Abstract

Therapeutic communities emerged to respond to individuals with substance use disorders. The studies carried out emphasize the importance of the Occupational Therapist in the process of constructing occupational meaning. However, there is a paucity of studies addressing the relevance of this profession in this specific context. To understand the intervention of Occupational Therapy in the Therapeutic Community “Clínica do Outeiro - Portugal”, describing the perception of individuals with substance use disorders, Occupational Therapists and other team members. Descriptive-exploratory study with a qualitative approach, by means of a case study research. We used interviews with clients and Occupational Therapists and focus group with the multidisciplinary team to collect data. Occupational Therapy is characterized by the greater proximity it establishes with users, as well as by the dynamism, creativity and motivation it infuses, playing a preponderant role in the (re) structuring of routines, performance of ADL and IADL, leisure and social participation of individuals with substance use disorders. The OT emerges as essential in this community, as a professional who is dedicated to the work of adapting and including the individual in the therapeutic community through the acquisition of the necessary occupational performance skills essential for everyday life in society.

Occupational therapy; Therapeutic community; Disorder by substance use

Introduction

Substance abuse is not new to most people, but the rehabilitation process is complex and difficult to understand for a less informed public. The term “substance abuse” is referred to as the harmful use of psychoactive drugs, which may result in the inability to fulfill personal or professional obligations, serious physical harm or recurring legal problems ¹1. World Health Organization (WHO). Substance abuse . 2016. [acessado 2017 Jul 15]. Disponível em: http://www.who.int/topics/substance_abuse/en/
http://www.who.int/topics/substance_abus... , constituting also significant health hazards. It usually occurs when a person is involved in a pattern of use of mood-altering substances such as alcohol, marijuana, cocaine, street drugs, designer drugs, painkillers, and other pharmaceuticals. Because of the effects that substance abuse has on a person’s physical, cognitive and psychosocial health, the individual’s occupational performance potential is also compromised. It is observed that over time, daily occupations can be adversely affected by substance use, impacting relationships, performance at work and daily routines that support health and effective copping ²2. American Occupational Therapy Association (AOTA). Overcoming Drug and Alcohol Abuse . 2002. [acessado 2017 Jul 15]. Disponível em:https://www.aota.org/~/media/Corporate/Files/AboutOT/consumers/MentalHealth/Drugs/SubAbuse.pdf
https://www.aota.org/~/media/Corporate/F... . This issue is assuming increasingly worrying proportions and, in this sense, there is an urgent need to develop responses that integrate and offer specialized support to individuals with substance use disorders ³3. Bhatia M, Garnawat D, Kaur J. Rehabilitation for Substance Abuse Disorders. Delhi Psychiatry Journal, 2013; 16(2):400. , such is the case of Therapeutic Communities. The therapeutic communities consist of Long-term Residential Treatment Specialized Units, aiming at “psychotherapeutic and socio-therapeutic” support, in order to “help to reorganize the inner world of drug addicts and to outlook their future” ⁴4. Departamento de Tratamento e Reinserção. Linhas Orientadoras para o Tratamento e Reabilitação em Comunidades Terapêuticas. Lisboa: Instituto da Droga e da Toxicodependência Obtido de Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências (SICAD); 2011. . These units must ensure in their services the physical and permanent presence of properly qualified health professionals and technical personnel, with adequate training, in the necessary number for the activities to be carried out ⁵5. Decreto Lei nº74/2016. Diário da República 2016; 8 nov. . On the other hand, the aspects of professional rehabilitation, residential rehabilitation and social participation must necessarily be developed outside health services and integrated into the community. They therefore require other resources and methodologies and presuppose a shared responsibility between mental health and other sectors, including primary health care.

There are a variety of treatments depending on the type of dependency and the rehabilitation programme. Occupational Therapy emerges in a unique position to help people struggling to recover from substance abuse, helping them re-establish the roles and identities that are most significant to them. Occupational Therapists base their practice “on occupation and its influence on the health of each individual,” ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. using activity as a therapeutic tool for linking to treatment, to facilitate the discovery of new interests or re-encounter with those who were lost ⁷7. Cáceres A, Mesias B. Atención a población sin hogar: Experiencia del Instituto de Adicciones de la Ciudad de Madrid. In: Bobes J, Casas M, Gutiérrez M, editores. Manual de Trastornos Adictivos. Madrid: Enfoque Editorial; 2011. p. 226-234. . It is essential the involvement and participation of the individuals in various occupations, in order to allow a harmony between work, self-care, leisure and rest, ensuring the maintenance of health and well-being, as well to promote a suitable an environment, minimizing inappropriate behavior and allowing individuals to acquire a structured life ⁸8. Petrova T, Punanova N. Behavioral Approach to Rehabilitation of Patients with Substance-Use Disorders. In: Söderback I, editor. International Handbook of Occupational Therapy Interventions . Estocolmo: Springer; 2009. p. 277-284. for a biopsychosocial reorganization “... people need to engage in an occupation to feel mentally healthy” ⁹9. Steiner A. O ccupational therapy for addiction? Experts say it’s back. [acessado 2017 Jul 15]. Disponível em: https://www.minnpost.com/mental-health-addiction/2017/03/occupational-therapy-addiction-experts-say-it-s-back
https://www.minnpost.com/mental-health-a... .

