ORIGINAL ARTICLE

 

Social skills of crack users accepted in therapeutic communities

 

 

Adauto Motta Filho^I; Andresa Aparecida Francisquini de Sousa^I; Randolfo dos Santos Junior^II; Júlio César André^III; Loiane Letícia dos Santos^IV

^IInstituição de Ensino Superior, Catanduva, SP, Brazil
^IIFaculdade de Medicina de São José do Rio Preto, Departamento de Psicologia, São José do Rio Preto, SP, Brazil
^IIIFaculdade de Medicina de São José do Rio Preto, Centro de Estudos e Desenvolvimento de Educação em Saúde, São José do Rio Preto, SP, Brazil
^IVInstituto Municipal de Ensino Superior, Departamento de Psicologia, Catanduva, SP, Brazil

Corresponding Author

 

 

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ABSTRACT

OBJECTIVE: through this study, we aimed to assess the social skills of crack users in abstinence, by characterizing the demographic profile and identifying possible deficits in social skills.
METHOD: with a convenience sample of 39 chemical dependents, with an average age of 40.7 years (± 10.48), hosted in therapeutic communities in the countryside of the state of São Paulo. The study is characterized as descriptive, transversal, with a quantitative delineation. Sociodemographic Questionnaire and Consumption Standard; Social Support Scale; Self-esteem Scale and the Social Skills Inventory (SSI) were the instruments utilized.
RESULTS: this study pointed out deficits in social skills in the general score (84.3%) of the participants and in the subcomponents of the social skills inventory. In the correlations of social skills and social support, affective (p < 0.0156) and emotional (p < 0.0299) factors were statistically significant, that is, the higher the social support indexes, the higher the social skills resources. The old age presented a negative correlation (p < 0,167) in social skills, that is, the older the age, the lower the social skills repertoire.
CONCLUSION: this study highlights the relevance of social support to the chemical dependent as a factor of better social performance, allowing subsidies for new researches in the area.

Descriptors: Crack; Therapeutic Community; Social Skills; Mental Health.

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Introduction

The psychoactive substance (PAS) use disorder has shown to be a multifaceted condition, with cognitive, behavioral and physiological elements of difficult control for both the user and society⁽¹⁾. Specifically in the connection with crack cocaine, it is noticeable the high power of compulsion and almost uncontrollable dependence, due to its rapid absorption, inducing the user to stimulating and extremely pleasurable sensations with greater fugacity⁽²⁾.

The most common profile among crack-cocaine users is male, young and adult individuals, with little formal education, unemployed, from vulnerable and low-income families. Several characteristic aspects are observed in this context of crack-cocaine users population, such as increased aggressiveness, involvement in illegal activities, lack of commitment to basic responsibilities, degradation of personal hygiene, and consequently, higher indicators of psychiatric comorbidities^(3-6).

In this context, the substance dependent individual suffers chronic discrimination and social exclusion, caused by the stigma related to crack cocaine, resulting from a social representation, with no precedent of change^(7-8).

According to epidemiological data from a national survey in Brazilian capitals and the Federal District in relation to the use of crack cocaine, 370,000 Brazilians are regular users, that is, they use once a week in Brazilian capitals (0.8%), 14% of which are children and adolescents, approximately 50,000. It was observed that 70% of users share tools for use such as pipes and cans of soda or beer. The northeast region presented the highest prevalence of PAS consumption, with about 150,000 drug users. The research also found that contamination by HIV virus among crack-cocaine users in Brazil is eight times higher than in the population in general⁽⁹⁾.

A national study on substance use showed that 0.7% of the sample (about 800,000 people) had used crack cocaine in the last twelve months and 1.3% (about 1.7 million Brazilians) reported having used crack cocaine at least once in their life, and the figures may be even higher since this study included no homeless participants, a portion of the population that is especially vulnerable to drug use⁽¹⁰⁾.

With the increasing epidemiological indexes in relation to crack cocaine, the Therapeutic Community (TC) became a place for those seeking treatment among the users of this substance. TC is a mode of service and integral care for chemical dependents, with a structured environment and without the presence of illicit substances, providing the achievement and management of abstinence, with comprehensive approach and bringing together professionals from various fields of scientific knowledge⁽¹¹⁾.

The stigma or stereotype in relation to crack-cocaine users is one of the factors of resistance to treatment. Thus, when experiencing a feeling of dysphoria and low self-esteem, associating to a possible hostile behavior of professionals as to their disease and substance of choice, they tend to have difficulty in adhering to the treatment. The professionals' hostility may be associated with the need to label, absence of empathy, or even a conservative and prejudiced view in relation to dependents⁽⁷⁾.

