Effects of Social Skills Training for Drug Users under Treatment

Efeitos do Treinamento em Habilidades Sociais para Usuários de Substâncias em Tratamento

Efectos del Entrenamiento en Habilidades Sociales para Usuarios de Sustancias en Tratamiento

Abstract

The Social Skills Training (SST) presents satisfactory results in different clinical and non-clinical populations. The objective of this study is to evaluate the effects of SST on the perception of quality of life of drug users under treatment in post-intervention and follow-up conditions. It is a quasi-experimental study. The instruments used in the study were: CHASO, EMES-M, Extensive Interaction Semi-structured Test and WHOQOL. The study sample was composed of forty male drug users who participated in SST in a Therapeutic Community. The results indicate a statistically significant increase in the ability of defending rights, dealing with and keeping calm upon criticism, with medium effect size on the ability to refuse requests, refuse drugs and quality of life (psychological domain). SST was found to contribute to the development of specific social skills and as a complementary strategy in the Therapeutic Community.

Keywords:
socialization; quality of life; men; psychosocial rehabilitation; drug rehabilitation; therapeutic community

Resumo

O Treinamento em Habilidades Sociais (THS) apresenta resultados satisfatórios em populações clínicas e não clínicas. Objetiva-se avaliar os efeitos do THS na percepção de qualidade de vida e habilidades sociais de usuários de substâncias em tratamento nas condições de pós-intervenção e follow-up. Trata-se de um estudo quase-experimental. Os instrumentos utilizados foram: CHASO, EMES-M, Teste Semiestruturado de Interação Extensa e WHOQOL. Participaram 40 homens usuários de substâncias que participaram do THS em uma Comunidade Terapêutica. Os resultados apontam para um aumento estatisticamente significativo nas habilidades de defesa de direitos, enfrentar e manter a tranquilidade diante das críticas, com tamanho de efeito médio nas habilidades de negar pedidos, recusar a droga e qualidade de vida (domínio psicológico). Identifica-se que o THS contribui no desenvolvimento de habilidades sociais específicas, sendo uma estratégia complementar do tratamento na Comunidade Terapêutica.

Palavras-chave:
socialização; qualidade de vida; reabilitação da droga; comunidade terapêutica

Resumen

El Entrenamiento en Habilidades Sociales (EHS) proporciona resultados satisfactorios en poblaciones clínicas y no clínicas. El objetivo de este estudio fue evaluar los efectos del EHS en la percepción de la calidad de vida y las habilidades sociales de los usuarios de drogas bajo tratamiento en condiciones de post-intervención y seguimiento. Se trata de un estudio cuasi-experimental Los instrumentos utilizados fueron: CHASO, EMES-M, Test Semiestructurado de Interacción Extensiva y WHOQOL. La muestra del estudio se compuso por cuarenta varones usuarios de drogas que participaron en el EHS en una Comunidad Terapéutica. Los resultados apuntan a un aumento estadísticamente significativo en la capacidad de defensa de derechos, afrontar, mantener la tranquilidad frente a las críticas, con un tamaño de efecto promedio en la denegación de peticiones, rechazo de drogas y calidad de vida (dominio psicológico). Se comprueba que el EHS contribuye al desarrollo de habilidades sociales específicas como una estrategia complementaria de tratamiento en la Comunidad Terapéutica.

Palabras clave:
socialización; calidad de vida; hombres; rehabilitación de drogas; comunidad terapéutica

Introduction

Social skills are defined by Caballo (1987) as a set of behaviors emitted by an individual in his social environment, which will express his feelings, desires, attitudes, opinions or rights in the most appropriate way to the situation, respecting such behaviors in other people and solving immediate problems, while decreasing the likelihood of future difficulties. Recently, Caballo (2017) stated that this concept seems to continue to be used as a consensus in the area, being that social skills compose the skills necessary for a satisfactory relationship between individuals. The behavioral model proposes that the occurrence of any social skill is related to personal and environmental variables and the interaction of both (Caballo, 2003).