Referring to the aforementioned impacts that dependencies have on occupational performance, namely at work, in daily life activities, in leisure and on roles, habits and routines ¹⁰10. Crouch R, Alers V, editors. Occupational therapy in psychiatry and mental health . Hoboken: John Wiley & Sons; 2014. , it is verified the necessary catalytic role of the Occupational Therapist (OT).

“through the therapeutic use of self, occupational counselling, individual and group activities based on occupation, training social skills and creative techniques (...) facilitating the process of recognizing maladaptive behaviours exhibited during activities” ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. .

Davies ¹¹11. Davies R. According to the models of care for the treatment of drug misusers, does occupational therapy have a role in the treatment of drug misuse? British Journal of Occupational Therapy 2006; 69(12):575-577. maintains that Occupational Therapy is vital in the treatment of drug abuse, rationalizing that the complex nature of the disorder requires professionals with a wealth of knowledge and skill. The author agrees with the role of the profession in the treatment of substance abuse and concludes that there is a lack of research to substantiate the potential of the profession in the rehabilitation of substance use disorders ¹²12. Stoffel V, Moyers PA. Terapia ocupacional e distúrbios do uso de substâncias. In: Cara E. MacRae A, editors. Terapia Ocupacional Psicossocial: Uma Prática Clínica . 2ª ed. Albany: Do Mar; 2005. p. 446-473 .

In the literature review, a small number of studies have been found that explain the role and importance of Occupational Therapy in Therapeutic Communities and that point to the need to increase scientific evidence in this area.

In this context, we aimed to answer the research question: “To what extent does Occupational Therapy in the ComunidadeTerapêuticaClínica do Outeiro contribute to the rehabilitation of individuals with substance use disorders?”

Consentaneously, were developed the procedures considered necessary to know the intervention of the Occupational Therapy of the ComunidadeTerapêuticaClínica do Outeiro (CTCO) in the rehabilitation of individuals with substance use disorders , as well as to obtain insights from all the participants in this process, mainly Therapists Occupational, other professionals of the team and, in particular of the clients that use these services.

Ethical procedures

For the collection of data necessary for the acomplishmentof this study and subsequent disclosure, prior authorization was requested from the CTCO, as well as the presentation of the study and the underlying signature of the free and informed consent term.

Methodological procedures

The research was carried out at CTCO in Portugal, using qualitative approach, with a descriptive-exploratory objective, materialized by a case study as a technical procedure. The case study research allows to generate a multifaceted, deep-seated and in-depth understanding of a complex issue in its real-life context through methods and techniques that were strictly conducted ¹³13. Ribeiro J, Brandão C, Costa A. Metodologia de Estudo de Caso em Saúde: Contributos para a sua Qualidade. In: Oliveira E, Barros N, Silva R, organizadores. Investigação Qualitativa em Saúde conhecimento e aplicabilidade . Oliveira de Azeméis: Ludomedia; 2016. p. 143-160 .

Ribeiro et al. ¹³13. Ribeiro J, Brandão C, Costa A. Metodologia de Estudo de Caso em Saúde: Contributos para a sua Qualidade. In: Oliveira E, Barros N, Silva R, organizadores. Investigação Qualitativa em Saúde conhecimento e aplicabilidade . Oliveira de Azeméis: Ludomedia; 2016. p. 143-160 also point out that the case study research can be used to

“... describe in detail the determination of diagnoses and episodes of care; evaluate priorities, outcomes and therapeutic intervention processes; to explore professional attitudes, provider-client relationships, professional relationships, experiences of a new initiative or service, development policy or, more generally, to investigate contemporary phenomena within their context. “

In this sense, given the research question: “To what extent does Occupational Therapy in the ComunidadeTerapêuticaClínica do Outeirocontribute to the rehabilitation of individuals with substance use disorders?” Aiming with the study:

• Know the intervention of Occupational Therapy in CTCO in the rehabilitation of individuals with substance use disorders;

• Understand the perception that individuals with substance use disorders have about the role of Occupational Therapy in their rehabilitation at CTCO;

• Describe the perception of the professionals who are part of the CTCO interdisciplinary team about the intervention of Occupational Therapy in the rehabilitation of individuals with substance use disorders.

