ABSTRACT

This research aimed to give visibility to the Adult Reception Units (UAA), in order to provide greater quality and context to the production of knowledge about them. This study was carried out from an exploratory case study on a UAA, located in the state of Rio de Janeiro, a transitional residential health service for users of alcohol and/or other drugs. Participatory observation techniques, documentary surveys, and open interviews with users and professionals were used for data collection. A description of the structure of this service, its operation and the relationship with other services, and the territory in which it is inserted are presented. Based on the results, it can be said that Adult Reception Units are a territorial-based service that follows the logic of psychosocial care, considering the subjectivity and context of each user, affirming itself as a care modality that is opposed to the logic of confinement and prohibition of ‘therapeutic communities’. It was also observed that the UAA allows changes in the forms of relationship between the community and users of psychoactive substances.

KEYWORDS:
Mental health; Harm reduction; Public health services; Sociocultural territory

Introduction

Health care for drug users has historically been marked by a repressive look, with hospitalization as a treatment method and abstinence as a goal to be achieved.

In Brazil, public health policies that help this population are recent. It was only in 2002 that they were implemented by the Ministry of Health, with the expansion and diversification of health care for drug users. The conception and prevention strategies have undergone some changes over the years, mainly from the movement of harm reduction¹1 Vaissman M, Ramôa M, Serra ASV. Panorama do Tratamento dos usuários de drogas no Rio de Janeiro. Saúde debate. 2008; 32(78-79-80):121-132.^,22 Passos EH, Souza TP. Redução de Danos e saúde pública: construções alternativas à política global de "guerra as drogas". Psicol. Soc. 2011; 23(1):154-162..

In 2006, the ‘new drug law’, Law No. 11343/06, came into force, bringing as one of the main provisions the prescription of measures for prevention, care, and social reintegration. The law also establishes punishments in a different way for those who use the drug for personal consumption and those who supply or produce it. However, the aspect of criminalization and repression of drug use and possession was maintained³3 Brasil. Lei nº 11.343, de 23 de agosto de 2006. Institui o Sistema Nacional de Políticas Públicas sobre Drogas - Sisnad; prescreve medidas para prevenção do uso indevido, atenção e reinserção social de usuários e dependentes de drogas; estabelece normas para repressão à produção não autorizada e ao tráfico ilícito de drogas; define crimes e dá outras providências. 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. 24 Ago 2006.^,44 Neves AGS. As políticas públicas de álcool e outras drogas no Brasil: uma análise da construção política de 1990 a 2015 [tese]. Rio de Janeiro: Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública Sergio Arouca; 2018. 123 p..

In the midst of advances and setbacks, there was a conflict regarding the attention to drug users. On the one hand, the prohibitionist policy, which focuses on considering the substance illicit and is based on actions of repression and criminalization; on the other hand, harm reduction policies that, through a set of strategies, aim to reduce health, social and economic damage related to the consumption of alcohol and other drugs, without necessarily reducing their consumption²2 Passos EH, Souza TP. Redução de Danos e saúde pública: construções alternativas à política global de "guerra as drogas". Psicol. Soc. 2011; 23(1):154-162..

The clashes continued to recur among these models, and in 2019, Federal Law No. 13840 amends the aforementioned law of 2006, which reinforces the focus on abstinence, dedicating itself to dealing with the modalities of hospitalization and strengthening the expansion of therapeutic communities⁵5 Brasil. Lei nº 13.840, de 05 de junho de 2019. Altera as Leis nos 11.343, de 23 de agosto de 2006, 7.560, de 19 de dezembro de 1986, 9.250, de 26 de dezembro de 1995, 9.532, de 10 de dezembro de 1997, 8.981, de 20 de janeiro de 1995, 8.315, de 23 de dezembro de 1991, 8.706, de 14 de setembro de 1993, 8.069, de 13 de julho de 1990, 9.394, de 20 de dezembro de 1996, e 9.503, de 23 de setembro de 1997, os Decretos-Lei nos 4.048, de 22 de janeiro de 1942, 8.621, de 10 de janeiro de 1946, e 5.452, de 1º de maio de 1943, para dispor sobre o Sistema Nacional de Políticas Públicas sobre Drogas e as condições de atenção aos usuários ou dependentes de drogas e para tratar do financiamento das políticas sobre drogas [internet]. [acesso em 2019 jul 5]. Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2019-2022/2019/lei/L13840.htm.
http://www.planalto.gov.br/ccivil_03/_at... .

