Motives behind the work of harm reducers with drug users: a phenomenological study

Abstract

OBJECTIVE  To understand the motives behind the actions of harm reducers when working with drug users.

METHOD  Qualitative research conducted in the municipality in Rio Grande do Sul (RS), Brazil, in May 2017, by means of phenomenological interviews with 17 harm reducers. We analyzed and interpreted the data using the social phenomenology of Alfred Schütz.

RESULTS  Data analysis led to the following three categories: expectation of changes in the user's sphere of life, motivation at work from the recognition of their actions, and relationship with others as a life-learning experience.

CONCLUSION  The reasons harm reducers work with drug users are related to the family, search for a home, employment, access to health care, rights, and stigma, as well as the positive results of their work, personal satisfaction, and learning with drug users.

KEYWORDS: Nursing; Mental health; Substance-related disorders; Drug users; Harm reduction

Resumo

OBJETIVO  Apreender os motivos da ação do redutor de danos ao desempenhar suas atividades junto ao usuário de drogas.

MÉTODO  Pesquisa qualitativa, realizada em um município do estado do Rio Grande do Sul (RS), Brasil, em maio de 2017, por meio da entrevista fenomenológica com 17 Redutores de Danos. Utilizamos a análise e interpretação da Fenomenologia Social de Alfred Schütz. RESULTADOSDa análise, constatamos três categorias: expectativa por mudanças no mundo da vida do usuário, motivação no trabalho mediado pelo reconhecimento de suas ações, e, relação com o outro como aprendizado para a vida.

CONCLUSÃO  O motivo da ação do redutor de danos está relacionado à família, busca por uma casa, emprego, acesso à saúde, direitos e estigma, bem como, através do retorno de suas ações, satisfação pessoal e aprendizado junto aos usuários de drogas.

PALAVRAS-CHAVE: Enfermagem; Saúde mental; Transtornos relacionados ao uso de substâncias; Usuários de drogas; Redução do dano

Resumen

OBJETIVO  Comprender el motivo de la acción del Reductor de Daños al desempeñar sus actividades junto al usuario de drogas.

MÉTODO  investigación cualitativa, realizada en un municipio del estado de Rio Grande do Sul (RS), Brasil, en mayo de 2017, a través de la entrevista fenomenológica realizada a 17 Reductores de Daños. Se utilizó el análisis e interpretación de la Fenomenología Social de Alfred Schütz.

RESULTADOS  Del análisis, constatamos tres categorías tres categorías: expectativa de cambios en el ámbito de vida del usuario, motivación en el trabajo mediante el reconocimiento de sus acciones y relación con el otro como aprendizaje para la vida.

CONCLUSIÓN  El motivo de la acción del reductor de daños está relacionado con la familia, búsqueda de una casa, empleo, acceso a la salud, derechos y estigma, así como, a través del retorno de sus acciones, satisfacción personal y aprendizaje junto a los usuarios de drogas.

PALABRAS CLAVE: Enfermería; Salud mental; Trastornos relacionados con sustancias; Consumidores de drogas; Reducción del daño

INTRODUCTION

Drug and alcohol use can be defined as the self-administration of any amount of drugs, while abuse is defined as a pattern of use that leads to physical and psychological risks to users¹. A study reveals the association between homeless people, illegal substance abuse, and some diseases such as hepatitis, tuberculosis, and human immunodeficiency virus (HIV). Moreover, this population is more likely to suffer from reduced immunity, limited access to health services, exposure to unprotected sex, sexual abuse, and contact with other sick people, which increases the risk of tuberculosis contamination². Another prevalent risk is the onset of depressive symptoms in homeless drug users, possibly leading to suicide³.

In this context, harm reduction is a strategy that minimizes the health risks of people living on the streets or not, who abuse alcohol and other drugs. The fundamental principle of harm reduction is the freedom of choice and access to health services of users⁴. Thus, the harm reduction policy becomes a life project for users by helping them understand they have the autonomy to make life-changing decisions and they are jointly responsible for building/rebuilding their lives and values⁵.