Eight individuals with the following characteristics participated: a 25-year-old OT, who started the service in the Community three years ago (TO1) and a second OT, 25 years old, who has been working for two years (TO2) ; two clients of the Community (C1, aged 43, 12th grade, C2, 53 years old, with fourth year of schooling) and four interdisciplinary team members, three psychologists and a social work professional.

As for the data collection instruments, were conducted a semi-structured interview with the OTs and clients and a focus group with the other members of the technical team. It is the use of these instruments that, according Coutinho ¹⁴14. Coutinho C. Metodologias de Investigação em Ciências Humanas. Coimbra: Almedina; 2011. allows cross-referencing, ensures different perspectives of participants and various measures of the same phenomenon, creating the conditions necessary for triangulation and confirmation of the validity of the process.

With the clients, due to more sensitive issues, the option was to use the individual interview to directly access their thoughts in a less restrictive environment. Consequently, the interview was selected to evaluate participants’ perceptions, thoughts and ideas about OT interventions and their relevance to the process of rehabilitation and reconstruction of daily life.

The choice of the semi-structured interview was more pertinent, since open answers provide richer/deeper information, translating into an abundant volume of diversified data, taking into account the peculiarities of each individual. With the target population, with possible cognitive impairments, allows flexibility in conducting the data collection process, and the interviewer can clarify and reformulate the questions,to ensure the interviewees’ comprehension, enabling the redirection of the speech of the individual in order to meet what is intended to be studied ¹⁵15. Alves Z, Silva M. Análise Qualitativa de dados de entrevista: uma proposta. Paidéia 1992; (2):61-69. .

To get team members’ information on the specific, focused, shared issue, in this case teaming with Occupational Therapists, the focus group emerged as the best technique to use. During the focus group, a moderator and observer were present to capture and record insights about OT’s work, contributions to team effort and clients for their rehabilitation, and possibly other contributions that could enrich the data. This data collection technique privileges the interaction between the members that make it up it, providing a broad approach to the focused theme ¹⁶16. Backes D, Colomé J, Erdmann R, Lunardi V. Grupo focal como técnica de coleta e análise de dados em pesquisas qualitativas. O Mundo da Saúde 2011; 35(4):438-442. . It is based on the assumption that it is in the group discussion that the participants deepen their points of view, investigating dimensions of the understanding little explored by other techniques ¹⁶16. Backes D, Colomé J, Erdmann R, Lunardi V. Grupo focal como técnica de coleta e análise de dados em pesquisas qualitativas. O Mundo da Saúde 2011; 35(4):438-442. . There is consensus among the authors that the focus group may be made up of four to ten elements ¹⁷17. Gondim S. Grupos focais como técnica de investigação qualitativa: desafios metodológicos. Paidéia 2003; 12(24):154. , and in the present study all the technicians (non-occupational therapists) in the institution were included.

In order to assert the validity of the instruments, the scripts of both methods of data collection were scrutinized by two professionals with experience in research and in mental health.

Considering the amount of raw data, it is necessary to synthesize the information to facilitate its understanding, interpretation and inference ¹⁸18. Moraes R. Análise de conteúdo. Revista Educação 1999 ; 22(37):7-32. . In this perspective, the data processing consubstantiated in the content analysis (CA), defined by Bardin ¹⁹19. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2013. as a set of communication analysis techniques, which uses systematic procedures and objectives to describe the content of messages, reaching an understanding of their meanings at a level that goes beyond a common reading. In the present study, the contents of the statements were appreciated in their entirety with the exploration of their implicit and explicit meanings (qualitative induction). Adopting the perspective of Bardin ¹⁹19. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2013. , the CA proceeded in three stages: pre-analysis, in which the organization of the material that was intended to be used in the investigation occurred, categorizing the data; and finally, the treatment of results, inference and interpretation, which established a relationship between the data obtained by performing a comparative analysis of the categories created in the previous stage. In this process, the CA relied on three indexes for the organization of the analysis: clipping, aggregation and enumeration. In the clipping, the units of analysis based on thematic cutouts were defined that illustrate the experiences of the clients and the characteristics attributed to the Occupational Therapy. It followed the aggregation that determined the conjunction and specification of units that were clustered around distinct categories. Finally, the enumeration allowed to gauge the gradient and the quantification applied to the referents of the material analysed.

