also tools for learning and reflection to determine that the therapeutic relationship has been effective.

Power of intellectual and emotional commitment when dealing with frustrating and complex realities

Some interviews reveal feelings of frustration, in having to deal with such powerful, heavy and difficult-to-manage realities. Individuals make commitments, but don't always follow through. The work is unpredictable, generating feelings of dissatisfaction among the participants.

The situation of the boys has required a super intense personal sacrifice on my part, professionally it's a highly complex job, where you have to be constantly developing professional skills, since every day there's a crisis, and you've got have to your wits about you [...] (SMC3)

Assisting drug addicts is complicated, because together with a series of interventions to support overcoming the drug dependence, there are activities of a psychological, biological and social nature; hence the importance of a comprehensive treatment for patients and collaboration between all members of the team¹⁶.

It's an extremely heavy experience. It's very powerful in emotional terms. Working with young adolescents means facing very tough realities where you run up against very frustrating situations, where there are parents who are supportive in word, you're counting on an intervention, however it starts losing steam and you have to come up with new motivational strategies quickly. Had it depended on first impressions, I don't think this would have been a project or proposal that would have interested me [...] (SMB2).

Mental health professionals are one of the groups of health workers most affected by stress. The professional who is caring for a patient with an addiction has to handle frustration levels somewhat more intense than with other types of patients, since the relapse rate, due to the very nature of the sickness, tends to be high and the level of difficulty in treating it is likewise high¹⁷.

It's a super frustrating job because you plan things and then find out that the kid was arrested or something else happened [...] and because of this, we also, as a team, schedule self-help and work on our difficulties, besides trying to protect ourselves as a team in this respect […]. (SMC3)

The profiles you're working with in addictions are very complex because they're very vulnerable kids and also because they started actively consuming from a very young age, plus criminal life greatly complicates the intervention with them and their families. During difficult times, we get together, give support to people and see how we can improve the situation, in order to contain their companions as well who are very complicated. (SMC3)

One aspect that comes out in these last parts of the interview is joining a mutual support team as a form of protection against the frustration caused by this type of work.

Perception of the interactional work

All nursing theories emphasize that the practice of the nursing role is carried out through an interpersonal process where care means entering into a relationship with the person and their family in order to help meet certain needs and overcome obstáculos¹¹. In analyzing the content of the interviews, it can be noted that there are different ways that interaction is perceived:

Staff member-patient interaction

In regards to the therapeutic relationship, J. Trabelbee (theorist on therapeutic relationships in nursing), emphasizes therapeutic relationships based on communication and active, respectful listening, which enables the purpose of the care to be achieved¹⁸.

What we do throughout the process is delve into the person's life story, where some issues intersect, their motivations, why they joined the community, what they hope to achieve, what things they want to fix, what things led them to make this decision. (SMA1)

My role is to go empowering the person who arrives in a damaged state due to substance abuse. I talk with them a little to see how they slept, what they're doing, what they'd like to do during the day, what they'd like to talk about, if they have had dreams about drugs, stealing, fights [...] then you have to start working with the anxiety. (SMD4)

It takes work to create a link, building a therapeutic relationship is the hardest thing, I think what's hardest is the trust part. (SMD4)

This interpersonal relationship for therapeutic purposes was also described in a study, in Brazil¹⁹, as an assistance-based relationship where exchange of knowledge occurs: on the one hand, the professional who prepares to intervene therapeutically, answering questions and reducing anxiety levels, and on the other, the patient who needs understanding, love and solidarity.

Patient-patient interaction

This is cultivated in group therapy where the therapeutic relationship stems from relationships between people, where the staff member encourages conversation about personal experiences.

Therapeutic communities are characterized by a style of treatment, by a way of dealing with people that is related to this daily social interaction where the group itself takes shape and generates certain dynamics or behavioral standards that allow members to start working out their problems and observing certain changes […] (SMB2)

In motivational therapies, a kind of inward mysticism is generated, where some hug each other, support each other and say encouraging words to one another (SMA1)

Humans develop and exist through interaction with others. Consequently, in group therapy patients discover possibilities for relationships, personal development, growth and change^20,21.

There are also recreational activities and sports to help them accept rules, respect other people, share and create collective bonds.

Sometimes I play cards with them, football a little, to bond with them. I try to play a lot with them. (SMA1)

Staff member-family interaction

The nurse-patient relationship contributes toward finding meaning in the experience of suffering . This concept is essential for helping the family accept the sickness and finds way to deal with it. This finding meaning in the experience motivates the sick person and their family to seek for strength from within in order to change the situation¹⁹.

They have their families and we have to help them to take the course, their responsibilities and resume their roles [...] We also work with the families individually, remove them from the context in which they find themselves [...] My job involves showing understanding and empathizing with their reality [...] It's my job to attend family workshops, I'm constantly supporting and helping them in the conversations with the family and above all, to give them that sympathetic, friendly and encouraging look of what it means to undergo treatment [...] (EB2).

One can infer from the accounts that the ongoing psychological support and empathy that is given to the family are the main ingredients for building an interpersonal therapeutic relationship¹³.

Staff member-multidisciplinary team interaction

Evidence of a cooperative and interactive work with other professionals on the team can be noted in the testimonies. Staff members, due to the greater amount of time they spend with the individuals undergoing treatment, create a special bond of trust that allows them to more easily penetrate the subjective world of the addicts. The information that staff members are able to obtain is shared with the rest of the team, after which therapies are scheduled or tailored, or patients are referred to a specialist within a specific field.

Someone cried last night, there's usually always something going on [...] there are kids who are dreaming about drugs and want to leave, others are bored, some are thinking about their families, their children. We share this information afterwards with the rest of the team, especially with the psychologist and the coordinator of the home. (SMA1)

I reinforce with them the dual work of the psychologist and social worker and the rest of the team. I show them the reasons behind things and in some way these families, some, not all, respond very differently to the role of authority of the psychosocial team or a multidisciplinary team. For example, sometimes it happens that they say to me: look this guardian said he's not going to come, see if you can convince him and usually I approach the family and point out the situation to them and remind them that we have a commitment, it's in these areas where I most get involved. (SMB2)

CONCLUSIONS

The theoretical and methodological framework refers to professional nurses, however it can be concluded that, in the therapeutic communities studied, staff members are authorized to provide care.

From the statements made by the participants, it can be seen that they use the basic concepts described in the therapeutic relationship. It could be that they learned them in the course of their daily work with the patients and families.

The staff members carry out a very important work in terms of cooperation, motivation and support for the activities conducted by the rest of the psychosocial support team. Furthermore, due to the empathetic nature of the therapeutic relationship they develop, they can identify needs in the psychic realm, thereby creating a very positive nexus between the psychosocial professionals and the drug user. They also appear to play a greater role with the families in terms of building trust when commitment toward the rehabilitation of patients is needed.

As far as the meaning attributed to the work they perform, the perceptions vary among the participants – some, perhaps, influenced by their own life stories as former drug users, which is reflected in their statements.

Further studies should be performed in order to pinpoint and understand the reasons why professional nurses are not included in the care of people suffering from drug and alcohol abuse in therapeutic communities.

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