Harm reduction strategies can also occur through harm reducers, who are the "professionals that work to ensure the care and protection of people at social and personal risk, as well as introduce teams to the value, ways of life and culture of people living on the streets"^(5:1). Harm reducers work with people who use alcohol, crack, and other drugs by performing educational and cultural activities, offering health protection inputs, and facilitating the users’ access to healthcare within their territory⁶. Care strategies within the territory help strengthen social ties between health workers and users and favor autonomy regarding self-care⁷.

Studies in the scientific literature on harm reduction reveal weaknesses in the social networks and a lack of understanding and involvement of health workers; moreover, they fail to include the harm reducer as a participant of the research^8-9. Thus, the research question of the present study is, “What are the reasons behind the work of harm reducers with drug users? The aim is to identify the reasons harm reducers perform their work activities with drug users.

METHOD

This study was extracted from a master's dissertation titled, Cuidado de pessoas usuárias de drogas: estudo fenomenológico na perspectiva do redutor de danos¹⁰. It is a qualitative, phenomenological study based on the theoretical and methodological framework of Alfred Schütz, conducted in a municipality of the state of Rio Grande do Sul, Brazil. Phenomenology deals with the intentional experiences of consciousness to reveal how the sense of phenomena is produced, called world, without ever diverting from the realm of experience¹¹.

In his theory of motivation, Schütz states that man acts according to directed reasons to achieve goals that point to the future. He called these reasons "in-order-to motives". In contrast, man has “reasons” for his actions that are anchored in past experiences and in the personality man develops in the course of his life. The author calls these actions "because motives". Only when the actor turns to the past does he become "an observer of his own actions"¹².

Phenomenological interviews were conducted and recorded with a digital recorder in May 2017 with 17 harm reducers. The phenomenological interview is not an intervention so no techniques are needed. The aim is to interpret comprehensively the language of a subject by perceiving the meaning of the ways he or she behaves, through body movements, eye expression, gestures and attitudes immediately perceived in the course of the interview. When the gestures and expressions of subjects are revealed, it is possible to perceive their reality in the world and position regarding their own conduct, facts, and events of the objective world¹¹. For this purpose, a period of rapprochement and adaptation was established in April of the same year.

The number of participants in the interviews was not predetermined; however, the interviews ended when the objective of the study was reached. In other words, the interviews stopped when we had enough meanings expressed in the statements. The interviewees signed an informed consent statement to confirm acceptance of their participation.

The criterion for inclusion was participants employed as harm reducers in the mental health system. The exclusion criterion was agents on leave (medical or otherwise) during the data collection period.

The interviews were conducted at the discretion of each participant during the break in the harm reducers’ room. The guiding question used in the interviews was, “What are your expectations when you work with alcohol and drug users?” A script was also used to collect information on the biographical status of the harm reducers, namely date of birth, gender, education, occupation, marital status, religion and whether they had done any training to work as harm reducers and attended any events/courses related to mental health.

The way the interviews were conducted allowed the harm reducers to talk freely about their experiences. To guarantee anonymity, each participant was generically identified from RD1 to RD17. The information was analyzed using the steps described by Tocantins¹³ for the social phenomenology of Alfred Schütz. First, the interviews were carefully transcribed and the transcription was read once. Subsequently, the material was re-read closely to identify the motives behind the actions performed by the harm reducers.

Here, the aim was to learn how the harm reducers experienced the studied phenomenon and the similarities of the experiences. Then, we sought to identify specific categories of the lived experiences by separating the statements and selecting and grouping fragments containing significant aspects to the harm reducers. Based on the typical characteristics identified in the statements, we sought to establish the meaning of the actions of the harm reducers and describe the typical and common actions of this social group¹³.

Ethical principles were observed in all the stages of research, in accordance with resolution No. 466/2012 of the National Health Council, and the research protocol of the committee of ethics in research (CEP) with humans was approved with opinion No. 1.967.534 and CAAE No. 664795817.0.0000.5346.

