Abstract

The growth of Brazilian therapeutic communities points to a return to the asylum paradigm, with public funding for hospitalizations based on labor therapy and religious conversion. The relationship between these institutions and government sectors has expanded since 2013 in the state of Espírito Santo, Brazil. Given this scenario, we aimed to analyze, through this qualitative research, the role of religious therapeutic communities in the treatment of individuals with problematic drug use, focusing on the impact of the religious methods employed in these places. To this end, we conducted semi-structured interviews with 28 individuals who had been treated in these places. The interviews were held for six months and subsequently transcribed in full. The data were analyzed using the Discourse Analysis. The subjects’ statements widely differed: 13 reported that institutions had an essential role in their treatment and pointed out that religious methods helped them, while 15 argued that institutions were inefficient in their treatment and religious methods were ineffective. The study elucidated the need for inspection of these institutions and stirred a reflection concerning their suitability as publicly funded places to treat the drug user population.

Key words:
Therapeutic community; Drug users; Mental health; Religion

Introduction

The Brazilian mental health care reform process is a global reference and has historically obtained several achievements¹1 Guljor APF, Amarante P. Movimentos Sociais e Luta Antimanicomial: contexto político, impasses e a agenda prioritária. Cadernos do CEAS 2017; 242:635-656., among which is the National Mental Health Law (10.216/01), which provided the protection and rights of people with mental disorders, redirecting the network of territorial services²2 Brasil. Lei nº 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental. Diário Oficial da União 2001; 6 abr.. This Law downsized psychiatric beds in the country - from 80,000 in the 1970s to as little as 25,988 in 2014 - and increased spending on psychosocial care - from 24.76% to 79.39% in the same period³3 Amarante P, Nunes MO. A Reforma Psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Cien Saude Colet 2018; 23:2067-2074..

The Psychosocial Care Network (RAPS) implementation in 2011 brings essential changes, such as free treatment in coordination between equipment. However, it also has challenges⁴4 Pande MNR, Amarante PDC. Desafios para os Centros de Atenção Psicossocial como serviços substitutivos: a nova cronicidade em questão. Cien Saude Colet 2011; 16(4):2067-2076.. In practice, such network equipment can experience integration challenges and focus their practices within the institution, maintaining an asylum-oriented guardianship and dependence rationale⁴4 Pande MNR, Amarante PDC. Desafios para os Centros de Atenção Psicossocial como serviços substitutivos: a nova cronicidade em questão. Cien Saude Colet 2011; 16(4):2067-2076..

These hardships are sometimes used as justifications by managers for divestments in RAPS in a contentious setting⁵5 Farias LL. Estado, contrarreforma e as políticas de saúde e saúde mental no Brasil. Argum Vitória 2019; 11(3):47-66.. Brazil has been undergoing an escalating dismantling of its social policies in recent years, involving historical underfunding, definancing, and setbacks with the implementation of Constitutional Amendment 95/2016⁶6 Brasil. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias para instituir o Novo Regime Fiscal e dá outras providências. Diário Oficial da União 2016; 15 dez..

In this context, we have the approval of Resolution No. 32/2017, which determined the return of the psychiatric hospital to the treatment network with readjustment of daily rates and expansion of vacancies in Therapeutic Communities (TCs) - intended for drug abusers - from 4 thousand to 20 thousand⁷7 Brasil. Ministério da Saúde (MS). Comissão Intergestores Tripartite. Resolução n° 32, de 14 de dezembro de 2017. Estabelece as Diretrizes para o Fortalecimento da Rede de Atenção Psicossocial (RAPS). Diário Oficial da União 2017; 14 dez.. TCs emerged in England in the mid-twentieth century, when the physician Maxwell Jones started the worldwide Psychiatric Reform movement, developing a TC model that aimed at greater patient participation in their treatment process and opposed the history of enclosure of allegedly socially maladjusted individuals⁸8 Lima RCC. Comunidades terapêuticas e a saúde mental no Brasil: um encontro possível? In: Vieira LLF, Rios LF, Queiroz TN, organizadores. A problemática das drogas: contextos e dispositivos de enfrentamento. Recife: Universidade Federal de Pernambuco; 2016. p. 142-171..