Some of the categories and subcategories used were predetermined based on the Portuguese version of the 2nd edition of the Occupational Therapy Practice Framework: Domain and Process ²⁰20. Marques A, Trigueiro MJ. Enquadramento da prática da Terapia Ocupacional: domínio & processo . Porto: Livpsic; 2011. , and others emerged from the data. In the structuring of the categories it is emphasized the obedience of the principles: a) exclusivity between categories; b) homogeneity within categories; c) completeness of the codified text; d) objectivity among coders; and, e) suitability and relevance to contents and objectives ¹⁹19. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2013. .

In order to facilitate this process, webQDA software was used to support qualitative data analysis ²¹21. Chaves M, Larocca L, Mafra M. Pesquisa qualitativa com apoio de software: Um relato de experiência. Investigação Qualitativa em Saúde 2015; 1:187-188. in which the collected information was first transcribed in its totality and later introduced into the program, categorised and coded by three researchers simultaneously in order to achieve the Intercoder reliability. This tool permitted the selection and manipulation of the most relevant categories, allowing a more intuitive information analysis, since the data were synthesized, easy to read and interpret.

Presentation and Discussion of Results

After categorizing the data obtained through the aforementioned instruments and their respective coding in context and registration units, three categories emerged that were more relevant to the study (Chart 1).

The occurrence count by category is assumed by several authors as a way of determining the main apprehensions / opinions of the participants, because the repeated words / ideas / thoughts are those that reflect primordial concerns. Although quantifying the speech can be a starting point, it cannot be a binding for inferences on important subjects ²²22. Stemler S. An overview of content analysis. Practical Assessment, Research & Evaluation 2001; 7(17). , so the findings are quantified and described below, being appropriately confronted with studies addressing the same theme.

Functional deficits

The use of substances has a negative impact on the performance of the individuals, being referred by the OT, Activities of Daily Living (ADL), Instrumental Activities of Daily Living IADL), leisure, work and social participation, as the most most-loss occupation areas also identified in the Bazzani ²³23. Bazzani L. La Terapia Ocupacional en el abordaje de las adicciones: una revisión actualizada. Revista Chilena de Terapia Ocupacional 2013; 13(2):57-64. review in 2013.

Table 1 presents references, according to the Occupational Therapy Practice Framework ²⁰20. Marques A, Trigueiro MJ. Enquadramento da prática da Terapia Ocupacional: domínio & processo . Porto: Livpsic; 2011. , contained in the statements of the different participants regarding functional deficits that interfere with the occupational performance of individuals with substance abuse disorders.

From the analysis of the data, there are frequent and significant references to the subcategory “Routines / Habits”, identified as the established sequences of occupations and activities that give structure to daily life. Four sources (GF, TO1, TO2 and C1) emphasise that the routine disruption and lack of client habits are reflected in negligence in the ADL, especially in hygiene and personal care, where it is assumed as primordial “to show the importance and to facilitate the involvement of the individual in the care of the own body” ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. .

One of the OT (TO1) also reports, in concordance with Bazzani ²³23. Bazzani L. La Terapia Ocupacional en el abordaje de las adicciones: una revisión actualizada. Revista Chilena de Terapia Ocupacional 2013; 13(2):57-64. , the loss of abilities in the IADL, namely, in the cleaning and maintenance of spaces.

Individuals with substance use disorders have very restricted leisure activities, according to the allusions found in the discourse of two sources (TO1 and C2) and when given the opportunity to experience new activities “show difficulties in exploring them” (TO1), as Ricou and Teixeira ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. corroborate when affirming that one of the first areas of occupation where there is a considerable decrease in performance is leisure. These individuals direct their interests to the search for, acquisition and consumption of the substance, repercussions in difficulties, when in abstinence, in the identification of leisure activities different from those associated with consumption ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. . According to C2, the lack of motivation is also a factor that contributes to the reduced range of interests and involvement in the activities. An OT (TO1) states that before joining the community, this population is usually unemployed or disability pensioner or, on the other hand, do not have work skills because they have never experienced or performed this type of activity, meeting the findings of Ricou and Teixeira ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. .

The American Society of Addiction Medicine ²⁴24. American Society of Addiction Medicine. Public Policy Statement: Short Definition of Addiction . 2011. [acessado 2017 Jul 15]. Disponível em: http://www.asam.org/docs/default-source/public-policy-statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0
http://www.asam.org/docs/default-source/... in 2011 highlighted the problem of interpersonal relationships. CTCO clients also find it difficult to establish and maintain interpersonal relationships, both within their family and in the community, as mentioned by one of the sources (TO1) of the two references obtained in the subcategory “Social Participation”, denoting deficits in social and communication skills, such as “difficulty in listening to others”, “they cannot have a dialogue”, “they do not come with correct communication, they are rude to people”, mentioned by three sources (TO1, TO2 and GF) in a total of seven references in the subcategory “Communication and social skills”.