There is evidence that some elements such as interpersonal conflict, expectations, emotional states, frustrations, social inhibition, and social pressure may contribute to hinder the social reintegration of chemical dependents. They may consist in deficit of basic Social Skills (SS) to perform tasks and activities of everyday life, among the simplest and most necessary for life in community⁽¹²⁾. Deficits in social skills result in psychological and behavioral distress conditions, leading to impairments in interpersonal relations⁽¹³⁾.

Social skills can be defined as a set of learned behavioral capacities that accomplish social interactions assertively. With the acquisition of such social skills, the individual learns an adequate and considerate behavior in relation to the attitudes, communication, beliefs, desires, way of expressing emotions and opinions, in interpersonal relations, which compose the entire repertoire of sociability of the individual, and, consequently, adapting to the cultural and contextual patterns of their experiences⁽¹⁴⁾.

The absence of this component of sociability involves both verbal and non-verbal aspects, correlating to cognition, emotions and poorly adaptive behaviors in the resolutions of social interaction problems. With lack of training and non-acquisition of these skills, relapses may occur more frequently⁽¹⁵⁾.

Thus, social skills can also be exemplified through the social learning paradigm, which posits that skills can be developed by means of interpersonal experiences, pertinent to observing the performance of others, by a process of successful mental assimilation of models. These experiences mediated by cognitive processes (beliefs, perceptions and thoughts) will influence the acquisition of certain skills in a particular and unique way for each individual⁽¹⁶⁾.

Possessing social skills, in addition to being an effective factor of protection and resilience, enables interactions with other people with positive and satisfactory effects⁽¹⁷⁾. Accordingly, studies indicate that socially skilled behaviors may result in lower detriments to users, enabling greater interaction, and may contribute to a higher quality in their social relations, consequently adding significant changes to their lifestyle. Such adaptive behaviors being learned and trained resulted in better response in coping with the disease^(18-19).

Therefore, a taxonomy that is broader and more organized into social skills may contribute to better behavioral resolutions: a) communication: prepare and give answers to questions, reciprocate and exalt qualities, ask and give feedback in social relations, start, maintain and end conversation; b) civility: saying please, reciprocating a gesture, introducing yourself, congratulating, withdrawing; c) assertive coping: disregard opinion, consenting to something or not, disregarding and assuming errors, effecting affective/sexual relationship, ending love involvement, expressing anger and requiring behavioral modification, interacting with figures of superiority, reflecting with criticism; d) empathic: explaining support through paraphrase, showing feelings and providing support; e) work: coordinating groups, communicating in public, deliberating problems, making decisions, and mediating conflicts; f) educational and expression of positive feelings: building friendship, showing support and working love⁽²⁰⁾.

Thus, considering the complexity of the subject, it has been addressed in research in the context of clinical care and in studies on drugs and contributions to determine dimensions between social skills deficit scores and associations with PAS dependence in adolescents^(21-22), alcoholics^(23-24), women^(19,25), men⁽²⁶⁾, and smokers^(27-28). The results of these studies pointed out that lacking social skills may be a major factor in the use of licit and illicit substances, and that other populations resulting from other conditions and contexts should be researched⁽²⁹⁾.

By observing the analyzed aspects, it is understood that evaluating and measuring cognitive elements and social skills is a necessity, for self-knowledge and attention to possible mental traps that may arise⁽³⁰⁾. Investing in communication and dialogue leads to increased interpersonal relations and intrapersonal self-care, enabling PAS dependents to recover self-esteem and self-efficacy, being essential factors to protect from and prevent possible relapses and to provide reintegration to healthy social coexistence⁽³¹⁾.

Therefore, given the importance of studying new treatment methods and possibilities for providing integral care to crack-cocaine users, this study aims to survey the sociodemographic data of abstinent patients, trace possible deficits in social skills, and thus correlate the social support and self-esteem variables to understand which aspects serve as protection and which promote vulnerability to use and consequently to relapse.

 

Method

The study is characterized as descriptive, cross-sectional, with quantitative design. After approval by the Ethics Committee (opinion 2,900,192), data were collected in two therapeutic communities in the São Paulo state's countryside.

Convenience sample consisted of 46 chemical dependents; however, 7 participants were excluded from the study due to the time of abstinence and for not having used crack cocaine, according to the exclusion and inclusion criteria, totaling 39 participants.