RESULTS AND DISCUSSION

Of the 17 harm reducers interviewed for this study, 13 were women and four were men aged between 22 and 53. In general, they were social workers or studying social services. In addition, most interviewees were married and followers of the Spiritualist doctrine. They had all been trained to work as harm reducers at the municipal harm reduction school (Escola de Redução de Danos) and frequently participated in meetings and events related to mental health.

Every action of an individual has an intention that seeks to meet expectations and needs; however, this sense of intention and meaning can only be expressed by the individual. The reasons people use to refer to something they want to accomplish, the goals they seek to achieve, have a temporal structure toward the future and form a subjective category of action¹². The statements of the harm reducers were used to build three concrete categories of experiences regarding the motives behind their actions, entitled Expectation of changes in the user's lifeworld; work motivation driven by recognition and personal satisfaction from their actions; and relationship with others as a life-learning experience.

Expectations of change in the user's lifeworld

The harm reducers hope their care actions will trigger changes in the lives of the users and make them think of future perspectives related to family, looking for a home, work, access to health care, rights, and reducing the stigma of society. Thus, the family is emphasized in their statements.

I hope to see some sort of return from that person, see them well, the family calm, that same family that was shocked and did not know what else to do, that nothing made sense. I hope she can turn her life around. (RD3)

I hope they are well, able to absorb the treatment, do it right, more aware of everything, especially the family. If things get better at home, it flows for everything else. (RD16)

I expect a better future for them in relation to the family, I think of what happened in his life for him to be in this situation, frequently, the thing is the broken home, a family that lacks structure, a family that does not pay attention, just working and no time for their son. But the friend at the corner has time, to help, to give him drugs that will relieve the pain. (RD15)

We always hope it will all work out [...], that he won´t start taking drugs again, that he will get closer to the rest of the family. He lost his father recently. It was also one of the reasons he went too far [...]. (RD4)

The expectations of the harm reducers in relation to the users is based on their own experiences in the lifeworld, which can be understood as the full sphere of experiences and interpersonal relationships¹². Family relationships can be determinant risk factors for drug use when there is a lack of dialogue and affection, rejection of family members, conflict, and moral and physical violence. Similarly, positive relationships can protect members from drug use. Regardless, the use of drugs disrupts family relations by generating discomfort and conflicts and by weakening bonds and overburdening the family¹⁴. The reasons people use drugs may be related to family issues such as losses or the inability to cope with everyday situations at home as in the case of arguments. Difficulties abstaining from drug use can also be related to good and bad situations in daily life¹⁵.

In the intersubjective world, people naturally perceive that the same objects of their knowledge may appear differently to others¹². In the same way, drug users have their own perspective related to living with their families. However, the reasons behind the work of harm reducers are approaching and establishing good social relationships with drug users and their families, something the harm reducers consider positive in the care of users.

The harm reducers experience and interpret the everyday lifeworld according to the experiences they inherit socially from their predecessors, i.e., people who existed before their birth. Thus, these experiences are transmitted to their social group¹². This fact helps them understand that having a home, job, access to health care, and social rights are fundamental. Consequently, they conduct their work with users with this purpose in mind. However, harm reducers believe this will happen according to the possibilities and goals the users wish for themselves, as shown in the statements below.

I hope that, within the possibilities the person seeks, he or she can achieve their goals. If they are sick, they can get treatment, get better or improve. If they are using use (drugs), they can take less or stop. Take advantage of some rights the person has if they are living on the streets, like get a home, even if it´s small, but have a shelter if that is what the person needs. (RD10)

I hope they get well, get a job, start organizing their personal lives better, if things fall into place for them, that is great for us. (RD16)

I believe that, let´s look to the future, not go back to feeling defeated, get a better life, I hope they get out of this situation, off the streets. Yesterday I found the one with the hood and asked him, are you getting paid? Rent a place (home), there is this place and it’s 250 furnished, with a bed, TV (television), all you have to do is go there and pay, it has light and water. Get a one-dollar meal. Pay attention and get off the streets, in the state you are in, sick, you cannot stay on the streets, it´s too hard. (RD11)

The idea behind the harm reduction policy is to extend and modify the forms of health care through education, prevention, promotion and rehabilitation based on actions that focus on the reality of each person and respect their right to choose. Harm reduction understands that, even when users choose to consume drugs, they are people with rights and they are worthy of care. Therefore, harm reduction becomes an educational tool in the streets that is coherent with its population¹⁶.

