Design
This is a quantitative, quasi-experimental pilot study with pre-test, post-test, and follow-up (Sampieri, Collado, & Lucio, 2013).
Participants
In this study, 25 drug users were evaluated and 13 participants were included in the study, as shown in Fig. 1.
The 13 participants were males who had had been diagnosed with SUD and were under treatment in a therapeutic community (TC) in the northwest region of the state of Rio Grande do Sul (Brazil). Participants with the minimum of 75% frequency in SST were included (participating in at least six of the eight meetings). Participants who were illiterate (evaluated by self-report inventories) and/or had cognitive impairment (evaluated by Cognitive Screening with WAIS-III) were excluded from the study.
The participants were of a mean age of 39.38 years old (SD = 9.49). Educational attainment was categorized as follows (number of participants in brackets): some elementary school, no degree (4); elementary school (4); some high school, no degree (3); high school (1); and some college, no degree (1). Most of the participants were receiving treatment for crack abuse (61.5%; n = 8), followed by treatment for alcohol abuse (38.5%; n = 5).
Assessment instruments
Questionnaire on Sociodemographic Data and Drug Abuse
This questionnaire was developed by the research group “Cognitive-Behavioral Interventions: Study and Research [Intervenções Cognitivo-Comportamentais: Estudo e Pesquisa - ICCEP]” and is aimed at assessing sociodemographic data, the criteria of the DSM-5 (American Psychiatric Association [APA], 2014) for diagnosis of SUD and the Brazilian Criteria of Economic Classification (BCEC), from the Associação Brasileira de Empresas de Pesquisa (ABEP, 2015).
Cognitive Screening with WAIS-III
This is a test for the exclusive use of psychologists, developed by Wechsler (1997) and adapted and standardized for Brazilian Portuguese by Nascimento (2004). Screening includes vocabulary and block design subtests and is aimed at evaluating cognitive impairment. The vocabulary subtest evaluates verbal comprehension of words presented to the examinee, who is supposed to define them orally. The block design subtest evaluates perceptual organization through a set of two-dimensional geometric patterns that the examinee must reproduce by using two-color cubes. Subtracting the weighted score of the vocabulary subtest from the weighted score of the block design test, the result is a difference of three points or more, which indicates cognitive impairment, according to Feldens, Silva, and Oliveira (2011). Cognitive impairment was an exclusion criterion in the present study.
Multidimensional Scale of Social Expression—Motor Part (EMES-M)
This scale was developed by Caballo (1987) and translated and adapted to Brazilian Portuguese by Pereira (2015). It is based on a 5-point Likert scale, which ranges from “Never or very rarely” to “Always or very often,” and it is intended to assess social skills in adults. The original version contains 65 items and 12 factors while the adapted version for Portuguese has 56 of the original items and eight factors (Pereira, 2015). In the present study, the omega values of the full scale were 0.678 in T1 (1 week before the intervention), 0.654 in T2 (1 week after the intervention), and 0.716 in T3 (a month after the intervention).
Depression, Anxiety and Stress Scale (DASS-21)
The DASS-21 was developed by Lovibond and Lovibond (1995), and adapted and validated for Brazilian Portuguese by Vignola and Tucci (2014). The scale has 34-point subscales, and each subscale is made up of seven items, which simultaneously assess the emotional states of depression, anxiety, and stress during the last week. The symptoms evaluated in the depression subscale are inertia, anhedonia, dysphoria, lack of interest/involvement, self-depreciation, devaluation of life, and discouragement. The anxiety subscale seeks to evaluate the following symptoms: excitation of the autonomic nervous system, musculoskeletal effects, situational anxiety, and subjective experiences of anxiety. The questions on the stress subscale assessment evaluate the following symptoms: difficulty in relaxing, nervous excitation, easy disruption/agitation, irritability/overreaction, and impatience. For calculation of the final score, the scores need to be multiplied by two. The classification of this assessment instrument corresponds to normal, medium, moderate, severe, and extremely severe. In the present study, the omega values were depression, 0.658 (T1), 0.661 (T2), 0.703 (T3); anxiety, 0.714 (T1), 0.658 (T2), 0.733 (T3); and stress, 0.722 (T1), 0.764 (T2), 0.736 (T3).
World Health Organization Quality of Life Assessment (WHOQOL-BREF)
This is an abbreviated version of WHOQOL-100, with 26 questions, focusing on the assessment of quality of life based on respondents’ perception. It is used by both healthy and clinical populations (World Health Organization (WHO), 1995). This assessment instrument has 24 facets that are grouped into four domains: physical health, psychological, social relationships, and environment. In addition, there are two questions about overall quality of life. Omega values obtained in this study were 0.843 in T1, 0.766 in T2, and 0.727 in T3.