The OT and the rest of the team also point out that these individuals often have associated memory deficits, executive functions, insight, decreased concentration and judgment, planning, conflict management and problem solving, also described by Ricou and Teixeira ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. .

Irritability, stress, anxiety and impulsivity are characteristics referenced five times in the subcategory “Emotional Regulation Skills” by three sources (TO1, TO2 and GF). These are mentioned as factors that result from the emotional lability that clients present, and they point out the lack of motivation for occupational performance, being “easily discouraged by what they are doing and are eternally dissatisfied” (GF).

As already mentioned, the enumeration of references by subcategory contributes to the interpretation of the data, highlighting the “primary concerns” ²²22. Stemler S. An overview of content analysis. Practical Assessment, Research & Evaluation 2001; 7(17). . Thus, Table 1 arises to synthesize the references found in the subcategories analysed.

Scope of Occupational Therapy intervention

As evidenced in Amorelli’s study ²⁵25. Amorelli C. Psychosocial Occupational Therapy Interventions for Substance-Use Disorders: A narrative review. Occupational Therapy in Mental Health 2016 ; 32(2):167-184. , also in CTCO, Occupational Therapy stands out at first, concentrating its interventions on functional independence through the use of significant occupations thus increasing the, also referred to by Ricou and Teixeira ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. , levels volition and motivation of the individual to remain abstinent and resorting to these activities to intervene in the necessary competences through the performance of truly transforming occupations for each subject ²³23. Bazzani L. La Terapia Ocupacional en el abordaje de las adicciones: una revisión actualizada. Revista Chilena de Terapia Ocupacional 2013; 13(2):57-64. . In this direction, the setting of the Occupational Therapy that sustains the triadic relationship is a promoter of activities. These, in turn, as a therapeutic tool, have several objectives, among them: observation, analysis, education, treatment, story composition and social insertion ²⁶26. Benetton J, Marcolino T. As atividades no Método Terapia Ocupacional Dinâmica/Activities in the Dynamic Occupational Therapy Method. Cadernos de Terapia Ocupacional da UFSCar 2013; 21(3):645-652. .

As mentioned previously, clients present functional deficits in several areas, and Occupational Therapy intervention is directed at minimizing and empowering clients’ autonomy, seeking to generalize the tools acquired in the community to society. This intervention encompasses the treatment of physical, mental and emotional factors, identification of stress factors and coping skills equally highlighted by Bhatia et al. ³3. Bhatia M, Garnawat D, Kaur J. Rehabilitation for Substance Abuse Disorders. Delhi Psychiatry Journal, 2013; 16(2):400. .

Firstly, the intervention is focused on the (re) structuring of a healthy routine and on the quality of life of the clients, through the acquisition of new performance standards, new occupational roles and the development of new habits ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. . In this proposal, the central nucleus is the triadic relationship, constituted by patient, OT and activities, characterized by enabling and maintaining a particular dynamic of functioning, in which movements of action and reaction are determinants of the relational dynamics between the three terms that the constitute it ²⁶26. Benetton J, Marcolino T. As atividades no Método Terapia Ocupacional Dinâmica/Activities in the Dynamic Occupational Therapy Method. Cadernos de Terapia Ocupacional da UFSCar 2013; 21(3):645-652. .

Taking as some examples of more individualized activities, Occupational Therapists refer to support in maintaining daily tasks: ADL training as “hygiene and personal care training” (TO1 and TO2) and IADL training, such as such as “folding clothes, tidying up the closet and cleaning their own spaces” (TO1), which operate as the basis of the intervention. Such an approach proposes habilitation in the areas of occupational performance related to leisure, productivity and self-care, provided they are endowed with meaning for the person and appropriate to their moment and context of life. It is verified that this referential is a working tool that coincides with the Psychosocial Rehabilitation assumptions because it emphasizes co-participation and accountability of the user for his/her therapeutic project, and for demonstrating flexibility in the use of diverse intervention models that meet the demands of each case ²⁷27. Màngia EF. Contribuições da abordagem canadense “Prática de Terapia Ocupacional Centrada no Cliente” e dos autores da desinstitucionalização italiana para a Terapia Ocupacional em Saúde Mental. Rev. Ter. Ocup. Univ. São Paulo 2002; 13(3):15-21. .