In recent years, in the context of the accelerated attack against the Unified Health System (SUS), in the field of mental health, proposals for changes in its policy against the movement of the Brazilian Psychiatric Reform were presented. Some of these changes were approved at the meeting of the Tripartite Interagency Commission (CIT)⁶6 Comissão Intergestores Tripartite. Resolução nº 32, de 14 de dezembro de 2017. Estabelece as diretrizes para o fortalecimento da Rede de Atenção Psicossocial (RAPS). Diário Oficial da União. 22 Dez 2017.. It is important to highlight that these changes occurred after a quick vote and without public debate with the social control spheres of SUS, disregarding the history, as well as the mental health policy built collectively by four national mental health conferences and by Law No. 10216/2001⁷7 Brasil. Lei nº 10.216, de 06 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. 9 Abr 2001..

Another serious episode was the reorganization of the National Policy on Drugs (PNAD), in 2018, regarding the promotion of abstinence and the financing of Therapeutic Communities (CTs) with resources also from the Ministry of Health. It is noteworthy that the CTs were already being financed within the scope of the Ministries of Justice and Social Development⁸8 Conselho Nacional de Políticas sobre Drogas. Resolução nº 1, de 9 de março de 2018. Define as diretrizes para o realinhamento e fortalecimento da PNAD - Política Nacional sobre Drogas, aprovada pelo Decreto 4.345, de 26 de agosto de 2002. Diário Oficial da União. 13 Mar 2018..

The allocation of resources from the Ministry of Health to the CTs meant a reduction in investment in the existing Psychosocial Care Network (Raps), increasing its deterioration and preventing the qualification of new services. Indeed, the fight against the investment of public resources in devices that impose restrictions and require abstinence is one of the great current challenges of the Brazilian Psychiatric Reform⁹9 Vasconcelos EM. Reforma psiquiátrica, tempos sombrios e resistência: diálogos com o marxismo e o serviço social. Campinas: Papel Social; 2016..

In many of these CTs, most of them with a religious and/or profitable nature, human rights violations occur. Their operation is based on moral actions and the imposition of abstinence, in addition to being favorable to a hospitalization policy - a position contrary to the Brazilian Psychiatric Reform, which advocates the production of anti-asylum care⁴4 Neves AGS. As políticas públicas de álcool e outras drogas no Brasil: uma análise da construção política de 1990 a 2015 [tese]. Rio de Janeiro: Fundação Oswaldo Cruz, Escola Nacional de Saúde Pública Sergio Arouca; 2018. 123 p.^,1010 Conselho Federal de Psicologia. Relatório da Inspeção Nacional em Comunidades Terapêuticas - 2017/Conselho Federal de Psicologia; Mecanismo Nacional de Prevenção e Combate à Tortura; Procuradoria Federal dos Direitos do Cidadão/Ministério Público Federal. Brasília, DF: CFP; 2018.. It is worth pointing out that the notion of anti-asylum refers to care in freedom and is associated with the struggle for resources that enable social exchanges, opposing, therefore, to the institutions of isolation and exclusion, which end up objectifying the subjects¹¹11 Amarante P, Nunes MO. A reforma psiquiátrica no SUS e a luta por uma sociedade sem manicômios. Ciênc. Saúde Colet. 2018; 23(6):2067-2074..

In its technical note, the Institute for Applied Economic Research (Ipea) indicates the growth of CTs in Brazil, a fact that can be attributed to the persistent health care gap in public services aimed at drug users¹²12 Instituto de Pesquisa Econômica Aplicada. Nota Técnica - Número 21: Perfil das Comunidades Terapêuticas Brasileiras. Brasília, DF: IPEA; 2017.. However, it also demonstrates a project of religious institutions in the country, using the question of drugs to strengthen the commercialization of assistance services.

In this sense, in a context in which the measures that point to the dismantling of the SUS increase, it is essential to have greater knowledge about the services offered to the population and the risks involved in the loss of equipment that has psychosocial attention and care as the guidance of care and harm reduction.

This study addresses one of the care services aimed at drug users, created within the scope of the Psychiatric Reform, which has not expanded to meet the needs of the population and is very little known: the Adult Reception Unit (UAA).