However, the expansion of these Brazilian institutions, which have been present since the 1960s, has been accompanied by alleged violations of the most basic human rights⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017.^,1010 Conselho Federal de Psicologia (CFP). Mecanismo Nacional de Prevenção e Combate à Tortura. Procuradoria Federal dos Direitos do Cidadão / Ministério Público Federal. Relatório da Inspeção Nacional em Comunidades Terapêuticas - 2017. Brasília: Conselho Federal de Psicologia; 2018.. Nevertheless, since 2011, TCs have been part of RAPS in the country¹¹11 Brasil. Ministério da Saúde (MS). Lei nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde. Diário Oficial da União 2011; 23 dez.. Amid the discourse of war against crack consumption, initiated in 2010 by the media and politicians, these institutions emerged and put pressure on the Federal Executive Branch to integrate them into drug user care⁸8 Lima RCC. Comunidades terapêuticas e a saúde mental no Brasil: um encontro possível? In: Vieira LLF, Rios LF, Queiroz TN, organizadores. A problemática das drogas: contextos e dispositivos de enfrentamento. Recife: Universidade Federal de Pernambuco; 2016. p. 142-171..

A set of documents are required as a multistep process, among which we highlight: Ordinance No. 131, which established financing for TCs¹²12 Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria n° 131, de 26 de janeiro de 2012. Institui incentivo financeiro de custeio destinado aos Estados, Municípios e ao Distrito Federal para apoio ao custeio de Serviços de Atenção em Regime Residencial, incluídas as Comunidades Terapêuticas, voltados para pessoas com necessidades decorrentes do uso de álcool, crack e outras drogas, no âmbito da Rede de Atenção Psicossocial. Diário Oficial da União 2012; 26 jan.; Resolution No. 01 of the National Drug Council (CONAD), which regulated TCs within the National System of Public Drug Policies (SISNAD)¹³13 Brasil. Presidência da República. Gabinete de Segurança Institucional. Conselho Nacional de Políticas sobre Drogas. Resolução nº 01, de 19 de agosto de 2015. Regulamenta, no âmbito do Sistema Nacional de Políticas Públicas sobre Drogas, as entidades que realizam o acolhimento de pessoas com problemas associados ao uso nocivo ou dependência de substância psicoativa, caracterizadas como comunidades terapêuticas. Diário Oficial da União 2015; 19 ago.; Ordinances N° 834/2016 and 1482/2016, which allowed TCs to request tax exemption through the Certification of Charitable Social Assistance Entities (CEBAS) in the health field¹⁴14 Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria nº 834, de 26 de abril de 2016. Redefine os procedimentos relativos à Certificação das Entidades Beneficentes de Assistência Social na área de Saúde. Diário Oficial da União 2016; 26 abr. and be included in the Table of Types of Health Establishments of the National Registry of Health Establishments (CNES)¹⁵15 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Portaria nº 1.482, de 25 de outubro de 2016. Inclui na Tabela de Tipos de Estabelecimentos de Saúde do Cadastro Nacional de Estabelecimentos de Saúde o tipo 83 - Polo de Prevenção de Doenças e Agravos de Promoção da Saúde. Diário Oficial da União 2016; 25 out.; and Decree N° 9.761, which approved the new National Drug Policy, with a provision for additional investment for TCs¹⁶16 Brasil. Atos do Poder Executivo. Decreto nº 9.761, de 11 de abril de 2019. Aprova a Política Nacional sobre Drogas. Diário Oficial da União 2019; 11 abr..

The regulations point to a return to the asylum paradigm, with public funding for prolonged hospitalization and deprived freedom for individuals¹⁷17 Perrone PAK. A comunidade terapêutica para recuperação da dependência do álcool e outras drogas no Brasil: mão ou contramão da reforma psiquiátrica? Cien Saude Colet 2014; 19(2):569-580.. There is a return to ethical treatment based on labor therapy and religious philanthropy: 82% of TCs in the national territory are linked to churches, especially those with a Christian matrix⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017.. Some TCs impose a strict prayer routine and mandatory participation in religious activities¹⁰10 Conselho Federal de Psicologia (CFP). Mecanismo Nacional de Prevenção e Combate à Tortura. Procuradoria Federal dos Direitos do Cidadão / Ministério Público Federal. Relatório da Inspeção Nacional em Comunidades Terapêuticas - 2017. Brasília: Conselho Federal de Psicologia; 2018.. Even so, the State has supported these religious entities, contrary to their secular character, provided for in the 1988 Federal Constitution¹⁸18 Brasil. Presidência da República. Casa Civil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out..

Another important aspect is that Brazilian TCs are hardly inspected, even when they receive public resources¹⁰10 Conselho Federal de Psicologia (CFP). Mecanismo Nacional de Prevenção e Combate à Tortura. Procuradoria Federal dos Direitos do Cidadão / Ministério Público Federal. Relatório da Inspeção Nacional em Comunidades Terapêuticas - 2017. Brasília: Conselho Federal de Psicologia; 2018., and their regulations do not have a team of professionals to deal with drug-abusing individuals¹³13 Brasil. Presidência da República. Gabinete de Segurança Institucional. Conselho Nacional de Políticas sobre Drogas. Resolução nº 01, de 19 de agosto de 2015. Regulamenta, no âmbito do Sistema Nacional de Políticas Públicas sobre Drogas, as entidades que realizam o acolhimento de pessoas com problemas associados ao uso nocivo ou dependência de substância psicoativa, caracterizadas como comunidades terapêuticas. Diário Oficial da União 2015; 19 ago.^,1616 Brasil. Atos do Poder Executivo. Decreto nº 9.761, de 11 de abril de 2019. Aprova a Política Nacional sobre Drogas. Diário Oficial da União 2019; 11 abr..