Lopes and Leão ²⁸28. Lopes RE, Leão A. Terapeutas ocupacionais e os Centros de Convivência e Cooperativa: novas ações de saúde. Rev. Ter. Ocup. Univ. São Paulo 2002; 13(2):56-63 consider that, in the context of collective practices that focus on human activity, OT is differentiated by the ability to analyse and adapt activities, as well as to evaluate the relationships that are established from them.

With regard to dynamized group sessions, occupational therapists highlight the activities of cognitive stimulation, such as “neuron warfare”, which consists of an activity in which several groups are formed and questions of general knowledge are posed, stimulating also the spirit of competition; the sessions of corporal expression that aim to promote interpersonal relations and verbal and non-verbal communication; the “therapeutic education” sessions for conflict management and role-plays with real daily situations, with the crucial objective of “alerting and educating to some situations, these sessions consisting of a space for reflection, discussion and sharing “(TO1); social skills training; creative/expressive activities, where objects are used to express feelings, lyrics or poems on paper, invoking self and hetero-knowledge and understanding of one’s own feelings and of others, and also using music therapy, dance therapy, art therapy and relaxation techniques, to help with stress management ³3. Bhatia M, Garnawat D, Kaur J. Rehabilitation for Substance Abuse Disorders. Delhi Psychiatry Journal, 2013; 16(2):400. ; and workshop crafts, “where creativity is called and where objects are created for them (the clients) and for the community” (TO1).

In this community, outside walks are also promoted to stimulate physical well-being and enable integration in society, with the exercise functioning as “a potential non-pharmacological treatment in this type of context, at any stage” ³3. Bhatia M, Garnawat D, Kaur J. Rehabilitation for Substance Abuse Disorders. Delhi Psychiatry Journal, 2013; 16(2):400. . In addition to this, there is a computer workshop, where it is intended to stimulate technical skills in computer science and therapeutic theatre.

The OTs point out that CTCO’s main objective is “to promote the physical and psychological well-being of the clients”, where they (re) learn to “know how to do and know how to be, getting involved in tasks and generalizing to the outside” (TO1).The intervention of Occupational Therapy “must be done in such a way as to enable a balance between work, self-care, leisure and rest, ensuring that the state of health and well-being is maintained or re-established” ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. in order to guarantee health and wellness. The practice of OT must be supported by models that reflect the use of the occupation, because through it Man interacts with the environment, produces modifications in it and is influenced by it ²⁹29. Polia AA, Castro DH. A lesão medular e suas seqüelas de acordo com o modelo de ocupação humana. Cadernos Brasileiros de Terapia Ocupacional 2010; 15(1):19-29. . In short, psychotherapeutic intervention always relies on the occupational restructuring of the person, with the acquisition of new ones or recovery of old lost occupational roles, the exploration of new occupation areas, the improvement of the person’s performance in the most affected areas, developing independence and autonomy, the maintenance or promotion of current competencies and functions, and the promotion of well-being in the community.

Difference between Occupational Therapy and other areas of practice

Table 2 summarizes the mentions found in the subcategories analysed.

Occupational Therapy plays a preponderant and prominent role in a first instance, more than any other area of expertise. The OTs have sought to improve themselves theoretically, technically and politically to work in the network of mental health care services at the level of prevention and health promotion, treatment, rehabilitation and social inclusion ³⁰30. Ribeiro M, Oliveira L. Terapia Ocupacional e saúde mental: construindo lugares de inclusão social. Interface (Botucatu) 2005; 9(17):425-431. . These professionals “concentrate on the integration of the user into the community” (GF), facilitating this process of adaptation and inclusion of the individual in the therapeutic community, in the rescue of the individual’s everyday meaning, in the individual and social aspects, as the main foundation for the his/her social insertion, justified in the eight references found in the focus group made in this study. In the OT’s profile are known the skills and propensity to adapt the environment and individual for inclusion. Also Dowling and Hutchinson ³¹31. Dowling H, Hutchinson A. Occupational therapy-its contribution to social inclusion and recovery. A Life in the Day 2008; 12(3):11-14. report that Occupational Therapy is a crucial part of the recovery and social inclusion agenda of people suffering from mental illness. OTs strive to support individuals to realize their potential by enabling them to participate and contribute to society ³¹31. Dowling H, Hutchinson A. Occupational therapy-its contribution to social inclusion and recovery. A Life in the Day 2008; 12(3):11-14. . They are well positioned to support and complement these purposes, particularly because occupational science advocates access to meaningful, valued and fulfilling activities as an occupational right for all ³²32. Le Boutillier C, Croucher A. Social inclusion and mental health. British Journal of Occupational Therapy 2010; 73(3):136-139. . At the same time, OT assumes the role of daily routines builder, because “it helps to get the message of how important it is to have this well-structured routine” (GF) fostering performance in the various areas of occupation. In this context, the identification, adaptation, implementation and development of habits, rituals and routines, addressing barriers and taking advantage of existing competences, often arise as objectives of intervention of Occupational Therapy with these individuals. Indeed, it is highlighted in many publications related to mental health and the rehabilitation of individuals with substance use disorders ³³33. Garnham M, Morley M, Forsyth K, Lee S, Taylor R, Kielhofner G. Occupational therapy care packages in mental health: preparing for payment by results . London: British Association of Occupational Therapists and College of Occupational Therapists; 2010.