Established through Ordinance No. 121, 2012, the UAA offers shelter to needy people due to the use of crack, alcohol, and other drugs, focusing on actions aimed at prevention, health promotion, treatment, and reduction of risks and damage consumption of associated psychoactive substances. As a transient residential component of Raps, it is aimed at voluntarily receiving and offering continuous care to users followed up by a Psychosocial Care Center (Caps) who are in a situation of social and/or family vulnerability and who require therapeutic and protective follow-up. Thus, all UAA must be referred to a Caps¹³13 Brasil. Ministério da Saúde. Portaria nº 121, de 25 de janeiro de 2012. Institui a Unidade de Acolhimento para pessoas com necessidades decorrentes do uso de Crack, Álcool e Outras Drogas (Unidade de Acolhimento), no componente de atenção residencial de caráter transitório da Rede de Atenção Psicossocial. Diário Oficial da União. 27 Jan 2012..

The reception units operate in two modalities: Adult Reception Unit (UAA), for those over 18 (eighteen) years old, of both sexes; and Child and Youth Care Unit (UAI), aimed at children and adolescents, aged between 10 (ten) and less than 18 (eighteen), of both sexes¹³13 Brasil. Ministério da Saúde. Portaria nº 121, de 25 de janeiro de 2012. Institui a Unidade de Acolhimento para pessoas com necessidades decorrentes do uso de Crack, Álcool e Outras Drogas (Unidade de Acolhimento), no componente de atenção residencial de caráter transitório da Rede de Atenção Psicossocial. Diário Oficial da União. 27 Jan 2012..

UAAs are territorial-based services that follow the logic of psychosocial care, consider the subjectivity and context of each user, as well as value their life experiences.

Lima and Yasui¹⁴14 Lima EMFA, Yasui S. Territórios e sentidos: espaço, cultura, subjetividade e cuidado na atenção psicossocial. Saúde debate. 2014; (38):593-606. , highlighting the multiplicity of meanings that make up the territory, call us to think of it as space, process, relationship, and composition. Thus, the territory does not refer to a static place, but, rather, to an active, dynamic place, full of interrelations, built daily, where collective life takes place. For this reason, a territorial-based service, in this case, the UAA, does not refer only to its area of coverage.

The UAA, as a transitional residential service, configures a type of care that is opposed to the CTs’ confinement and prohibitionist rationale, which has been advancing widely. The UAA, is peculiar and guarantees the rights of having a shelter, family and social conviviality. It also ensures individual and free care, incorporating the principles of Psychiatric Reform.

With the main purpose of offering a portrait of this service, and thus contributing to its greater visibility, this study sought to answer the following questions: how is the UAA’s operation dynamics? How is its relationship with other health services? How is its relationship with the territory where it is located?

Material and methods

The research was carried out from September 2018 to March 2019, as a single exploratory case study on a UAA located in the state of Rio de Janeiro. This methodological design was chosen due to the need to obtain a more detailed view of the health unit investigated, as well as to enable the construction of analytical hypotheses capable of guiding future works¹⁵15 Vasconcelos EM. Complexidade e Pesquisa Interdisciplinar: epistemologia e metodologia operativa. Petrópolis: Vozes; 2002.. It also proved to be the most appropriate method for the main study perspective of knowing and giving visibility to the structure and dynamics of the UAA. It also makes it possible to understand an organization or community, opening space for more general theoretical formulations on the regularities of the process and social structures¹⁶16 Becker H. Método de Pesquisas em Ciências Sociais. São Paulo: Hucitec; 1993..

In the study, techniques of qualitative methodology were used, such as documentary surveys, participant observation, and open interviews with users and professionals of the selected unit.

The documentary survey was carried out considering the following aspects: team organization; internal activities; activities in the territory; team meeting structure; material resources of the unit; relationship with the Caps; relationship with other institutions; organization of the unit’s routine and conviviality rules; and profile of the people received by the unit. Internal documents of the UAA were consulted: logbook, minutes of team meetings and ‘daily census’, covering the period from August 2013 to August 2018.

Participant observation followed a script that focused on the following issues: internal organization; case discussion; construction of the Singular Therapeutic Project (PTS); unit dynamics; external activities; relationship with other institutions; relationship with the community; adverse situations and relationship between the unit and the users after the end of their reception period. The observation was also essential for a previous interaction with the reality of the possible participants before the interviews were conducted.

The selection of participants for the interviews took place in order to listen to the main social agents present in a UAA. In the category of users, those who spent longer periods and shorter periods of hospitalization in the unit were included. We also tried to add different genres and prioritize users who have gone through other forms of institutional care, such as shelter or hospitalization. As for the professionals, we sought to include participants from the technical and support teams, who were selected considering: the criterion of seniority in the UAA (longer and shorter working period), living close to the territory, and previous work in another mental health service.

In addition, interviews were planned with family members of users who have already been received by the unit, considering that they are important in participating and establishing a partnership in care and that also demand attention and care from mental health services. However, due to difficulties in getting in contact with family members and the deadline for completing the research, it was not possible to conduct these interviews.