Inclusioncriteria were being chemical dependent, crack-cocaine user, older than eighteen years, and male. Exclusion criterion was being participant admitted to the institutions who did not have a minimum of 10 days of abstinence. The instruments used were:

1. Sociodemographic data and consumption pattern questionnaire: this instrument devised by the researchers was developed to characterize participants as to age, marital status, educational level, religion, abstinence time, age of first use, frequency of use, use of substances with family members, suicidal thoughts, problems with justice, among other items.

2. Social Support Scale: It determines multidimensional indicators in social bonds, showing functional aspects of social relations. Composed of 19 items comprising five functional dimensions of social support: material, affective, emotional, positive social interaction, and information. This instrument covers: material social support (four questions) provision of practical resources and material aid; affective social support (three questions) physical displays of love and affection; positive social interaction social support (four questions) having people to relax and have fun with; emotional social support (four questions) social networking skills to fulfill individual needs in relation to emotional problems, for example, situations that require secrecy and encouragement in difficult moments of life; information social support (four questions) relying on people who advise, inform, and guide. For all questions, five answer options were presented: 1 "never"; 2 "rarely"; 3 "sometimes"; 4 "almost always"; and 5 "always"⁽³²⁾.

3. The self-esteem scale: Self-esteem has been widely determined using the Rosemberg Self-Esteem Scale (1965), conceptualized as an instrument that enables measuring and classifying the level of self-esteem into low, medium, and high. The scale consists of ten closed sentences, five referring to positive "self-image" or "self-value" and five referring to "negative self-image" or "self-depreciation." The sentences are arranged in the four-point Likert format, ranging from "totally disagree" or "disagree" to "agree" or "totally agree." Regarding the score, the higher the score obtained on the scale, the higher the self-esteem level of the individual^(33-34).

4. Social Skills Inventory: this is a self-reported instrument that evaluates situational and behavioral dimensions and traces the classes and subclasses of social skills that are deficient or as available element in the individual's inventory. Composed of 38 items, each describing a situation of interpersonal relation and a required skill to react to that situation. Respondents should estimate the frequency with which they react as suggested in each item, considering the total number of times they were in the situation described, and estimate the frequency of their response, on a five-point Likert scale ranging from zero (never or rarely) to four (always or almost always). In some items there is a "nega+tive" phrasing, that is, higher score indicates deficit of social skills, and in these the score should be reversed to obtain the zero. The instrument produces a general score, referenced in terms of percentiles, and scores in five sub-scales of social skills⁽³⁵⁾.

This study was conducted in two main stages, due to data collection being performed in different locations and cities.

1^st stage: group presentation, that is, with all of those admitted to the institutions, got informed of what the study is about in the two therapeutic communities and accompanied by a team member of both institutions.

2^nd stage: after individual guidance on the objectives of the research and ethical information, having agreed to sign the informed consent form, the collection of samples was initiated, individually configured, by applying a semi-structured interview plan, with the instruments described, with an average time of 40 to 50 minutes each application.

For analysis of sociodemographic data we used descriptive statistics, and for correlation we conducted Spearman test with 95% confidence interval (95%CI), considering p<0.05 significant. The analyses were performed using the GraphPad Prism software version 6.

 

Results

The total sample of this study consisted of 39 participants, with mean age of 40.7 years (±10.48), minimum age was 18 years, and maximum age was 64 years. The sample consisted solely of males, mainly characterized as white (56.5%), catholic (59%), with elementary education (48.7%), single (51.2%), and the predominant professional activity was general services (20.5%).

 

 

Table 2 presents the characteristics and history of substance abuse of the sample participants, in which the substance use initiation (53.85) was 13 to 18 years of age, (77%) reported having a history of use in the family, use with a family member was reported by (74.3%), and PAS use with more than one family member was (43.5%). The previous hospitalizations variable shows that 69.2% have used this treatment resource, 84.6% have some kind of family support, and 53.9% have support from friends.

 

 

Table 3 presents the results of the instruments used in this study, and as shown in the Rosemberg Self-esteem Scale the overall scores (17.1%), the Social Support Scale the overall score presented (14.1%). The Social Skills Inventory self-reported instrument generally indicated a deficit score (84.3%).

 

 

Table 4 shows the description in frequency (n) and percentage (%) of the data of each factor of the Social Skills Inventory (SSI). The components indicated well-developed repertoire (18%), good repertoire above the median (12.9%), good repertoire below the median (7.6%), and deficit in social skills (61.5%).