From this setting, Brazilian society faces the challenge of knowing how the experiences of individuals in these places have been taking place. This paper analyzes the role of religious TCs in the recovery of drug-abusing individuals, focusing on the impacts of religious methods for subjects who have resided in these institutions in the state of Espírito Santo. Thus, this work is structured as a brief presentation about the TCs in this state, the research’s methodological paths, and the results obtained from the analysis.

Therapeutic communities in the state of Espírito Santo

The state of Espírito Santo covers a total area of 46,074.444 km²2 Brasil. Lei nº 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental. Diário Oficial da União 2001; 6 abr., distributed into 78 municipalities, and a total population estimated at 3,972,388 inhabitants¹⁹19 Instituto Brasileiro de Geografia e Estatística (IBGE). Estimativas da população residente no Brasil e unidades da federação com data de referência em 1° de julho de 2018. Rio de Janeiro: Fundação IBGE; 2018.. Compared to other Brazilian states, the state is characterized by a significant presence of Pentecostal evangelicals and currents of mission evangelicals due to the strong influence of colonization of German origin in the region²⁰20 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico - Características Gerais da População e Instrução 2010 (resultados da amostra). Rio de Janeiro: Fundação IBGE; 2010..

TCs from Espírito Santo have always maintained a relationship with the state apparatus²¹21 Garcia MLT, Silva JA. Comunidades Terapêuticas Religiosas de tratamento de Dependência Química no Estado do Espírito Santo. Jornal Brasileiro de Psiquiatria 2004; 53(4):243-252.. However, as of 2013, through the launch of the “State Program of Integrated Actions on Drugs”, the state government provided for partnerships between the third sector, municipalities, the Federal Government, and households²²22 Leal FX, Santos CCM, Jesus RS. Política Sobre Drogas no Estado do Espírito Santo: consolidando retrocessos. Textos Contextos 2016; 15(2):423-436.. A reception center that refers drug-abusing individuals to hospitalization was created, with accredited TCs being one of the possibilities. Subsequently, the program became the “Integrated Program for the Valorization of Life (PROVIV)” under the responsibility of the State Secretariat for Human Rights (SEDH), as per information from the SEDH website.

There is also a financial investment, funded by the Espírito Santo State Health Secretariat (SESA), in hospitalizations via legal measures in private clinics to treat people with mental disorders and drug users. According to data from the Espírito Santo Transparency Portal, in 2018, spending was BRL 41,332,558.84 and BRL 35,173,587.14 in 2019. According to a diagnosis produced by that Secretariat, in 2017, we had 724 hospitalizations of this type, approximately 94% of them due to drug use and only 6% of them due to other causes²³23 Secretaria do Estado da Saúde do Espírito Santo (SESA). Subsecretaria de Regulação e de Organização da Atenção à Saúde. Gerência de Regulação e Ordenação do Sistema de Saúde. Diagnóstico da morbimortalidade dos transtornos mentais, dependências de álcool e outras drogas no Espírito Santo; 2018..

Meanwhile, RAPS has a shortage of Psychosocial Care Centers for Alcohol and Other Drugs (CAPS ad) - strategic devices for the care of patients with alcohol and other drug abuse²⁴24 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Coordenação Geral de Saúde Mental. Reforma psiquiátrica e política de saúde mental no Brasil. Documento apresentado à Conferência Regional de Reforma dos Serviços de Saúde Mental: 15 anos depois de Caracas/ Ministério da Saúde. Brasília: MS; 2005. -, beds in general hospitals and care units in all the administrative regions of the state²³23 Secretaria do Estado da Saúde do Espírito Santo (SESA). Subsecretaria de Regulação e de Organização da Atenção à Saúde. Gerência de Regulação e Ordenação do Sistema de Saúde. Diagnóstico da morbimortalidade dos transtornos mentais, dependências de álcool e outras drogas no Espírito Santo; 2018., characterizing disputes over public funding of treatment of drug users.

In this scenario, the prioritization of TCs reinforces our objective of analyzing their role in the recovery of these individuals, focusing on the impacts of religious methods on subjects who previously stayed in these institutions.