Six interviews were conducted, three with each category of participants, supported by an open script. In the case of users, we sought to know: the reasons that led to the reception; the routine at the UAA; the relationship with team professionals and other users; the expectations and assessment regarding reception; the relationship with the territory; access to other health services, social assistance, education, culture, and leisure during the period in which they were at the UAA. As for health professionals, the script included: reference and admission to the UAA; routine at the unit; drug use management; conclusion of reception; articulation with other health, social assistance, education, culture and leisure services; actions to promote the reintegration and rehabilitation of the host; difficulties in the relationship with the territory.

In an initial stage, the material collected in the participant observation and in the documentary survey was systematized considering the axes and categories of analysis that could contribute to answering the research questions. In the analysis of the interviews, the reports were transcribed, organized, and related to the data already systematized. The information generated in the second moment, in which data from all sources are included, were analyzed in order to feed the final discussion of the work.

The research was approved by the Research Ethics Committee of the National School of Public Health Sergio Arouca - Ensp/Fiocruz, under opinion 2,732,930, and by the Ethics Committee of the Municipal Health Secretariat where the UAA under investigation is located. As risk protection and prevention strategy, the anonymity of the participants was guaranteed. The UAA, as well as its location, was not identified, which, in a way, limited the disclosure of some analyses of the study, especially regarding the insertion of the unit in the territory. Reflecting on the challenges of the UAA in a territory where the militia is dominant was one of the initial objectives of the research. However, addressing such challenges would lead to the identification of the Unit and put respondents at risk, given the small number of UAAs. Therefore, it was necessary to prioritize the principle and ethical care and emphasize the main objective of the research and give visibility to the structure and dynamics of a UAA.

Results and discussion

Considering the initial proposals of this study, results and discussion will be presented considering three interconnected axes: space and its social agents; daily organization; and relationship with the territory.

Space and its social agents

The region where the UAA is located has been experiencing major economic and sociodemographic transformations in the last 15 years: the construction of a highway, the presence of a federal and a municipal housing program, as well as sustainability, and urbanism program, which caused impacts on the dynamics of the territory.

In the territory, militia groups with political and financial interests are present. Justifying their intention to offer community security and combat drug trafficking, these groups provide ‘surveillance’ of the region, associated with illegal practices.

In this context of changes, in a territory where the power of the militia stands out, the care services to drug users are implemented. The Center for Psychosocial Care for Alcohol and Other Drugs (Caps AD) was opened in 2012, while UAA activities began in 2013. It is essential to highlight that part of the challenges experienced by these services refers to the fact that they are located in a territory where the militia imposes its power.

The UAA is located close to the Caps AD to which it is referred, which favors contact and exchange between services. The physical space of the unit has an external area consisting of a garden, several fruit trees, a balcony, and a lawn in the back. The internal area has a one-story house, with large windows, six bedrooms, three bathrooms, a TV room, pantry, storage room, laundry, administration room, games room, meeting room, team room, and a bedroom so that the employees can rest. The guest rooms have two to three beds. To preserve it as a more private place for those who occupy it, users are advised not to enter each other’s rooms. But each one goes in and out their room at any time.

The technical team consists of a technical coordinator, a social worker, a nurse, a psychologist, an administrative assistant and 16 orderlies. The support team, on the other hand, includes two butlers, four estate agents, and four general service assistants.

Regarding the profile of users received by the unit, in five years of operation, the UAA under investigation received 245 people, 75.5% of whom were men and 24.5% of whom were women. Of the total users, 80% live in the same region where the unit is located, and 20% come from other regions of the state.

The UAA has 15 vacancies available, and there is no limit to the number of times a user can be accepted. Considering that the same person can be accepted more than once, the unit had 523 receptions, from 2013 to 2018. The average length of stay is 34 days, and the average age of users is 37 years old. Of the total number of hospitalizations, only 16 lasted more than six months.

Using Fischer’s¹⁷17 Fischer Gustave-N. Psicologia Social do Ambiente. Lisboa: Instituto Piaget; 1994. psychosocial reading of places as a reference, the UAA is similar to a residential space, also presenting characteristics of an institutional space. The idea of home can be expressed in several ways, but its fundamental characteristic is that it is a space for protection from external dangers.

UAA as a home assumes aspects of personal space, a privileged place, the object of affective investment, reference, and presupposes certain stability. The housing space is where the feeling of identity is found, and it is also a place for socialization. This translates, for example, into the effort to maintain accommodations that guarantee the privacy of those welcomed and, at the same time, enable collective practices and a network of services and relationships, fundamental to the process of care in freedom.