The learning of social skills occurs in the course of human development, based on interpersonal relationships (Limberger, Mello, Schneider, & Andretta, 2017). Among the factors that contribute to the increase in the repertoire of social skills, positive learning experiences stand out. In addition, social skills need to be exercised in order to be developed and improved (Argyle, Bryant, & Trower, 1974).

Difficulties in learning social skills can occur for two main reasons: a) social interactions show up as negative experiences during development and b) lack of socially skilled models (Caballo, 2003). Low levels of social skills are considered risk factors for substance use, as pointed out by a systematic review of the literature that analyzed 13 empirical studies from 2004 to 2014 (Schneider, Limberger, & Andretta, 2016). In that review, it was identified that most studies had adolescent and young university students as participants, with only four studies with the adult public of substance users (Schneider et al., 2016).

National and international studies describe difficulties in the social skills of substance users (Sintra, Lopes, & Formiga, 2011; Schneider & Andretta, 2017). Deficits in the social skills of coping / self-affirmation with risk and conversation and social resourcefulness were found in users of illicit substances, compared to the group of non-users, according to a study carried out in Portugal with 124 participants (Sintra et al., 2011). Impairments in conversation skills and social resourcefulness and self-control of aggression in aversive situations were identified in crack users, with statistically significant differences in relation to the group of non-users, according to a Brazilian study with 96 participants (Schneider & Andretta, 2017). Another Brazilian study compared the social skills of 123 users in treatment due to the use of alcohol with 114 users of primary health care services, who were not dependent on alcohol or other substances (except tobacco). Alcohol users presented lower scores in self-control of aggression, when compared with the group of non-users (Felicissimo, Santos, Fontoura, & Ronzani, 2016).

Facing this scenario, the literature points to the need for Social Skills Training (SST) inserted in the treatment of Substance Use Disorder (Del Prette, Ferreira, Dias, & Del Prette, 2015; Hulka et al., 2014; Petersen et al., 2007; Wagner & Oliveira, 2015). The SST is an intervention of a generally group character, which aims to practice specific behaviors of social skills, so that new behaviors are integrated into the individual’s repertoire, based on instructions, modeling, behavior testing, feedback and reinforcement (Caballo, 2003; Del Prette & Del Prette, 2014).

SST also seeks to improve overall quality of life (Caballo, 2003), which has been shown to be impaired in substance users (Marcon, Rubira, Espinosa, & Barbosa, 2012; Moreira et al, 2013). Thus, the quality of life refers to the individual’s perception of his position in life, in the cultural context and in the value system in which he lives, relating to his expectations, objectives, standards and concerns (World Health Organization, 1995).

The lack of studies on SST in the treatment of Substance Use Disorder was evidenced in a systematic review of empirical studies based on Medline Complete, Scopus, IBECS, Index Psi and LILACS. As a result, only five studies that performed SST with users of substances under treatment were identified (Limberger, Trintin-Rodrigues, Hartmann, & Andretta, 2017). In that review, SST was conducted both in hospitals and in community treatment centers and clinics.

In the Brazilian context, there is an increasing search for the treatment modality of Therapeutic Communities (TCs), (Costa, Mota, Paiva, & Ronzani, 2015). Such institutions have a transitory residential character and offer continuous health care for up to nine months, focused on the clinical needs resulting from the use of crack and other drugs (Ministry of Health, 2011). In the Brazilian context, most TCs serve men, mainly in the age group from 18 to 65 years old (Perrone, 2014). There are questions about the practices carried out in certain STCs, however, it is worth highlighting that the methodological and conceptual bases of the TCs are match with the principles of Psychiatric Reform, seeking changes in the lifestyle of users under treatment (Perrone, 2014), having social skills an indispensable role in this context (Limberger et al., 2017).