Ethical procedures
This study is part of a larger study entitled “Evaluation and Training in Social Skills in Chemical Dependents in Specialized Units,” approved by the Research Ethics Committee (Ethical Opinion Report No. 13.172) of the University of Vale do Rio dos Sinos (UNISINOS). After a letter of consent was sent by the Therapeutic Community Center, the patients were invited to participate in the research. An informed consent form was read out loud and explained individually to each participant to clarify that their participation was expected to be totally voluntary. The participants who agreed to join the research signed two copies of the form: one for the participant and one for the researcher.
Data collection procedures
The assessment instruments were applied by psychologists and psychology students, members of ICCEP (a group for teaching and research on cognitive-behavioral interventions), with prior training. This training was conducted by professional psychologists with previous experience in the treatment of drug users and SST management. The trainees received a “Researcher Manual,” and undertook practical assessment instrument application activities within the group. Moreover, data collection was supervised by experienced professionals.
After qualification of the research group members, the first meeting was held in the Therapeutic Community Center. With the purpose of motivating participation, the researcher gave a lecture to all the therapeutic community users. In this lecture, practical activities were carried out on social skills, and the users were given explanations about the research and invited to participate. The research started that week.
The assessment instruments were applied individually in rooms at the therapeutic community facilities. Two meetings were held for the application of all the instruments, each lasting for approximately 2 hours. All the assessment instruments were read out loud to the participants to ensure they clearly understood the questions. It should be noted that in order to make the participants feel more comfortable when answering the questions, the researchers who applied the latter assessment instruments were not the same as those who applied the SST.
During the first research week, the illiterate participants were identified and the Cognitive Screening with WAIS-III was applied to identify the participants with cognitive loss. The participants who agreed with the inclusion criteria moved on to the next stage in the subsequent week when the following assessment instruments were applied: Questionnaire on Sociodemographic Data and Drug Abuse, Mini International Neuropsychiatric Interview (MINI), Multidimensional Scale of Social Expression—Motor Part (EMES-M), and Depression, Anxiety and Stress Scale (DASS-21).
After the application of the assessment instruments and allocation of marks, the research team gave feedback to the respondents; they emphasized those social skills which could be strengthened and those that required further practice. Next, the respondents were invited to participate in the social skills training, which started that week. The assessment instruments were applied at three different times: 1 week before the intervention (T1), 1 week after the intervention (T2), and a month after the intervention (T3).
Intervention details
The intervention design was based on the review of literature and other references in the field of SST. The SST structure proposed by Lin et al. (1982) was selected: two 90-min weekly sessions for 4 weeks, in which the participants could choose the social skills they wished to develop.
The group format of the SST was decided on because it has benefits which tend to produce longer-lasting effects when compared to SST individual sessions (Argyle, Bryant, & Trower, 1974). All the sessions included the following elements:
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1.
Checking mood and diaphragmatic breathing
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2.
Homework review
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3.
Psychoeducation activity about the social skills to be learned
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4.
Social skills practice
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5.
Homework assignment
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6.
Feedback
The detailed description of each session is provided in Appendix.
The pilot study was conducted in a Therapeutic Community Center where the therapeutic program involved work and spiritual activities. During SST, the participants were encouraged to practice, with their peers, the skills they had learned in the intervention. The SST training was given by two psychologists with previous experience in the treatment of drug users. Both of them had participated in an SST training program to develop their SS. Subsequently, they conducted an SST training program with a non-clinical group and after that they conducted a pilot study under weekly supervision.
Statistical analysis
The data were analyzed using the Statistical Package for Social Sciences—SPSS, version 20.0. Descriptive analysis covered frequencies, percentage, mean, and standard deviation of the sample. Inferential analysis was performed based on an analysis of repeated measures, when comparing the average of the variables (social skills, quality of life, symptoms of depression, anxiety, and stress) among the three assessment times (T1, T2, and T3). In that analysis, sphericity was assessed by Mauchly’s test and, in cases of sphericity violation, the Greenhouse-Geisser correction was used. In situations of high variability of the standard deviation (asymmetric distributions), Freedman’s non-parametric test was applied as a resource. Intervention effect size, in turn, was analyzed by Cohen’s d. For statistical decision criteria, the significance level of 5% was adopted (p value < 0.05). For the assessment instruments, a decision was made to calculate the omega instead of the alpha value, because according to Crutzen and Peters (2017), alpha is an inadequate estimate for the validity and reliability of a scale. McNeish (2017) points out that alternative measures, such as omega, present greater reliability compared to Cronbach’s alpha.