Methods

This qualitative research involves semi-structured interviews with individuals with a drug use history and former members of religious TCs. We conducted 28 interviews: 21 of them based on the indication of professionals from CAPS ad in the Metropolitan region (Vitória, Vila Velha, and Serra) - a region with the highest concentration of drug user treatment institutions in the state²³23 Secretaria do Estado da Saúde do Espírito Santo (SESA). Subsecretaria de Regulação e de Organização da Atenção à Saúde. Gerência de Regulação e Ordenação do Sistema de Saúde. Diagnóstico da morbimortalidade dos transtornos mentais, dependências de álcool e outras drogas no Espírito Santo; 2018. - and seven through indication of professors and researchers from a research group on the topic of drug use to diversify the sample.

The semi-structured interview roadmap consisted of sociodemographic data (date of birth, schooling level, marital status, and religion (if any)) and open-ended questions to draw the hospitalization period and the post-hospitalization period in the TCs. The roadmap was tested in a pilot interview, which was incorporated into the sample after verifying that it met the research objectives. A preset number of individuals to be interviewed was not established. The sample size was defined by theoretical saturation when data collection is interrupted when no new elements to support the desired theorization were provided²⁵25 Pires AP. Amostragem e pesquisa qualitativa: ensaio teórico e metodológico. In: Poupart J, Deslauriers JP, Groulx, LH, Lapemère A, Mayer R, Pires AP, organizadores. A pesquisa qualitativa: enfoques epistemológicos e metodológicos. Petrópolis: Editora Vozes; 2008. p. 154-211..

The interviews were conducted between October 2017 and March 2018, without interruptions and exclusions, with an average time of 40 minutes each. All interviews were recorded by an audio recorder and transcribed in full. The sharing of transcripts with the participants for comments or corrections was not provided for in the research due to the difficulty of scheduling visits with the respondents and the impossibility of doing it remotely because most of them do not have an email address or access to the Internet.

All data were collected by the principal researcher - a doctoral student and higher education professor - in closed rooms at CAPS ad or the university. The researcher had no previous relationship with the participants. No third parties were present during the interviews, and there was no need to repeat any interviews.

Besides the interviews, from the perspective of data triangulation²⁶26 Morrow S. Quality and trustworthiness in qualitative research in counseling psychology. J Couns Psych 2005; 52(2):250-260., we searched in the respondents’ medical records indicated by the professionals to gather information regarding: 1. Sociodemographic data (name, date of birth, gender, schooling, religion, and access to social benefits); 2. The access route to health services; 3. Registration of admissions in TCs. This information was necessary before the interviews to obtain telephone contact for the indicated subjects; and, after the interviews, to complement the information already obtained or clarify doubts.

The Discourse Analysis was employed²⁷27 Bakhtin M. Estética da criação verbal. Os gêneros do discurso. 2ª ed. São Paulo: Martins Fontes;1997. to analyze data without any filing. After transcription, we read all the interviews to familiarize ourselves with the several discursive forms used by the subjects and identify meanings and ruptures in the material. Next, we identified analytical devices for accepting and denying TCs and their religious methods. Finally, we apprehended the ideological formations that permeated the respondents’ discourses - a set of representations that originate the rules outlining discourse production in a context²⁷27 Bakhtin M. Estética da criação verbal. Os gêneros do discurso. 2ª ed. São Paulo: Martins Fontes;1997..

The Research Ethics Committee of the Federal University of Espírito Santo (Opinion N° 2.333.891) and the Municipal Health Secretariats of Vitória, Vila Velha, and Serra approved the project. Fictitious names replaced subjects’ names, and all agreed to sign the Informed Consent Form (ICF).

Results

Respondents were primarily male (20), aged between 21 and 56 years. Regarding schooling, 12 had incomplete (nine) or complete (three) elementary school, 14 had incomplete (three) or complete (11) high school, and four had incomplete (three) or complete (one) higher education. Most respondents were black. The length of stay and the number of hospitalizations in the TCs varied among the participants, which is not a determining aspect for the proposed analysis.

Their statements differed around the evaluation of their experiences within the TCs. These were organized into two axes: positive and negative evaluation. As it is not just a straight “yes” or “no”, part of a group had a varying outcome - the respondents evaluated it positively but criticized it.