In order to guarantee the privacy of each user, the rooms have few beds, and the users have individual lockers to store their belongings. In the rooms, the influence of each user welcomed in the space was observed, through organization, tidiness, and decoration. Other characteristics of the UAA that allow the appropriation of space are the daily activities that the users perform in the environment and the shared management of the collective areas of the house.

Daily organization

The reception of users is indicated exclusively by the team of the reference Caps. The Caps are responsible for the PTS and its follow-up, for the planning of the exit (in partnership with the UA), and for the care follow-up¹⁸18 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Articulação de Rede de Atenção. Nota Técnica nº 41, de 2013. Esclarecimentos e Orientações a respeito da republicação da Portaria nº 121, de 25 de janeiro de 2012, republicada no Diário Oficial da União, 21 Maio 2013, nº 96, seção 01, página 41. [Brasília] 2013. [acesso em 2019 fev 2]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2015/marco/10/Nota-T--cnica-Portaria-121-2012.pdf.
https://portalarquivos2.saude.gov.br/ima... .

In the UAA studied, the reception process takes place based on a joint evaluation. The user’s Reference Caps contacts the UAA team to present the case and the relevant issues to be worked on. In a second moment, once the case has already been discussed, with consensus among the teams regarding the pertinence of the reception, Caps, UAA, and the user set up a PTS, which may include activities in the Caps, actions related to documentation, clinical care, work, leisure, education, among others, always according to each case. From reference and follow-up of the case, new proposals can be built during the reception itself. It is understood that, during the reception period, care should be shared between Caps and UAA. In the event that there is no consensus regarding the indication for reception, new meetings are held to discuss the case.

The acceptance to the unit does not necessarily occur when the case is discussed. However, from the discussion, it is possible to think and define what the strategies of approximation between the user and the UAA will be, how to enter the host, and when this entry will take place. The main indications by the team to be received by the UAA are broken family ties, the need for a period to recover after more intense substance abuse, and difficulties related to the user’s home territory.

Regarding the closure of the reception, each user’s process must be respected. However, both Ordinance No. 121/2012 and Technical Note No. 41/2013, from the Ministry of Health, highlight the importance of attention to the length of stay, with the maximum limit of six months as a parameter. These documents indicate that the PTS of each user must include, in addition to the actions to be developed, the expected length of stay¹³13 Brasil. Ministério da Saúde. Portaria nº 121, de 25 de janeiro de 2012. Institui a Unidade de Acolhimento para pessoas com necessidades decorrentes do uso de Crack, Álcool e Outras Drogas (Unidade de Acolhimento), no componente de atenção residencial de caráter transitório da Rede de Atenção Psicossocial. Diário Oficial da União. 27 Jan 2012.^,1818 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Articulação de Rede de Atenção. Nota Técnica nº 41, de 2013. Esclarecimentos e Orientações a respeito da republicação da Portaria nº 121, de 25 de janeiro de 2012, republicada no Diário Oficial da União, 21 Maio 2013, nº 96, seção 01, página 41. [Brasília] 2013. [acesso em 2019 fev 2]. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2015/marco/10/Nota-T--cnica-Portaria-121-2012.pdf.
https://portalarquivos2.saude.gov.br/ima... . It was observed that the departure of a user from the unit is related to the accomplishment of what was proposed at the beginning. Thus, the PTS may include the time period, but it is not restricted to it.

The departure from the reception is considered as a process so that it is not abrupt. During this period, the link between the user and the UAA is strengthened, and strategies are gradually being devised to include other actors, in order to promote the user’s reintegration into the community.

In the dynamics of the UAA, the internal and external activities developed can be highlighted, which, for the most part, are related to the organization of the home, the articulation of the user support network in the territory, and the social reintegration of the sheltered people.

The house has a movement that varies according to the users being received and their PTSs, as well as the insertion of each user in the territory. Throughout the day, some users study, work and attend their reference Caps. In daytime, most of the external actions proposed in each PTS are carried out, and participation in external activities is encouraged, as a strategy to maintain and expand the network of each one.

Internal collective activities take place more frequently on weekends, or at night, in order to facilitate the participation of the users. The conviviality between the users and the team results in spontaneous collective activities, which are made possible by the UAA. In this regard, the research identified reports of barbecues and parties, usually on commemorative dates, such as birthdays, Christmas and New Year.