 

 

Table 5 shows the correlation between indicators of social skills and the factors of the Social Support Scale, Self-Esteem Scale, substance use initiation age, and current age of the sample participants. Relevant aspects were found in the Social support Scale variables in the affective factors (p<0.0156) and emotional factors (p<0.0299), and in the current age variable (p<0.0167).

 

 

It is important to emphasize that the results of this study showed direct associations in the dimensions of social skills and social support, primarily the affective factors (p<0.0156) and emotional factors (p<0.0299) with statistical significance value. These results indicate that the higher the social support values, the greater the social skills. For those admitted to therapeutic communities having social support is positive and of paramount importance, both for coping with the disease and for performance of social competence.

 

Discussion

Psychoactive substance use in adolescence has increased the vulnerability and dependence, considering the impacts on school dropouts⁽³⁶⁾. Another study, with 35 polyusers undergoing outpatient treatment, evaluated the Social Skills (SS) and possible correlations with PAS use of these patients, presenting significant relations in factors related to coping skills and self-affirmation with risk and difficulties in conversation and social resourcefulness in the Social Skills Inventory (SSI), pointing to lack of SS to deal with situations that require social agility⁽³⁷⁾.

It is observed through the historical variables of use in family, degree of kinship, and history of use with family members that the power to influence in the process of psychoactive substance (PAS) abuse, in a serious way, the adolescent's identity construction in the family context is most significant and of paramount importance. Thus, it has been found that these families, who have history of PAS use and consequently the lack of healthy values, influence the formation of this individual, even more because that is a period of biopsychosocial transformation of constitution of the personality, the use of drugs can foster significant losses in the development of this subject⁽³⁸⁾.

The individual's development process occurs in the primary family environment, since the social responses are assimilated by the transfer of behaviors observed and experienced along with other people in the family environment. Accordingly, a family with a history of drug use presents a highly deficient process of learning and acquiring strategies in social skills⁽³⁹⁾.

Another study by Schneider and Andretta⁽⁴⁰⁾ showed correlation of aspects associated with deficits in social skills, self-control, aggressiveness toward aversive situations and abusive use of drugs. The results indicate that individuals whose father, sibling or other family members had a history of drug use had a higher risk for the initiation and development of their abusive consumption. Through highly conflictual family relationships, this individual learns to relate in a non-assertive way, finding difficulties in exposing and controlling their behaviors.

The multifaceted aspect of self-esteem indicated low general levels of the participants, suggesting indications that possible alterations are associated with the continued use of PASs and treatment site. Factorial analysis proposed by the scale confirms what is being observed in this low self-esteem crack-cocaine users population, due to self-destruction and upset, caused by the highly pernicious impact of the substance on the user⁽³³⁾.

As for the social support aspect of the participants of the study, it indicated that at some point in life they may rely on the support of family members and friends for stressful situations. We found in the subcomponents of the scale evidence that social bonds have a significant influence on the maintenance and improvement of the quality of life of these users and that the lack of this resource post-discharge can be determinant for lapses and relapses⁽⁴¹⁾.

Deficient incidence in social skills was found in the abstinent crack-cocaine users, consistently with other researches tat found in this population deficits in more significant social skills, due also to the harmful damage caused by the substance. Comparative studies with dependents and non-dependents found in the sample characterized by dependents results of lower scores in this dependent population. Finding of social skills deficit has been confirmed in association with different conditions⁽⁴²⁾.

In Portugal, a study analyzed anti-social and criminal behaviors and social skills, in different contexts, divided into three subgroups: non-users of illicit substances, dependents in therapeutic community, and a host house for damage reduction. The existence of deficiency differences was found in the sample of dependents, at the level of social skills in the factorial scores of coping and self-affirmation with risk, the subgroup of chemical dependents in TC obtained a low value, while the group in the host house presented lower mean levels of conversation and social development⁽⁴³⁾.

Another study conducted a systematic review in the Medline Complete, Scopus, IBECS, Index Psi and LILACS databases, resulting in 89 articles, of which 13 were analyzed in full, and 5 articles were selected. This review concluded that drug users show negative scores in SS, and that training in SS may be an effective strategy; such studies show the evolution of the care that has been provided to treat this disease⁽⁴⁴⁾.