Salvation by faith

Part of the respondents (13 respondents) pointed that the TC experience was positive, as follows:

It was a perfect place, a place where I learned a lot. [...] They don’t give medicines there, right? You are treated through the word of God: preaching and worship. It’s for God’s sake. No medicine, nothing. So, it was good for me to have stayed there. (Davi)

We get better after we get in there, got it? The pastor will guide you, telling you that now it will be a new life, that you will change, that you are already someone else after you crossed the gate. You are no longer that person you used to live there looking out for drugs. (Alexandre)

In these cases, the positive experiences were associated with accepting the religious methods they endured since, according to their statements, a new connection to God and a valued contact with His word in the worshipping moments could be observed within these locations. Resorting to God to stop using drugs appeared as the only alternative for some. In this sense, what appeared after their religious conversion was their dependence on God in many areas of their lives. The conversion was expressed as a process where one is “born again”, a discourse very present in the statement of these respondents, which materialized through substantial changes in their lives from communicating with God:

And change happened from the moment I accepted Jesus. I did some soul searching: it’s not easy. You really want to use them (drugs), but you try to find other ways, and the only way I found it was to cling to Jesus. [...] So, within three months, I started to read a lot, to read the Bible, to search and pray [...]. I saw it was coming in, impregnating me. That’s how my life changed. (Miguel)

Accepting Jesus is the repeated mantra that points to conversion, understood as the highest point in assimilating the teachings accessed within the TCs. For evangelicals, the conversion consists of rebirth, from evident changes that usually occur when people are repentant and seek a solution to a disruptive situation, convinced that God would help them²⁸28 Bittencourt L. Escravos de Deus: algumas considerações sobre toxicomania e religião evangélica. In: Baptista M, Cruz MS, Matia R, organizadores. Drogas e pós-modernidade. Rio de Janeiro: EdUERJ; 2003. p. 265-273.. Respondents also started to associate drug use with the influence of the devil and other evil forces, through the invitation to use made by the devil disguised as a man:

Look how the adversary disturbs us. At that time, I was not an evangelical. [...] from that door out, there will be many trays; trays are the friends who will see you. They will say ‘where were you, man?’, [...] Then they will introduce you to drugs and cachaça. ‘Oh, don’t worry. One sip won’t make a difference’. That’s where you fall [...] So, I said in my mind, ‘Satan is rebuked, in the name of Jesus! (Silvia)

Blaming the “foe” for the use of drugs, the respondent’s distancing from the understanding of the phenomenon of drugs in society was perceived, a distancing from the millenary history of drug use and capitalism’s empowerment of these substances as goods²⁹29 Souza DO. A questão do "consumo de drogas": contribuições para o debate. Serv. Soc Saude 2012; 11(2):269-286.. With this process of moving away, what was left was to rebuke and watch over the evil force, moving away from ways of life that did not resemble the God’s Word.

The act of entrusting to deities and religions the solution to problems or the responsibility for what happens to them can be understood as a strategy of human beings who live in a situation that exploits and oppresses them. Once inserted in such reality, they need illusions to survive³⁰30 Marx K. Crítica da Filosofia do Direito de Hegel. São Paulo: Boitempo; 2005.. In this sense, men dream of a fantasy world and project their essences onto a superior being, perhaps because they are unable to see, in the real-life of society, the conditions for developing their humanity³¹31 Chagas EF. A crítica da religião como crítica da realidade social no pensamento de Karl Marx. Trans/Form/Ação 2017; 40(4):133-154..

Such movement denoted a self-distancing of these respondents as social beings, a movement of inhumanity, which was socially constructed in their daily lives³²32 Lukács G. Para uma ontologia do ser social II. São Paulo: Boitempo; 2013.. In a social and political dimension, as an expression of man’s alienation from his real world, this process can be understood as alienation that sometimes contributes to the perpetuation of a given society³³33 Marx K, Engels F. A Ideologia Alemã. São Paulo: Boitempo; 2007.. We can observe this self-distancing in the reports mentioned above. However, sometimes, even defending TCs as beneficial in their treatments, some (four) individuals criticized the institutions.

I have my caveats against this salvation process

Part of these 13 respondents criticized the TCs. The main complaints were the food served, staff’s authoritarianism, the lack of inspections, and residents’ exploitation in exhaustive and compulsory work. Regarding the last aspect, the most mentioned by these participants, the criticisms referred to the work for the internal maintenance of institutions, such as cleaning, weeding, food preparation, and work carried out outside the TCs, such as the sale of products in collective vehicles. Such activities are called “labor therapies” and are one of the main working methods of these institutions and are justified as they promote discipline and change the habits of residents³⁴34 De Leon G. A Comunidade Terapêutica: teoria, modelo e método. São Paulo: Loyola; 2003..