34. Bryant W, Fieldhouse J, Bannigan K, editors. Creek’s Occupational Therapy and Mental Health E-Book . Amsterdam: Elsevier Health Sciences; 2014.^-3535. Crouch R. Substance Use Disorders. In: Weideman Z, editor. Occupational Therapy Prescribed Minimum Benefits . Hatfield: OTASA; 2007. p. 175-177. . This concern with the necessary structuring of routines is consistent with the AOTA indications ³⁶36. Opp A. Recovery with purpose: Occupational therapy and drug and alcohol abuse . 2007. [acessado 2017 Jul 15]. Disponível em: https://www.aota.org/About-Occupational-Therapy/Professionals/MH/Articles/RecoveryWithPurpose.aspx
https://www.aota.org/About-Occupational-... ^,3737. Champagne T, Gray K. Occupational therapy’s role in mental health recovery. AOTA Fact Sheet . 2016. [acessado 2017 Jul 15]. Disponível em: https://www.aota.org/About-Occupational-Therapy/Professionals/MH/mental-health-recovery.aspx
https://www.aota.org/About-Occupational-... , looking at the individual’s functionality and well-being and, consequently, their adaptation in the contexts of life.

The occupation, the foundation of OT’s practice, provides structure and routine to our day, contributes to our dynamic sense of identity and keeps us connected to others and to the world around us. These additional aspects have also proved to be essential for health and well-being ³⁸38. Gallagher M, Muldoon O, Pettigrew J. An integrative review of social and occupational factors influencing health and wellbeing. Frontiers in psychology 2015; 6:1281. .

Continuing the analysis of the above table, it is verified that the proximity to the client is the subcategory most referenced by the five sources (GF, TO1, TO2, C1 and C2), showing a more differentiating characteristic of the other professional areas in the CTCO.The TO is considered the professional that deals more directly with the clients, having a level of proximity to them, superior to the other professionals, concretizing their work in the very contexts of these individuals (GF, TO1 and TO2): “we are there for them, in the room to sort things out with them, in cognitive stimulation to see their difficulties”(TO2).Therefore, this fact “is extremely important because they come to certain situations that we do not reach” (GF),presenting an increased capacity for observation, “a careful and trained look, in order to signal situations” (GF) that are often not detectable by the rest of the technical team (GF and TO2). Bonsaksen et al. ³⁹39. Bonsaksen T, Vøllestad K, Taylor R. The Intentional Relationship Model-Use of the therapeutic relationship in occupational therapy practice. Ergoterapeuten 2013; 56(5):26-31. have identified a large number of publications that point to a generalized understanding within the profession that success in promoting client participation in occupations depends in part on the quality of client-therapist relationship, particularly close contact with the client’s contexts. Proximity in the relationship between health professionals and clients allows to know the client and his/her needs, promoting the humanization of care and meeting the clients’ needs ⁴⁰40. Diogo P. Relação Terapêutica e Emoções: Envolvimento versus Distanciamento Emocional dos Enfermeiros. Pensar Enfermagem 2017; 21(1).^,4141. Palmadottir G. Client-therapist relationships: Experiences of occupational therapy clients in rehabilitation. British Journal of Occupational Therapy 2006; 69(9):394-401. .

Lopes and Leão ²⁸28. Lopes RE, Leão A. Terapeutas ocupacionais e os Centros de Convivência e Cooperativa: novas ações de saúde. Rev. Ter. Ocup. Univ. São Paulo 2002; 13(2):56-63 highlight another differential that specifies the practice of Occupational Therapy, such as the prioritization of the action, the process of ‘doing’, to the detriment of the final product. The authors point to professional training as a determining factor for the valuation of this professional in the new mental health services. They attribute, as a differential to Occupational Therapy, the “look”, that is, how one understands and intervenes in each situation.