Regarding the daily dynamics of the UAA, it was observed that some standards were built or modified based on the unit’s own experience of operation, such as, for example, the daily flow of circulation in the territory. The users can leave the unit alone, either for combined actions in the PTS or for any other reason they wish to leave, but they have to always communicate to the team the time they will return. They must return until 7 pm, and any departure after that time must be arranged with the technical team. These guidelines seek to encourage communication between the users and professionals, as well as to organize the routine of the unit.

In certain situations, it is not advisable for the users to go out at night, and, if they insist, they are advised to return the next morning. Even when the user returns during the night or dawn, he/she is taken care and evaluated. If, at that moment, the user cannot remain in the UAA, due to a particular situation (of intoxication, for example), he/she is referred to Caps AD to wait for care.

An important aspect of daily care refers to clinical issues and the articulation with basic health units. Those receiving clinical demands are advised to go to the primary care service at their referral address. In some cases, the user is advised to go to the service of primary care that covers the address of the UAA. While the users are at the UAA, the team follows up their clinical care.

Another dimension of the unit’s daily routine refers to the tools that the providers use to address the challenges brought by daily situations in the UAA. In other words, the paths and management that the team takes or has to guarantee the continuity and development of the PTS. For example, on occasions when the team realizes that the user is under the effect of some substance abuse, or even when he/she uses drugs inside the unit, he/she is asked to throw away the substance, considering that it is not allowed to carry or use drugs within the unit (other than tobacco and prescribed medications). Assistance is provided to assess how the patient is feeling and understand what led him/her to such an action. If the user is severely altered or intoxicated, he is sent to Caps AD for specific care. Otherwise, he remains in the UAA.

Among the management of common situations in this UAA, the following should be mentioned: listening, talking, making agreements, guiding, accommodating people in another environment to avoid fights, evaluating medication use, sharing with Caps AD issues related to intoxication or PTS, following up the moves through the territory. Those tools have the potential of expanding the user’s daily contact with the team and the follow-up of each person’s path. And they are the ones that give UAA particular meaning and differentiate it from institutions that focus on confinement and that disregard subjectivity, such as the CTs.

UAA is a residential service, and as such, it is aimed at being a space designed for reception, hospitality, and conviviality. It is worth mentioning that the possibility of living in the unit and the enrichment of social networks are central axes in the offer of “rehabilitation as citizenship”¹⁹19 Assis JT, Barreiros CA, Jacinto ABM, et al. Política de saúde mental no novo contexto do Sistema Único de Saúde: regiões e redes. Rev. Divulg. Saúde debate. 2014; (52):88-113. [acesso em 2018 mar 12]. Disponível em: http://cebes.org.br/site/wp-content/uploads/2014/12/Divulgacao-52.pdf.
http://cebes.org.br/site/wp-content/uplo... .

Dwelling is related to a degree of appropriation of the space where one lives, the feeling of belonging and to the sense of sticking to a contract. Therefore, it is understood that, in the UAA, the acts of daily life, such as eating, talking, sleeping, walking, working, exchanging affections and goods, happen in different places and times for each one. In inpatient institutions or in therapeutic communities, this daily life is not validated. There is a rule for each act, and regulation does not give the user a chance to appropriate the space individually. In such situations, you are not living in the place, you are ‘at’ the place. Where there is no way to exercise singularity, there is rigidity in the rules of conviviality and a series of prohibitions, based on actions aimed at generalizing and maintaining the condition of guardianship²⁰20 Saraceno B. Libertando Identidades. Da reabilitação social à cidadania possível. 2. ed. Belo Horizonte: Te Corá Editora; 2001..

Appropriation is a psychological process of action and intervention in a space, in order to transform and personalize it. This system of influence on places involves the forms and types of intervention on it that translate into relationships of possession and attachment. Appropriation expresses a form of occupation of space and

it consists of producing diversity by investing in the space of intentions and acts that allow the individual to survive the banality of everyday life and give himself an identity ¹⁷17 Fischer Gustave-N. Psicologia Social do Ambiente. Lisboa: Instituto Piaget; 1994.⁽⁸³⁾.

UAA demonstrates a type of flexible organization that allows for the expression of some mechanisms of appropriation by the users. There are some rules of conviviality in the unit, as well as in every social space. However, it is possible for the users to receive some degree of intervention to structure the space according to their own criteria.

A contract, on the other hand, implies the opening of negotiation spaces, that is, increasing the possibilities of exchanges. The formal and informal institutions of the community represent resources, with infinite possibilities of articulations between service, user, and community, who are capable of producing meaning and contractuality²⁰20 Saraceno B. Libertando Identidades. Da reabilitação social à cidadania possível. 2. ed. Belo Horizonte: Te Corá Editora; 2001..