In view of the literature presented, it is considered that low levels of social skills contribute to the use of substances, with difficulties mainly in men (Andretta, Limberger, & Schneider, 2016; Caballo, 2003; Schneider et al., 2016; Sá & Del Prette, 2014). It is understood that SST, which already has positive results in different population (Bellack, Bennet, Gearon, Brown, & Yang, 2006; Corrigan, 1991; Lin, Bon, Dickinson, & Blume, 1982; Petersen et al, 2007; Tenhula, Benett, & Kinnaman, 2009), can contribute to the development and improvement of the social skills of users of substances who are under treatment in the Therapeutic Community, helping in the quality of life (Limberger et al., 2017; O’Connell, 2009). Facing the perspectives presented, it is believed that there will be an increase in the quality of life and in the specific social skills of the participants in the post-intervention and follow-up conditions. Thus, the objective of this study is to evaluate the effects of SST on the perception of quality of life and social skills of drug users who are under treatment in the conditions of post-intervention and follow-up.

Method

Outline

The present study is defined as a quasi-experimental study, with a pre-test (T1), a post-test (T2) and a follow-up (T3) (Sampieri, Collado, & Lucio, 2013). The pre-test was performed one week before the intervention, the post-test one week after the intervention and the follow-up one month after the intervention.

Participants

Forty male substance users being treated for Substance Use Disorder participated in the study. The present study is considered a non-probabilistic sample, in which there is a subgroup of a population whose choice does not depend on probability, but on the characteristics of the research (Sampieri, Collado, & Lucio, 2013). The inclusion criteria were: being under treatment at the time of data collection and participating in the assessment and intervention stages, having at least 75% attendance at SST meetings, that is, participating in at least six of the eight meetings. As an exclusion criterion it was decided that the participants who did not complete the follow-up of one month after the intervention would not be considered.

Thus, from the 58 participants who started the intervention, 45 completed and 40 completed the follow-up, as shown in the flowchart in Figure 1. Such participants were between 18 and 58 years old, being in an average age of 39.8 years old (SD = 12.45). and they were abstinent at the time of the survey. The abstinence was assessed based on self-report, in addition to considering that in the TC the use of substances was not allowed. Participants who used any prescribed medication correspond to 57.5% (n=23) of the sample.

Figure 1
Flowchart of participants selection

Instruments

Questionnaire on Sociodemographic Data and Substance Use

In order to assess sociodemographic data, pattern of substance use (type and time of each substance used), data about the treatment, DSM-5 criteria (American Psychiatric Association [APA], 2014) for the diagnosis of Disorders for Substance Use and frequency of social skills in TC. This questionnaire is composed of open and closed questions and it was developed by the research group Cognitive Behavioral Interventions: Study and Research (ICCEP - UNISINOS).

Social Skills Questionnaire (CHASO)

CHASO was developed by Caballo, Salazar and the CISO-A Research Team (2017). The questionnaire is available in Portuguese and Spanish, it consists of 40 items, on a five-point Likert scale, with options from “very uncharacteristic of me” to “very characteristic of me”. The purpose of the instrument is to assess the frequency of 10 social skills in adults: interact with strangers; express positive feelings; face criticism; interact with people who attract me; keep calm when receiving critics; speak in public/interact with superiors; deal with situations of exposure to ridicule; defend your own rights; apologize; and deny orders. The score is obtained from the sum of the items, with the highest scores indicating greater social skills. There are no studies that indicate cohort points or score classification. For the present research, the accuracy of this instrument was evaluated using Cronbach’s Alpha of the scale, which was 0.85 at T1.