Given the increase in national studies addressing social support, we highlight the effort that is employed to determine the support of these individuals. This perceived support refers to the perception of support in a certain difficult and stressful situation faced. Therefore, social support probably establishes singular aspects of the personality, considering that the events that occur in life may compromise the skills and that this support is effective⁽⁴⁵⁾.

Moreover, the sum of complications resulting from the combination of parameters of compulsive use, which crack cocaine causes in the lives of these users, the wide range of damage is unquestionable, especially as to that which intrinsically relates to the rupture of the family bond, leading to extremely deficient social support⁽⁴⁶⁾.

The current age variable presented a negative correlation, that is, the higher the age, the lower the social skills indicators. When evaluating the senior population with deficits in social skills there was scarcity in the literature; it was found that the present sample in the therapeutic communities resulting from the involvement with crack-cocaine use brings harm to users, indicating lack of social skills, compared with the younger individuals, thus limiting social performance with resourcefulness. Several factors such as early use initiation, genetic inheritance, and institutionalization may negatively contribute to segregate this repertoire of sociability⁽⁴⁷⁾.

Studies show the importance of behavioral changes in people in this age group, and this social integration is essential for improving the physical and mental health of these users⁽⁴⁸⁾.

Because of the relevance of seeking innovative possibilities of more effective treatment for substance users, this subject has been addressed by many researchers in the last decade. Recently, a study showed circumstances associated with deficient scores in the Social Skills Inventory (SSI) among crack-cocaine users. With a sample of 519 individuals, of which 497 men (95.8%) and 22 women (4.2%), it was found that 52.8% presented deficit. Another important aspect observed was the SS-deficient relationships with mourning for the loss of children, involvement in illegal activities. The scores show that high social support is related to social skills, consistently with the present study⁽⁴⁹⁾.

Therefore, it is evident to the several discussions involving the subject, about risk and protection factors of chemical dependents, and the SS are associated with both aspects. A study showed the relation of the SS divided into two groups, crack-cocaine users and non-users. In the users group, the results showed higher skills on coping with risk and lower skills of conversation and social resourcefulness. Moreover, the study showed that having children and not having a companion (single or divorced) also increased the probability of using crack cocaine⁽⁵⁰⁾.

Finally, it is important to consider the limitations of this study, which correspond to the restriction of the research sites, becoming evident that other empirical studies should be carried out comprising other communities and sex, so as to provide a broader understanding of the phenomenon, thus guaranteeing the effectiveness of programs scientifically based on prevention and integral care in the treatment of chemical dependents.

 

Conclusion

The present research enabled through the results found the comprehension of several aspects that are characteristic of this population, which may be related to the triggering of the repertoire of crack-cocaine use. It was found that the greater the social support, the better the repertoire of social skills, possibly influenced by the need to restore the bonds in the help to cope with abstinence.

It was also found that senior individuals possess less resources in Social Skills (SS) than the younger participants in this study. The study shows that some elements such as early age at the psychoactive substance use initiation, having a history of use in family, use with a family member, low self-esteem, lack of social support, and deficits in SS resources presented relevance, and are related to multiple risk factors and vulnerabilities for possible relapses.

Thus, this study aimed to contribute to the understanding of chemical dependence and associations with social skills in individuals in therapeutic community, obtaining as a result the need for inclusion of social skills evaluation and training in the therapeutic intervention method of these treatment sites, in order to increase the repertoires of coping with drug use and decrease relapses through reintegration into social coexistence.

 

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Corresponding Author:
Loiane Letícia dos Santos
E-mail: loiane.psicologia@gmail.com

Received: Mar 5^th 2019
Accepted: Jul 29^th 2019

 

 

Authors' Contribution: Study conception and planning: Adauto Motta Filho, Andresa Aparecida Franceschini de Sousa, Loiane Letícia Dos Santos. Data collection: Adauto Motta Filho, Andresa Aparecida Franceschini De Sousa. Data analysis and interpretation: Adauto Motta Filho, Andresa Aparecida Franceschini de Sousa, Randolfo Dos Santos Junior, Loiane Letícia Dos Santos; Statistical Analysis: Randolfo Dos Santos Junior, Loiane Letícia Dos Santos; Manuscript writing: Adauto Motta Filho, Andresa Aparecida Franceschini De Sousa, Randolfo Dos Santos Junior; Manuscript critical review: Adauto Motta Filho, Andresa Aparecida Franceschini de Sousa, Randolfo Dos Santos Junior, Júlio César André, Loiane Letícia Dos Santos.
All authors approved the final version of the manuscript.
Conflict of interest: The authors declare no conflict of interest.