Considering the daily organization of the unit, it is possible to observe important points of opposition between UAAs and CTs. The UAA, as presented in this axis, guarantees individualized and free care, following the logic of harm reduction and psychosocial care. Meanwhile, the CTs, according to the Report of the National Inspection in Therapeutic Communities (2017¹⁰10 Conselho Federal de Psicologia. Relatório da Inspeção Nacional em Comunidades Terapêuticas - 2017/Conselho Federal de Psicologia; Mecanismo Nacional de Prevenção e Combate à Tortura; Procuradoria Federal dos Direitos do Cidadão/Ministério Público Federal. Brasília, DF: CFP; 2018.) and the Profile of the Brazilian Therapeutic Communities¹²12 Instituto de Pesquisa Econômica Aplicada. Nota Técnica - Número 21: Perfil das Comunidades Terapêuticas Brasileiras. Brasília, DF: IPEA; 2017. , have their operation based on the imposition of abstinence, in isolation, in the restriction of social conviviality, and defends a policy of prolonged hospitalization.

As there are few public services aimed at drug user assistance, the population tends to seek their own resources to deal with these issues. In this circumstance, CTs are a possible response of the population, and, although they have a social support role, they also present numerous problems of violation of human rights, as well as the rigidity of rules, disregarding care that respects the singularity of each one²¹21 Vasconcelos EM, Cavalcante R. Religiões e o paradoxo apoio social/intolerância, e implicações na política de drogas e comunidades terapêuticas. São Paulo: Hucitec; 2019.

Relationship with the territory

An important part of the work carried out during the reception at the UAA is the rapprochement with organizations and social actors in the territory. This includes dialogue with residents of the region, traders, the residents’ association, and other agents, in order to promote the user’s reintegration into the community.

This approximation occurs in situations in which the provider follows up the user in activities in the territory, according to the PTS, or based on an assessment made by the team. Among such situations, the following can be highlighted: visits to public attendance services, such as the Social Assistance Reference Center (Cras), the National Social Security Institute (INSS) and consultations and/or examinations with primary care; personal matters, such as trips to the bank, looking for a place to rent, visits to children in shelters and burials of the users’ friends or relatives. There are also outings with those welcomed for leisure and cultural activities, such as carnival blocks, events in museums, walks by the beach, participation in a typical party in June of the Caps and in theaters.

In the relationship with the territory, the articulation with the intersectoral network also stands out, especially health, social assistance, culture, justice, and education. It is a job that occurs, for example, when the team, represented by one or two professionals, participates in meetings and forums, such as Cras territory meeting, AD State Forum, Mental Health Forums, Income Generation and Culture Forum and Supervision of Caps AD.

The professionals interviewed point out that, throughout the years of operation of the UAA, the community began to see the unit differently. At first, the community was concerned that a service aimed at drug users in the neighborhood could increase the number of users circulating in the region. Currently, the community’s conception of UAA is different, and some professionals report that they are approached by residents of the region who request information on how to start treatment. One of the professionals noted that this change occurred precisely due to the insertion of treatment units for alcohol and drug users (Caps AD and UAA) in the territory.

The territorial characteristic of the UAA increases the possibilities of exchanges, as well as of articulations with different actors of the community, which also generates questions and conflicts of different orders. However, it is important to highlight that conflicts can be ways of creating dialogues, rethinking practices, and building new responses. Saraceno²⁰20 Saraceno B. Libertando Identidades. Da reabilitação social à cidadania possível. 2. ed. Belo Horizonte: Te Corá Editora; 2001. states that conflict itself is also a resource for the health service, and that, therefore, it is important to think about creating conditions for its expression and for overcoming it, but not silencing it.

It is common for people to ask for information, and even confuse UAA with Caps AD. One of the professionals interviewed says that, from time to time, residents who know her talk to her about a user, even if he is no longer being followed up at the UAA. The professional says that a good relationship between the UAA and the community favors articulations with the territory. For this reason, she identifies the importance of being on the streets, in the squares, always communicating with the people in the surrounding areas.

The work of the reception unit is not limited to the internal space and presents the construction of possibilities with the territory as an important characteristic. This conviviality with the surrounding community is necessary to establish and maintain a relationship that is aimed at enhancing the UAA partnership network, expanding the forms of care for users, as well as placing itself as a reference point for the community with regard to care related to drug use.