Social Skills Questionnaire in the Therapeutic Community

The frequency of Social Skills in the Therapeutic Community (SSTC) is an adaptation of CHASO (Caballo, Salazar and CISO-A Research Team, 2017), for social skills that occur in the TC. In this way, the main difference of CHASO for the SSTC concerns to SS that are specific to the TC, as an example: “I said no to a TC employee”; “I praised a colleague from TC”, etc. As the original scale was already translated and validated for the Brazilian language, the other steps to adapt the instrument were not necessary, such as: translation of the instrument, synthesis of the translated versions, analysis of the version synthesized by expert judges and reverse translation into the language of origin (Sireci, Yang, Harter, & Ehrlich, 2006). The adapted scale is a five-point Likert, with 27 items. The response options range from zero (I did not have this behavior in the past week) to four (I have had this behavior every day). There are three questions for each of the following skills assessed: interacting with strangers in the TC; express positive feelings in the TC; face criticism in the TC; maintain tranquility when facing criticism in the TC; speak in public/interact with superiors in the TC; deal with situations of exposure to ridicule in the TC; defend rights in the TC; apologize at TC and deny requests at TC. The higher the score on each social skill, the greater the participant’s social skill and the sum of all scores indicates a total score for social skills in the TC. For the present research, the precision of this instrument was evaluated using the Cronbach’s Alpha of the scale that was 0.92 in T1.

Semi Structured Test of Extensive Interaction (STEI)

The test consists of informing the participant about a task to be performed by him, with the instruction to act “as if” the interaction was real (Caballo, 2003). For this purpose, four situations are presented that involve the skills of interacting with strangers, defending rights, expressing positive feelings and refusing the drug that motivated the treatment. Each situation was recorded on video, with the consent of the participants.

Interviewers refrain from starting the conversation and limit responses to the subject’s initiatives (approximately five words). Thus, the responses of the interviewers are neutral, avoiding frequent smiles and nods. The evaluation of the videos is done by two independent judges, previously trained on social skills and the instrument, based on the Behavioral Assessment System of Social Skill (BASED), developed by Caballo (1987). The non-verbal, linguistic and verbal components of the subjects are scored from one to five, for a total of 21 items. A score of three or higher indicates a suitable behavior. In its turn, a score below three points to a difficulty in that component (Caballo, 1987). After the analysis of the judges, the average score issued by the judges was adopted (Gastaud, Carvalho, Goodman, & Ramires, 2015).

Multidimensional Scale of Social Expression - Motor Part (M-MSSE)

The scale aims to identify the frequency of eight factors of social skills in adults, being developed by Caballo (1987) and translated and adapted to Brazil by Pereira (2015). It is a five-point Likert scale, ranging from “Never or very rarely” to “Always or very often”. The original version has 64 items and 12 factors and the version adapted for Portuguese, used in the present study, has 56 of the original items and eight factors, namely: skills to initiate and maintain conversations; skills to say no; skills in receiving praise; public speaking skills; skills to express positive affection; skills to express negative affection; skills to express disagreement/opposing opinions and skills to defend rights (Pereira, 2015). For the present research, the precision of this instrument was evaluated using the Cronbach’s Alpha of the scale which was 0.75 in T1.

WHOQOL-bref

The WHOQOL-bref aims to assess the subject’s perception of his quality of life. The instrument was developed by the World Health Organization’s Quality of Life Group and it was validated for the Portuguese language by Fleck et al (1999). It is a reduced version of the WHOQOL-100, it has 24 facets that make up the four domains: physical; psychological; social relations and the environment. In addition, there are two questions about the overall quality of life. For the present research, the precision of this instrument was evaluated using the Cronbach’s Alpha of the scale that was 0.62 in T1.

Procedures

Ethical procedures

The present study is part of a larger study, entitled: “Evaluation and Training in Social Skills in Chemical Dependents in Specialized Units”. The approval was made by the Research Ethics Committee (report No. 13,172) and after the issuance of the Therapeutic Community Letter of Consent, all participants were invited to participate in the research in a lecture with the delivery of a nominal invitation for each individual. The Free and Informed Consent Term was read and explained individually for each participant, explaining the voluntariness in the study. The participants who agreed to participate in the research signed the term in two copies, in which one copy was for the participant and another copy for the researcher.

Data collection procedures

All instruments were applied individually by psychologists and psychology students, members of the Research Group Cognitive-Behavioral Interventions - Teaching and Research (CBITR), with previous training on research instruments and procedures. The instruments were applied individually, in rooms of the Therapeutic Community. Two meetings were held with each participant for the application of all instruments, lasting approximately two hours each. All instruments were read to the participants in order to help them understand the issues.