Also, a total of 16 references were brought up by five sources (GF, TO1, TO2, C1 and C2), which indicate the OT as a professional motivation inducer, as it shows creativity in the proposal of activities appropriate to the difficulties and interests of each client, since they are technicians in the health area who also resort to “the arts, music, dance” (GF and TO2), using these recreational activities to “captivate the attention of the clients, motivating them, being a fundamental piece so that we can intervene later “(GF).In addition, when there is a need to modify / change the course of intervention, these professionals have this flexibility (GF). Motivation is intrinsically related to volition, one of the three subsystems that act on human behaviour. Volition has a pervasive influence on occupational life that shapes options, experiences, and feelings, and consequently behaviours. It is rooted in the client-centred intervention of Occupational Therapy and has been instilled from the beginning of OT training as a crucial investment in the process of (re)habilitation of an individual ⁴²42. Kielhofner G. Conceptual foundations of occupational therapy practice. Philadelphia: FA Davis; 2009. .

Although these characteristics have been identified as differentiating the OT’s practice from the other areas, it is crucial to raise awareness of the importance of teamwork, since, as mentioned by TO1: “The intervention must encompass all areas, work together, it is not “Occupational Therapy”, it is not “Psychology”, what each area can give enriches the treatment of the client ...” .

Conclusions

Responding to the question “To what extent does Occupational Therapy contribute to the rehabilitation of individuals with substance use disorders, in the Therapeutic Community “Clínica do Outeiro”, which served as a theme for the study, it can be concluded that the support provided by this profession plays in the life of this population, a major role at various levels, being an “area linked to health promotion, in this case, mental” (GF). Because it is a profession that brings together knowledge from various disciplines, Occupational Therapy can “be an important element in the construction of new directions for health care, integral, globalizing and in the perspective of the totality, subjectivity and uniqueness of the person” ⁴³43. Medeiros MHR. Terapia Ocupacional: um enfoque epistemológico e social . São Paulo: Hucitec; 2003 . Emphasis was given to the importance Occupational Therapy exercises in the process of meaning-making. In an initial moment is highlighted the benefit in the (re)structuring of the routine of these people, in relation to their involvement in the care of their own body, in the organization of the day to day, in the “being more active”, that is, on the client’s willingness to comply with the tasks ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. . From the point of view of a OT (TO1), it is also evident the evolution that the clients present in the level of the self-esteem, being perceptible the insecurities on the part of the individuals in the beginning of the activities. However, in the final phase they were satisfied with the results achieved. Clients add that Occupational Therapy gives them back activities of interest which motivates them to face the present (C1) and “helps a lot to forget the past” (C1). In this sense, it is reinforced that activities related to leisure and self-care provide an increase in self-esteem and facilitate the decrease of depressive mood ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. .

The effort of the Occupational Therapists, as facilitators of this process of transformation, according to the clients of the Therapeutic Community, also results in the attainment of a psychic welfare, “provokes the well-being of the person and liberates the mind” (C1) being that “when I am doing these tasks I feel good about myself” (C2). The discovery or rediscovery of significant activities mediated by Occupational Therapy can develop the necessary motivation for the change process ⁶6. Ricou M, Teixeira C. Volição em Toxicodependentes que frequentam a Unidade de Desabituação do Norte pela primeira vez e em indivíduos reincidentes. Revista Toxicodependências 2008; 14(2):25-35. “I had no interest” (C2), “Occupational Therapy gave me the opportunity to know the activities that are important to me” (C2 ), “When I have nothing to do, I start to read a book or I make a drawing or paint it” (C2).

On the other hand, relaxation, obtaining a full state was mentioned by the clients as a benefit of Occupational Therapy intervention, because “it helps me to relax a lot” (C1), “I’m already more controlled” (C2).

In conclusion, the data obtained allow us to verify that in the CTCO, from the perspective of all participants, Occupational Therapy plays a preponderant role in the process of daily reconstruction of individuals with substance use disorders. It is a contribution for the reflection of politicians, administrators and other professionals about the need of Occupational Therapists in these rehabilitation contexts.

Finally, the contribution of the qualitative approach that allows a study focused on a specific context, allowing the necessary deepening in close contact with those who are closer to the action and professionals of Occupational Therapy, stands out. Although eventually limited by a smaller extent, it is observed that what was lost in extension, was gained in particularity and quality.

Acknowledgments

This work is equitable authored by lecturers and students of the Degree in Occupational Therapy of The School of Health Sciences of the Polytechnic of Leiria - Portugal. The authors would like to thank all the professionals of the Comunidade Terapêutica Clínica do Outeiro, in particular their Occupational Therapists (year 2016).

References

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