Another way in which the community accesses the UAA is to communicate or warn about an event that it is believed to be of importance to the professionals of the unit.

A brief illustration of the relevance of this relationship can be seen in a case in which the UAA neighbor went to warn the team that a user was on a street, two blocks away from the unit, drunk and taking risks when passing in front of the cars. The team was then able to manage to send two professionals to the location indicated by the neighbor. When they arrived at the site, there was an ambulance, which helped in the initial assessment and in guiding the user to the Caps AD, where detoxification procedures were carried out, continuing the care.

It is important to point out that, although the UAA studied is linked to the reference Caps AD, it receives users from all regions of the municipality, and even users from other municipalities in the state, as long as the geographical distance is taken into account at the time of indication and construction of the PTS. The UAA has approximately one million inhabitants in its coverage area, in addition to supporting cases from other regions. In such situations, the priority is that the actions of the PTS occur where the user has a connection, in order to maintain the ties and relationships already established, observing the singularity of each case. In this way, the UAA articulates with both Caps and Caps AD from various regions of the municipality. This direction of work has been designed over the years and based on the demands of other Raps services.

Only Caps can refer users to the UAA, which means that most of the articulations carried out are established with this service. The relationship with the other components of the intersectoral network is based on the demand of each case received, so that this dialogue is better established with the services of the coverage area of the UAA. The cases received from other regions, although they have articulation with the UAA, depend more on the reference Caps of the patient.

The reception at the UAA provides places for socializing and promotes the rescue of bonds, which implies that it is not a self-referential space, closed in itself, contrary to models of hospitalization and confinement. Through the offer of other forms of conviviality and negotiation, the user received at the UAA finds the possibility of new subjective arrangements.

Frare²²22 Frare AP. No litoral da casa e do serviço: a psicanálise no serviço residencial terapêutico [tese]. Rio de Janeiro: Programa de Pós-Graduação em Psicanálise da Universidade do Estado do Rio de Janeiro; 2012. 170 p. highlights that the encounter with others, with the rules of conviviality, and with social contracts is the trigger for subjective organization. Therefore, it is understood, that the reception at the UAA and its way of dealing with those received in everyday situations at the house and in the city open up possibilities for other forms of relationship with drug use, with treatment, family members, neighborhood, among others.

Final considerations

Harmful drug use is a field permeated by many disputes - whether political, academic, or technical - that have been intensifying amid dismantling movements in the current public mental health policy. The lack of extra-hospital services and the difficulty in accessing the health system contribute to the fact that other factors, other than health, gain space. Important discussions have been raised regarding the support and funding that CTs have received. These institutions, in general, are based on isolation and the imposition of abstinence for drug users and use the problem of drug abuse to legitimize prolonged hospitalization, typical of the asylum culture.

UAA is a SUS-based service that addresses the issue of hospitalizations for alcohol and other drug users. In the dispute between treatment models, UAAs appear in line with the principles of the Brazilian Psychiatric Reform. Thus, it can be said that UAAs were created to address the practical issue of local places to accommodate people with needs due to alcohol and/or other drug abuse, following the direction of free care.

Over the years of operation, the UAA team developed several discussions, from a theoretical understanding of harm reduction, psychosocial care, psychiatric reform to more practical issues, such as internal rules and regulations, which made it difficult to or helped users and facilitated or not the improvement of their quality of life, among many other relevant topics. In this process, the team developed its way of working with the users, the community and the intersectoral network. It is a continuous process, which is still ongoing, with recognition of advances and the clarity that there is still much to be done.

This is an extremely important moment to evaluate the service, the UAA experience, and the paths that have been traced, as it is necessary to think of strategies that guarantee care in freedom in the territory and harm reduction as a direction of this care. The general context of economic and political crises and the setbacks in rights and social policies call for thinking about resistance tactics.

The UAA implies the creation of the most different strategies to deal with issues related to the abuse of alcohol and drugs, since it deals with the issues of ‘living’ - not only in a house, but also in the city - of those most directly affected by inequality and marginalization. Its territorial characteristic seeks to enrich the user’s social network and increase the possibilities of exchanges, as well as articulations with different community actors, generating debates and questions of all types.

This research aimed at developing an exploratory case study on a UAA, in order to provide greater quality and context to produce knowledge about it. Thus, it is believed that the main objective of this research has been accomplished, as it has contributed to give visibility to this type of health service.

Given the complexity of the object, several points raised in this study need to be deepened, which emphasizes the importance of conducting studies related to the theme, especially in a scenario of disputes in which asylum and prohibitionist speeches have been gaining space.

References

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