The collection was conducted by two teams: a group for the application of the instruments and another for the application of the intervention. The data collection team had weekly and group supervision by the study researcher. In its turn, in the application of the intervention, therapist and co-therapist received supervision from the study advisor at each session.

Details of the intervention

The Social Skills Training was conducted in four groups by a therapist (researcher) and a co-therapist, over the course of four weeks, two sessions per week. The researcher is a psychologist and has experience in the treatment of Substance Use Disorder and in the conduct of SST, with prior training in her social skills. All four groups were conducted by the researcher as a therapist. The role of co-therapist was played by four psychologists, one for each group of the SST, all of them are members of the research group with previous training. In the first meeting, the participants chose six social skills to be worked on during the SST. More information about the intervention can be seen in the experience report by Limberger and Andretta (2019). Table 1 shows the skills that were worked on in the four groups. It is important to note that the order of the social skills worked on was established based on the increasing degree of difficulty, as pointed out by Caballo (2003). Such skills were assessed using the CHASO instrument.

Table 1
Social Skills worked in groups

Grup	1st Session	2nd Session	3rd Session	4th Session	5th Session	6th Session	7th Session	8th Session
1	Initial session	Express positive feelings	Apologize	Keep calm when facing criticism	Deny orders	Defend your own rights	Deal with situations of exposure to ridicule	Closure
2	Initial session	Express positive feelings	Speak in public / Interact with superiors	Deny orders	Keep calm when facing criticism	Deal with situations of exposure to ridicule	Interact with strangers	Closure
3	Initial session	Express positive feelings	Keep calm when facing criticism	Face criticism	Deny orders	Speak in public / Interact with superiors	Interact with strangers	Closure
4	Initial session	Apologize	Interact with people who attract me	Deny orders	Speak in public / Interact with superiors	Keep calm when facing criticism	Deal with situations of exposure to ridicule	Closure

Data analysis procedures

The data was analyzed using the Statistical Package for Social Sciences - SPSS, version 20.0. The descriptive analysis included frequencies, percentage, average and standard deviation. To meet the objective of the present study, which was to evaluate the effects of Social Skills Training on the perception of quality of life and social skills of users of substances who are under treatment in the post-intervention and follow-up, an analysis of repeated measures was carried out, through Friedman’s Anova procedure. In its turn, the Mann-Whitney Post-hoc test with Bonferroni adjustment was used and to evaluate the size of the effect of the intervention, it was used the formula (Field, 2010). Given that the sample distribution it did not present normality criteria, it was decided to use non-parametric tests. For statistical decision criteria it was adopted a significance level of 5% (p-value ≤ 0.05).

Results

In the stage that preceded the intervention (T1), using the CHASO instrument, the lowest scores were identified in the following skills, in ascending order: interacting with strangers, dealing with situations of exposure to ridicule, maintaining tranquility when facing criticism, defending the own rights and deny requests. On the other hand, at SSCT it was found that the lowest scores were on the following skills, in ascending order: denying requests, defending one’s own rights, facing criticism, maintaining tranquility when facing criticism and apologizing. Finally, recordings on STEI showed lower scores on the ability to defend rights and express positive feelings. Further details and M-MSSE scores can be seen in Table 2. It is worth noting that M-MSSE has a different number of items for each social skill, which is why it is not possible to describe such skills in an order of increasing difficulty.