Labor therapy is used in more than 90% of Brazilian TCs⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017.. It is far from care-based methodologies because, among other aspects, it is not formulated on a technical, theoretical, or scientific basis. It is also not part of the singularities of each individual since, in most institutions, there is a lack of a singular therapeutic project¹⁰10 Conselho Federal de Psicologia (CFP). Mecanismo Nacional de Prevenção e Combate à Tortura. Procuradoria Federal dos Direitos do Cidadão / Ministério Público Federal. Relatório da Inspeção Nacional em Comunidades Terapêuticas - 2017. Brasília: Conselho Federal de Psicologia; 2018.. Also, TCs are prohibited from submitting those receiving shelter to forced or exhaustive activities, subjecting them to degrading conditions¹³13 Brasil. Presidência da República. Gabinete de Segurança Institucional. Conselho Nacional de Políticas sobre Drogas. Resolução nº 01, de 19 de agosto de 2015. Regulamenta, no âmbito do Sistema Nacional de Políticas Públicas sobre Drogas, as entidades que realizam o acolhimento de pessoas com problemas associados ao uso nocivo ou dependência de substância psicoativa, caracterizadas como comunidades terapêuticas. Diário Oficial da União 2015; 19 ago..

Furthermore, when they were activities that generated money for the institutions, individuals felt exploited, as they did not consider that the profit obtained from sales was used for the benefit of the residents, but only for the benefit of the managers. Such annoyance was enhanced when the residents were aware that the TC received different types of resources to operate:

How did I feel? Pay to work for others? I’m really telling the truth, right? [...] I worked in the fields, a farm there that I had to clear, take the scythe and pull it out, understand? I paid two minimum wages and a staple food basket, besides the government that contributed. (Reinaldo)

According to a report by the Institute for Applied Economic Research (IPEA) (2017)⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017., 25% of the existing TCs in the country receive public funds. Furthermore, we have that 75.4% of the places receive donations from people who support the cause, 66.6% receive voluntary contributions from the residents’ relatives, and 63.5% receive church donations⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017.. Even in the face of funding, 46% of national TCs charge a monthly fee to the sheltered ones, and, despite this, they keep the place’s maintenance activities under the responsibility of residents⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017..

It is important to emphasize that such criticisms did not lead them to evaluate the general experience lived within the institutions negatively. Thus, these 13 respondents assessed TCs as institutions that helped them in their drug abuse treatment, and all of them showed great acceptance of the religious methods accessed during admissions.

A swamp in the search for help

Unlike these participants, other 15 respondents in the survey expressed that the passage through the TCs did not play a positive role in their recovery processes and TCs were not efficient institutions for the treatment of drug abuse:

I am going say it straight out. I didn’t learn anything there. I used even more drugs. It didn’t do me any good. I just went to make my family know I was there just as make-believe...just to cheer them up, understand? (Reinaldo)

So, it was nothing. After I left there, the time I was there didn’t add anything to me. (Débora)

These respondents criticized and rejected the institutions’ religious methods such as prayers, cults, and biblical exercises. They stated that prayers were not adequate for the treatment and criticized reading and interpreting the Bible, not generally agreeing with the understanding given to them by the leaders. They opposed the path of religious salvation, to the idea that God supplies everything and, thus, a relationship of dependence with Him in all areas of life:

There is no such thing as the devil, demon, and the like. Don’t spiritualize everything, no. ‘You’re using it because it’s the devil; you’re possessed, it’s the demon that put an arrow in you’. It has nothing to do with it. I want to do this [...], so I have to work with this desire of mine and this desire to deny what I feel. It is elementary for me to transfer my guilt to others, which is much simpler. (Bruno)

The respondent fought against a view among neo-Pentecostalism adherents: that everything that happens on the earthly plane derives from what happens on the spiritual plane³⁵35 Mariano R. Guerra espiritual: o protagonismo do diabo nos cultos neopentecostais. Debates do NER 2003; (4):21-34.. This belief alleviates our guilt, our responsibility, and our autonomy in the face of the world³⁵35 Mariano R. Guerra espiritual: o protagonismo do diabo nos cultos neopentecostais. Debates do NER 2003; (4):21-34.. For the participant, it is necessary to leave the scope of “it’s God’s will” or “because the devil wished so”. However, when stating, “I want to do this”, he mentions a single dimension of drug use and leaves out the social and economic dimensions. In other words, polarization masks the multiple dimensions in the drug-human relationship.

These participants also opposed the rules of the institutions, reporting, above all, discomfort with the control to which they were submitted, with the deprivation of freedom and with the authoritarianism of employees in the institutions:

So, I lived this terror. Obliged to have to do...you have to get up. You have to do your work. You have to be at the table. You have to do this. You have to do that right away: an obligation, you know? They don’t let us think about anything or stop and think... even that, even that they keep watch, God is more! [...]. I couldn’t talk on the phone. I couldn’t contact my family. It looks like you’re defeating yourself there. (Rita)

Look, a violation is that constant of you not being able to leave, right. I never liked being stuck, not having access to the street. (Adriano)

Such reports meet the characteristics of most Brazilian TCs: 35% of them allow family visits from the onset of treatment; the others establish temporal rules and, sometimes, participation in preparatory activities⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017.. Only 5% of locations allow visits at any time⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017.. Some also prevent contact with friends (17%) and boyfriends/girlfriends (11%)¹⁰10 Conselho Federal de Psicologia (CFP). Mecanismo Nacional de Prevenção e Combate à Tortura. Procuradoria Federal dos Direitos do Cidadão / Ministério Público Federal. Relatório da Inspeção Nacional em Comunidades Terapêuticas - 2017. Brasília: Conselho Federal de Psicologia; 2018.. In this research, participants reported that visits took place on specific dates and were monitored.