Sometimes, society does not understand the life story of drug users and their peculiarities, feelings, and desires. A dominant stigmatizing representation of the lazy, violent delinquent creates the idea of a non-citizen with no right to a social place who can be excluded¹⁷. Harm reducers work to help users make changes in their lives due to the stigma they suffer in society, as observed in the statements.

I hope they can change their lives, it doesn't need to be much, I hope they can leave that suffering, that life of humiliation, contempt. People reject them, cross the street, think the kids are rubbish [...]. (RD12)

It bothers me to know they are on the street, I know they are having problems and laughing on the outside and crying on the inside, they are trampled on because sometimes people dodge a dog, by they do not dodge them. I help, talk, guide, show the way, but I know it's in their time, I hope they leave this way of life. (RD6)

I think I'm doing a good job. I hope to contribute, help those people that nobody approaches, they are excluded from the society that wants them far away. I think I'm doing something relevant, I feel I'm contributing somehow. (RD2)

I dream of a more equal world, without prejudice, where people are not treated like crazy people or invalids because they use drugs. Where they are not seen as sick regardless of whether they use alcohol or other drugs, live on the street or make a living as sex workers. (RD13)

The stigma is very evident in mental health, where, in addition to overcoming issues related to the disease and drug use, they must cope with beliefs, stereotypes, and prejudice. Here, it is important to stress self-stigma, also described as internalized stigma, where stigmatized people become aware of the negative stereotypes people impose on them and agree with and apply these stereotypes to themselves. The consequences of internalized stigma are usually associated with low self-esteem, hopelessness, reduced self-efficacy, incapacitation, exacerbating existing problems and diminished social conviviality¹⁸.

The harm reducers perceive the problem of stigma among drug users by experiencing the contempt and humiliation these users suffer. Therefore, harm reducers work to change the lifeworld related to the social exclusion of drug users.

Work motivation driven by recognition and personal satisfaction from their actions

Harm reducers are driven by positive experience and recognition of their work, mediated by the changes they see in users and their personal satisfaction as harm reducers. The appreciation of the drug users regarding their work is considered a motivation, as shown in the following statements.

Today I work with teenagers who are doing time at the CASE [socio-educational center]. We created a harm reduction group for the people there [CASE] here at the CAPS (psychosocial alcohol and drug support center). The coordinator said they are asking about me. (RD5)

I have people on the streets today who did not go back to the life of crime, and they were hardened criminals. Just working, accompanying the group, makes you happy. I did this work as a harm reducer, offered them a course. They said: I learned this from you, man the work I did was not in vain. (RD7)

It was really nice to know they were doing well. One thing that keeps me working, that makes me love what I do it when I am someplace and people come and say, look how well I am now, I'm fat. (RD13)

In the social setting, the harm reducer comprehends the subjective meaning through the stream of consciousness, that is, through the things people think about as they speak. Harm reducers need to interpret and construct the intentional acts of others as the others choose their words. Consequently, through the we-relationship, they experience a particular moment in the lives of drug users and manage to live in their significant subjective context within the realm of a real we-relationship with content when users show the effects of the reducer’s actions. Through the stream of consciousness, harm reducers understand a story of life and shared achievement in the we-relationship¹².

The lifeworld is intersubjective and our actions are social since they place us in a relationship with others. Through the relationship with drug users, harm reducers indicate personal satisfaction as a reason for their actions.