Table 2
Average of social skill scores in the T1

Instrument	Social Skill Assessed	Average	DP
CHASO	Interacting with strangers	9.30	3.68
	Expressing positive feelings	16.25	3.09
	Facing criticism	12.60	3.86
	Interacting with people who attract me	12.52	4.23
	Keeping calm in the face of criticism	10.82	3.13
	Speaking in public/Interacting with superiors	12.00	3.80
	Dealing with situations of exposure to ridicule	9.42	2.66
	Defending your own rights	11.80	3.81
	Apologizing	15.00	2.66
	Denying requests	11.92	3.79
	Total score	121.65	19.13
SSTC	Interacting with strangers in the TC	5.50	2.91
	Expressing positive feelings in the TC	6.37	2.60
	Facing criticism in the TC	3.27	2.77
	Keeping calm when facing criticism in the TC	3.70	3.13
	Speaking in public/Interacting with superiors in the TC	4.92	2.92
	Dealing with situations of exposure to ridicule in the TC	5.42	2.80
	Defending rights in the TC	2.95	3.08
	Apologizing in TC	3.70	3.13
	Denying requests in TC	2.25	2.53
	Total score	38.32	19.61
M-MSSE	Starting and keeping conversations	23.80	7.16
	Saying no	13.87	3.96
	Receiving praise	7.77	5.64
	Speaking in public	6.45	3.76
	Expressing positive affection	25.45	6.35
	Expressing negative affection	19.62	6.09
	Expressing disagreement/opposing opinions	14.87	4.75
	Defending rights	15.40	8.19
STEI	Interacting with strangers	62.45	4.17
	Defending rights	56.35	19.41
	Expressing positive feelings	57.47	19.73
	Refusing the drug that motivated the treatment	63.37	3.38

As shower in Table 3, the social skills in which it was possible to identify differences between the times of the intervention were the skills to deny requests (T2 obtained higher average positions in relation to T1 and the effect size of this difference was average); ability to refuse the drug (T3 obtained a higher average rank compared to T1 and the effect size of this difference was average) and the psychological domain of WHOQOL (T3 obtained a higher average rank compared to T1, and the effect size of this difference was average). Furthermore, there was also a statistically significant increase in the skills of denying requests, maintaining tranquility when facing criticism, defending rights and facing criticism. In these variables, there was an increase in the mean posts, and when making multiple comparisons in the Post-hoc test, no differences were found between specific pairs, making it impossible to calculate the effect size. It is important to highlight that in the other variables evaluated by M-MSSE; CHASO; SSTC; STEI and WHOQOL there was no statistically significant difference between the three times.

Table 3
Comparison of social skills and quality of life in three stages

Variable		Time	Average Stationsa	Gl	sig.	Post Hoc b	r
M-MSSE	Defending Rights	1	1,63	2	p = 0.01	1X2	-
		2	2,20			1X3	-
		3	2,18			2X3	-
CHASO	Denying requests	1	1,66	2	p = 0.016	1X2	-
		2	2,15			1X3	-
		3	2,19			2X3	-
	Keeping calm when facing criticism	1	1,70	2	p = 0.04	1X2	-
		2	2,10			1X3	-
		3	2,20			2X3	-
SSTC	Facing Criticism	1	1,71	2	p = 0.034	1X2	-
		2	2,04			1X3	-
		3	2,25			2X3	-
	Defending Rights	1	1,71	2	p = 0.043	1X2	-
		2	2,23			1X3	-
		3	2,06			2X3	-
	Denying requests	1	1,58	2	p = 0.001	1X2	0.33*
		2	2,24			1X3	-
		3	2,19			2X3	-
STEI	Drug refusal	1	1,57	2	p = 0.001	1X2	-
		2	2,01			1X3	0.30*
		3	2,42			2X3	-
WHOQOL	Psychological	1	1,54	2	p =0.001	1X2	-
		2	2,09			1X3	0.26*
		3	2,37			2X3	-

• ^aAnova de Friedman; ^b Test Post Hoc (Mann-Whitney) with adjustment from Bonferroni; *p < 0.01

Discussion

In the first stage of the SST, which deals with evaluation, it was noticed that the combination of self-report instruments of general social skills with the evaluation of specific social skills of the TC, as well as the use of recordings enabled a broader understanding of which are the greatest facilities and difficulties of the participants. As a result, a multimodal evaluation battery was created, since the choice of different types of measures for the evaluation of participants at different times contributes to analyze the effectiveness of the intervention (Caballo, 2003).