Concerning the means of communication, 91% of the TCs do not allow the residents to use a cell phone, and 86% do not allow internet access. Some also prohibit access to television (7%), books, magazines, and newspapers (39%)⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017.. This research obtained reports that the programming that could be accessed on television was only religious, previously selected by the leaders of the institutions. Access to books was restricted to the Bible.

Regarding discipline, we can note that TCs have a series of obligations, which consist of compulsory participation in therapeutic activities, including courses (60%), religious ceremonies (53%), and labor therapy tasks (73%)⁹9 Instituto de Pesquisa Econômica Aplicada (IPEA). Diretoria de Estudos e Políticas do Estado, das Instituições e da Democracia. Nota Técnica nº 21. Perfil das comunidades terapêuticas brasileiras. Rio de Janeiro: IPEA; 2017..

Contrary to the Psychiatric Reform, TCs are similar to total institutions, defined by Goffman³⁶36 Goffman E. Manicômios, prisões e conventos. São Paulo: Perspectiva; 2005. as places of residence and work where a large number of individuals, separated from society, lead a closed and formally managed life. Thus, TCs resemble total institutions in several aspects, especially in social isolation and discipline, as they lead to a loss of individuality and subjectivity of subjects who start to be controlled at all times³⁷37 Natalino MAC. Isolamento, disciplina e destino social em comunidades terapêuticas. In: Instituto de Pesquisa Econômica Aplicada (IPEA), Santos MPG, organizadores. Comunidades terapêuticas: temas para reflexão. Rio de Janeiro: IPEA; 2018. p. 37-61..

All these characteristics violate what is provided for in CONAD Resolution N° 01/2015, according to which TCs must ensure the participation of the family or person indicated by the patient in the reception process and social reintegration actions¹⁴14 Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria nº 834, de 26 de abril de 2016. Redefine os procedimentos relativos à Certificação das Entidades Beneficentes de Assistência Social na área de Saúde. Diário Oficial da União 2016; 26 abr.. Furthermore, they violate the 1988 Federal Constitution of 1988, which includes under its principles human dignity¹⁹19 Instituto Brasileiro de Geografia e Estatística (IBGE). Estimativas da população residente no Brasil e unidades da federação com data de referência em 1° de julho de 2018. Rio de Janeiro: Fundação IBGE; 2018.; and the Bill of Rights of Health Users, which advocates that every citizen has the right to adequate, respectful, humanized, and effective treatment, free from any discrimination³⁸38 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde. Carta dos direitos dos usuários da saúde. 3ª ed. Brasília: MS; 2011..

These participants also criticized labor therapy, mentioning that they felt exploited. Other criticisms of the institutions were identified: reports on the directors’ appropriation of money and belongings of patients received; mention of drug use within one of the TCs by employees, coordinators, and residents; and physical violence perpetrated against the patients. These reports lead us to question the fundamental objectives of some of these institutions since promoting drug use is something that opposes the objective to which the TCs are publicly committed: the spiritual rebirth of individuals, traversing abstinence as an essential condition for that goal.

In a punitive and moral approach, the use of violence and punishment towards residents is based on the understanding that the drug user is an offender, a violator of limits, or even a sinner in need of harsh and merciless correction³⁷37 Natalino MAC. Isolamento, disciplina e destino social em comunidades terapêuticas. In: Instituto de Pesquisa Econômica Aplicada (IPEA), Santos MPG, organizadores. Comunidades terapêuticas: temas para reflexão. Rio de Janeiro: IPEA; 2018. p. 37-61..

It is important to emphasize that, while these respondents denied TCs and their religious methods as a treatment option, four of them recognized that religion could play an essential role for those who seek to abandon or reduce drug use, but not within TCs’ compulsory schemes.