I find it pleasurable! It is nice when we see they managed to find their balance again when they resume their lives, I think it's quite rewarding, I feel good, I like this work, I like helping others. (RD8)

That's a good thing, this exchange, today you are well so we help you, another day I am not too good, I go there and they say, Hi! They wave. It is nice, the exchange of I help you, you help me, it is gratifying to exchange and make ourselves available. (RD17) 

It is about being happy to contribute to improving someone’s quality of life, to achieve what she wanted. Whatever that person asks of me, I will do my best to make it possible. (RD14)

A study conducted with mental health workers identified engagement, satisfaction, and affective commitment to the job despite the lack of organizational support between the team and management. Such factors tend to improve performance in these spaces, thus reflecting the worker’s pleasure in being part of a group, and creates a more articulated link with issues involving mental health¹⁹. Similarly, the harm reducers and drug users get involved in a reciprocal relationship in the lifeworld.

People cannot experience the lifeworld alone. Learning the consciousness processes of others is not merely based on the things people deliberately share with us, but also through the observation and interpretation of their movements, facial expression, gestures, and rhythm and intonation of speech, etc.¹². Thus, harm reducers perceive the affectivity of users when they wave to greet them, revealing a relationship of exchange and satisfaction in their work.

Relationship with others as a life-learning experience

We observed that the harm reducers learn with their peers and they absorb everyday experiences. The face-to-face relationship is a social encounter through which one learns with the other, as revealed in the statements of the harm reducers.

I see harm reduction as a learning experience because it is not about merely taking information to someone. It's an exchange of information because I'm always learning. (RD1)

Sometimes, you're going through a bad patch, and then you make a home visit and the person has nothing at home but they are smiling and talking with you. The reducer grows with the work, with each situation you are in. It makes you grow as a human being. (RD15)

Learning, everything is construction, everything is learning. For life, for your personal life. I think everyone has problems and your problem is bigger. I think it is that, something to think about every day, to value the things we have. We complain a lot, you have to remember that there are people who are in a worse situation than mine. (RD10)

I think about my problems and I see that others have worse problems than me, and I put myself in their shoes and mine becomes insignificant. You know that we can solve our problems more easily, just seeing the difficulties of others, look at that guy's problem, using crack, living on the street, without having a bath [...]. (RD17)

The harm reducers learn about themselves through the experience they share with others. By establishing a relationship with users, the harm reducers understand that facts they considered difficult in their lives are insignificant when they observe the reality of the other. The harm reducers, as observers, seek to clarify the motives behind the subjects they observe and interpret the actions of others by putting themselves in their shoes¹².

Putting yourself in the place of another can be defined as an act of empathy. It is a social skill that helps to build and maintain the ties needed in care. Empathic behavior is an ethical and moral duty of people who are willing to help others²⁰. In this sense, the harm reducers also work with the hope of learning from the drug users. By experiencing the reality of others, the harm reducers reflect on their own lives and conduct in relation to their problems and behavior as human beings.

CONCLUSION

Based on the phenomenological perception and analysis of the social phenomenology of Alfred Schütz, we sought to identify the reasons behind the work harm reducers perform with drug users. By establishing a relationship with drug users, the harm reducers perform their work with perspectives for the future. Consequently, the reason for their actions is related to the possibility of changing the lifeworld of users. Through their work, harm reducers hope to make changes in the family by strengthening ties between the family members and by establishing a good relationship with them. Moreover, harm reducers work to help users get a home and a job and ensure access to health care and their rights in society. However, they understand that these issues will be resolved within the possibilities and objectives of users. Furthermore, harm reducers work to build life changes due to the stigma drug users suffer in society.

Similarly, they mention recognition for their work, on the part of users, and personal satisfaction as a motive for their actions, through the exchange and emotional involvement between them and users. It was also observed that harm reducers are motivated by the personal learning opportunity with users through the experiences they share with them.

These findings can increase the visibility of damage reduction actions and the motives behind the work performed with drug users. This study can support the construction of harm reduction actions and the social relationships between harm reducers and drug users. Scientific research on this subject is a challenge in the construction of knowledge because it is still an unexplored field that demands constant advances. Further studies should be conducted in other regions of Brazil to provide further insight into this phenomenon.

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Publication Dates

• Publication in this collection
  10 June 2019
• Date of issue
  2019

History

• Received
  24 May 2018
• Accepted
  13 Sept 2018