When identifying that some social skills had lower scores, it can be said that the participants do not have difficulties in social skills as a whole, but in specific skills. Regarding this, Sá and Del Prette (2014) state that difficulties in the general repertoire of social skills do not characterize Substance Use Disorder by themselves, but specific skills can predict substance involvement.

Based on the frequency of social skills in the TC, interpersonal difficulties were identified during treatment, and the performance of the SST was indicated in this context. According to a study carried out with 96 men, divided between users and non-users of substances, it was identified that the men who were being treated for the use of crack in Therapeutic Communities showed significant losses in the conversational skills and social resourcefulness and self-control of the aggressiveness in aversive situations, when compared to the group of non-users (Schneider & Andretta, 2017). In its turn, a multiple case study of women using crack in treatment, pointed to difficulties in the use of social skills during hospitalization, present in aggressive (discussion with colleagues and employees) and passive (being silent in front of groups) treatment, fail to claim their rights) (Limberger & Andretta, 2017).

When specifically analyzing the data referring to the intervention, it was observed that the hypotheses were confirmed, with an increase in the quality of life and in the specific social skills of the participants in the post-intervention and follow-up conditions. Regarding the increase in the ability to refuse the drug, similar results were identified in a study with users of substances being treated in a Therapeutic Community, with 47 participants in the experimental group and 42 participants in the control group (Hawkins, Catalano, & Wells, 1986). In that study, a better performance was identified in situations that involved avoiding the use of drugs and dealing with relapses in the experimental group (Hawkins et al., 1986).

It is understood that the ability to deny requests is related to the ability to refuse the drug, because in such skills there is a greater likelihood that the “no” will be received with discomfort on the part of the interlocutor. In this sense, the relationship between the ability to refuse drugs and the belief of being effective in the face of negative emotions was identified in a Brazilian study with 100 men undergoing treatment in the Therapeutic Community (Rodrigues, Alves, & Martins, 2019).

The ability to refuse drugs is essential in maintaining abstinence, because after leaving the TC, individuals will be exposed in many situations that the substance will be offered, and it is up to the participants to say no. In this perspective, social pressure and the search to appear “normal” contribute to the use of substances (Bellack et al, 2006). Thus, the specificity of SST in the treatment of Substance Use Disorder is the training of the ability to refuse the substance, contributing to the adoption of a new repertoire of coping strategies (Glasner & Drazdowski, 2019).

The increase in the quality of life in the psychological domain one month after the intervention contributes to a difficulty presented in the national and international literature, which refers to losses in the quality of life of substance users (Marcon et al., 2012; Moreira et al., 2013 ; Muller, Skurtveit, & Clausen, 2016; Said, Okasha, Okasha, Haroon, & Fikry, 2012). Such domain is composed of the facets of self-esteem, body image and appearance, positive feelings and negative thoughts, learning processes, memory and concentration, spirituality, religion and personal beliefs (Fleck et al., 1999). Considering that the participants were inserted in the treatment of TC while performing the SST, it is not possible to state that such result is specific to the SST, with the possibility of corresponding both to the SST and to the treatment in the TC. In this perspective, improvements in the psychological symptoms of patients undergoing treatment in TC were identified in relation to the control group, according to a systematic review of the literature on the results of the treatment in TCs (Vanderplasschen et al, 2013). It is also necessary to consider that the only instrument in the study that presented low reliability was the WHOQOL-bref. In this way, it is required to analyze with caution the data on the psychological domain.

Going into the questions about treatment in the TCs, it is reinforced that the SST appears as a complementary proposal in the Substance Use Disorder, not replacing the existing interventions. In addition, the transitory residential character characteristic of the TC (Ministry of Health, 2011) also reinforces the need for satisfactory coexistence for all, in order to occur changes in the lifestyle (Perrone, 2014).