These participants recognized the religious spaces of society as a source of social support. According to Valla et al.³⁹39 Valla VV, Guimarães MB, Lacerda A. Religiosidade, apoio social e cuidado integral voltado à saúde: uma proposta de investigação voltada para as classes populares. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Abrasco; 2006. p. 103-117., these places offer support groups and create motivations for individuals, especially in poverty, to face their problems in a society that daily denies them opportunities. Evangelical churches stand out in this type of support because they represent the working classes, promote a sense of group belonging, and disseminate an optimistic perspective of life³⁹39 Valla VV, Guimarães MB, Lacerda A. Religiosidade, apoio social e cuidado integral voltado à saúde: uma proposta de investigação voltada para as classes populares. In: Pinheiro R, Mattos RA, organizadores. Cuidado: as fronteiras da integralidade. Rio de Janeiro: Abrasco; 2006. p. 103-117..

Notwithstanding this, these respondents considered the religious spaces a complement to treatment, as they include drug abuse as a health issue. They reported that they only improved with the monitoring of professionals in this field, and the most mentioned equipment was the CAPS ad, as it provided free treatment for individuals.

In a nutshell, these 15 individuals did not recognize that TCs and their methods were efficient for drug use treatment. On the other hand, they advocated the understanding of drug use as a health issue, which should be monitored professionally, with respect, and without the need for deprivation of liberty.

Conclusion

The research evidenced discourses regarding the role of religious TCs: 13 respondents reported that institutions played an essential role in their treatment processes, and 15 respondents argued that the institutions were inefficient in their treatment. Regarding the impacts of the religious methods accessed inside the places, we could apprehend that the same 13 participants mentioned advocated that the moments of prayer and reading of the Bible helped them, whereas the other 15 participants reported that these methods were ineffective.

Thus, on the one hand, these subjects indicated a relationship between acceptance of religious methods and positive evaluations of admissions and the denial of religious methods and negative evaluations of admissions, on the other. Such associations do not seem random since one of the pillars of Brazilian TCs is the moral-spiritual-religious restoration of individuals. When this principle is denied, it is as if, in general, the institution was being denied as a possibility of treatment.

We emphasize that the respondents who incorporated the religious ideology started to attribute the events of their lives to the spiritual plane, a “spiritual war” waged between good and evil, whose leading figures are not human beings, but God and the devil/demons. These ideas denote alienation: the distancing of the social being and the detachment from social life with its historical relations of power, class struggle, and economic structure.

To morally transform subjects, TCs focus on conversion. They impose an understanding of drug use as an individual issue, associated with sin and the interference of malignant forces, on an alienating trajectory of such a complex phenomenon. Under the devil’s guise, the man-drug relationship takes on explanatory particularities and specific prescriptions for overcoming it.

In turn, in its social and political dimension, religion acts as an expression of man’s alienation from his real-world and social conformation with this world, perpetuating a given society as an anesthetic that paralyzes individuals in the service of capitalism³⁴34 De Leon G. A Comunidade Terapêutica: teoria, modelo e método. São Paulo: Loyola; 2003..

Although this alienation observed in religious TCs caused the respondents to distance themselves from themselves, it also caused, for some, an approximation of explanations that could provide emotional comfort, social support, and hope for a better life. Thus, we understand that we cannot reduce religiosity to mere alienation in its negative sense⁴⁰40 Vasconcelos EM, Lima RCC. Apresentação: A importância da produção acadêmica e do debate sobre as religiões/espiritualidades na atual conjuntura social e política brasileira e, particularmente, na política de drogas. In: Vasconcelos EM, Lima RCC, organizadores. Religiões e o paradoxo apoio social. Intolerância, e implicações na política de drogas e comunidades terapêuticas. São Paulo: Hucitec; 2019. p.13-31..

We could also observe that both respondents who rated the TCs positively and negatively criticized the institutions, especially about food, staff’s authoritarianism, the routine of activities to which they were submitted, and the lack of inspection of the spaces. Besides these criticisms, other complaints about violence and drug use within the TC were also made, but only by those who denied these institutions as a place of care and treatment. They advocated the treatment in freedom, in health facilities, with access to qualified professionals, and medication use, commonly citing the CAPS ad as an example. The participants’ criticisms and the fact that these institutions are increasingly accessing public funding point to the urgent need to be properly inspected by the government.

Also, we highlight the importance of research dedicated to an in-depth understanding of the functioning of Brazilian TCs, especially those that do not use forced labor or other impositions, since some individuals claimed to have benefited from the treatment accessed. The limits of this work were found within the experiences reported by the former residents, not covering a study of the institutions themselves, which can be better exposed to avoid generalizations.

We also emphasize the importance of studies that assess the effectiveness of TCs concerning the abstinence of drug abusers since the data pointed to a trend that, in most cases, abstinence was not maintained when the users left the institutions.

Finally, given the objectives and working methods of the religious TCs, there remains a debate about their relevance as publicly funded places for the treatment of the drug user population. The reports here express the need not to naturalize moralistic, standardizing, and authoritarian practices and theories found in our society.

References

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