The other skills in which there was an increase in the average posts, such as denying requests, maintaining tranquility when facing criticism, defending rights (general context), defending rights in the TC and facing criticism in the TC, were also skills that the participants had lower scores in the initial evaluation, expressing that there were difficulties in its execution. It is based on the assumption that such skills require greater persistence and handling of the discomfort that can be generated by the interlocutor, when refusing a request or when dealing with criticism, for example (Caballo, 2003). Such abilities are opposed to an aggressive and impulsive way, characteristic of the Disorder caused by the Use of Substances. It is understood that the fact that the participants interact on a daily basis with the other participants in the group may have contributed to the practice of such skills, with a greater willingness to develop new behaviors and interact in a socially skilled way.

As important as understanding the significant results, it is also important to analyze which skills the intervention did not present statistically significant results. It is identified that from the analyzes performed, the SST did not show results for all the skills that were worked on in the groups. In this sense, difficulties in social skills of substance users can be specific, that is, they can be very skilled in other situations (Caballo, 2003). Thus, skills such as expressing positive feelings, apologizing, interacting with strangers and dealing with situations of exposure to ridicule had higher scores in the initial assessment of social skills.

Another aspect to be considered in understanding the non-significant data is the fact that not all skills were worked on in all groups, considering that the groups were able to choose which skills would be developed. In addition, a Brazilian study in the university context also found that there was no difference in self-affirmation skills in the expression of positive affection, conversation, social resourcefulness and self-control of aggression after SST with 35 participants (Lopes, Dascanio, Ferreira, Del Prette, & Del Prette, 2017).

Finally, when analyzing the intervention in a general way, the viability of SST is observed as a complementary strategy to the treatment of Disorder caused by the Use of Substances. A good cost-benefit ratio is identified, given that the intervention is in group and that the majority of participants have completed the intervention. The choice of open access instruments also makes it possible for professionals to assess social skills and consequently practice SST. The main aspect that requires attention concerns the qualification of the professional who will conduct the intervention. It is suggested that initially the professionals develop their own social skills from the SST, to later lead a group. In addition, group management skills are essential. Thus, the greatest investment in the intervention is the training of professionals who conduct the intervention, being necessary a continued training in the TCs with a focus on continuous professional improvement.

Final Considerations

Based on the proposed objectives, it was possible to identify that there are social skills that the participants had lower scores on and that the SST showed potentialities in the increase of some of the evaluated social skills, with average effect size: ability to refuse in the TC and ability to refuse the drug that motivated the hospitalization. In addition, the psychological domain of quality of life also had a medium effect size.

As an innovation in the area, it is worth highlighting the realization of a specific SST for the treatment of Disorder by the Use of Substances in TCs in the Brazilian context, with the choice of social skills by the participants. In this perspective, considering that different skills that were worked with each group, it is necessary to analyze the data with caution. The small number of participants does not allow for more robust statistical analysis, which is a limitation of the study. It is suggested further studies in order to keep avaliating the effects of SST with substance users in longitudinal terms, including maintenance sessions.

The use of different instruments for the assessment of social skills is highlighted as an important aspect, in order to contemplate observational and self-report issues. For future studies, it is suggested to keep instruments such as CHASO and STEI. However, it is identified that there is no need to continue using M-MSSE and CHASO in the same research, given that CHASO is a more recent version, in addition to being shorter than M-MSSE and with better reliability, as identified in the present study.

The frequency of social skills in the TC also requires studies with greater depth about its psychometric properties. Its satisfactory alpha indicates potential, at the same time that such data needs to be analyzed with caution. Therefore, it is believed that future studies on this instrument will contribute to a better assessment of social skills in the context of the Therapeutic Community.

Considering the aspects presented, it is observed that there are possibilities for innovative interventions in the Therapeutic Community, such as SST. In this perspective, it is adopted a posture that qualifies and improves the existing treatments, emphasizing the relevance of professional training for the conduct of SST.

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Publication Dates

• Publication in this collection
  26 Sept 2022
• Date of issue
  Apr-Jun 2022

History

• Received
  13 Jan 2020
• Reviewed
  19 Oct 2020
• Accepted
  06 Feb 2021