Introduction

Substance Use Disorders constitute a maladaptive pattern of use, including impairment in different areas of the subject's life (^{American Psychiatric Association (APA), 2014}). People who are affected by such disorders have greater cognitive and behavioral impairment when compared to nonusers, and such difficulties are more evident in self-regulation and self-control skills (^{Czermainski, 2016}) .e.

Deficits related to inhibitory control of cocaine and crack users were identified in a systematic literature review, which points to high levels of impulsiveness, contributing to this population experiencing insufficiency in self-regulation and self-control (^{Czermainski, Willhelm, Santos, Pachado & Almeida, 2017}). Specifically in crack users, the skills dysfunctions previously mentioned that act as executive functions make cognitive processing difficult in planning and executing goals. Such alteration occurs in the same prefrontal region where neuronal connections that moderate self-control, making this ability even harder in drug addicts (^{Hess, Silva & Almeida, 2017}).

In female crack users, the self-control of aggression in aversive situations is especially relevant, as impairments of this ability make social interactions difficult and may lead to social isolation (^{Caballo, 2003}). The self-control of aggression to aversive situations is defined by ^{Del Prette and Del Prette (2001}) as a type of social skill in which the expression of dislike or anger is performed in a socially competent manner, avoiding future problems in social interactions.

Different factors can hinder aggression self-control: the use of stimulant substances such as crack, the contexts of interaction, situations related to drug use and psychiatric comorbidities, as it will be explained bellow. The literature points out that the search for immediate rewards and impulsivity, characteristic of crack use, can hinder this self-control (^{Bungay, Johnson, Varcoe, & Boyd, 2010}). The increase of impulsive behaviors and the decrease of executive functions (control of impulsive behaviors) were identified in female crack users, when compared to the control group, according to a Brazilian study with 98 women (^{Hess, Menezes & Almeida, 2017}). In its turn, difficulties in aggression self-control may also contribute to drug use, being the drug used as a maladaptive way of dealing with interpersonal situations (^{Caballo, 2003}). According to a multiple case study with three female crack users, it was found that difficulties in aggression self-control occurred since childhood, not being an exclusive factor in drug use. The family context whose manifestation of anger occurs in a maladaptive manner may contribute to such difficulties (^{Limberger & Andretta, 2017}).

The literature also points out that situations related to drug use, such as trafficking, are related to difficulties in aggression self-control. Low levels of self-control were associated with drug use and use-related offenses, according to a study in Israel with 60 inmate women, divided into groups according to the type of crime committed (violent crimes, by fraud and related to drugs) ( ^{Shechory, Perry, & Addad, 2011}). In the study mentioned, it was found that the higher the self-control levels were, the lower were the aggressiveness rates. In addition, women who had lower levels of self-control belonged to the group of participants who committed an infrational act for drug-related crime and reported higher drug use. In another study, users who had greater difficulties in social skills were also the most involved in crimes such as robbery and theft (^{Horta et al., 2016}). In this sense, it is understood that everyday violence in the contexts of use (^{Bungay, Johnson, Varcoe, & Boyd, 2010}) hinders the performance of a socially skilled repertoire translated by important deficits of aggression self-control.

In its turn, contexts of interaction that are not related to drug use can promote a socially skilled repertoire, including self-control of aggression, given that the development of social skills takes place through lifelong learning experiences. in contexts like family, school, work, etc. (^{Argyle, Bryant, & Trower, 1974}; ^{Caballo, 2003}). From this perspective, high social skills were presented by crack users when they had significant social support, according to a Brazilian study with 519 crack users (^{Horta et al., 2016}).

Psychiatric comorbidities, such as personality disorders, can also hinder aggression self-control, with impaired interpersonal functioning (^{APA, 2014}). In its turn, depression and anxiety disorders can also hinder the performance of social skills as a whole, by their characteristics (sadness, over-worrying, etc.) competing with a socially skilled repertoire (^{Caballo, 2003}), and in some cases, depressive symptoms manifest from aggressive behavior (^{Hebenstreit, Deprince & Chu, 2014}; ^{You & Lim, 2015}; ^{Yavuzer, Albayrak & Kılıçarslan, 2016}).

Considering the impulsivity related to crack use (^{Hess, Menezes, & Almeida, 2017}), the presence of damage in the aggressiveness self-control in crack users (^{Almeida, Flores & Scheffer, 2013}; ^{Czermainski, Willhelm, Santos, Pachado & Almeida, 2017}) and the lack of specific studies with female crack users (^{Limberger, Nascimento, Schneider, & Andretta, 2015}), there is a need for evidence to explain which factors contribute to the difficulties in self-control of aggression by female crack users in order to promote advancement in the area and greater attention of health and public policy professionals (^{Limberger, Schneider, & Andretta, 2015}). Thus, the objective of this study is to identify the predictive value of psychiatric comorbidities, interaction contexts and situations related to drug use in the self-control of aggression of female crack users.

Method

Participants

A total of 62 women hospitalized by the Brazilian public health system, called the Unified Health System (SUS), participated in this study for detoxification due to the use of crack. The sample size calculation was performed using STATS 2.0 statistical software, with a desired confidence level of 80%.

The following inclusion criteria were adopted: women aged between 18 to 59 years old, with DSM-5 diagnostic criteria (^{APA, 2014}) for Crack-Related Disorder, abstinent for at least seven days, between the seventh and the fifteenth day of hospitalization. The choice for such period of time was in order to delimit the treatment time (^{Kopetz et al., 2014}). Simultaneous use of other drugs could occur as long as crack was the drug that motivated the decision for hospitalization.

Likewise, the exclusion criteria were: presenting psychotic syndrome (verified through Mini International Neuropsychiatric Interview) and having cognitive impairments (verified through the vocabulary subtests and cubes of WAIS-III Cognitive Screening), instruments that will be described below. It is noteworthy that abstinence was assessed from self-report, in addition to considering the closed regime of hospitalization.

The steps to selec participants can be observed in Flowchart 1.

Flowchart 1 

A total of 62 participants, mostly single (62.9%; n = 39), reported incomplete elementary school (50%; n = 31) and an average age of 33.45 years old (SD = 8.14). Before hospitalization, 51.6% (n = 32) of the women interviewed worked. As for the region, the majority came from hospitals in the metropolitan region (83.87%; n = 52) and 16.13% (n = 10) from hospitals in the northwest region of Rio Grande do Sul state - Brazil.

Results

Initially, the general repertoire of social skills of female crack users undergoing treatment was evaluated. Specifically regarding the aggressiveness self-control, focus of this study, it was indentified that 38.7% (n = 24) of the participants presented deficit, 19.4% (n = 12) reported repertoire bellow the average, 11.3% (n = 7) reported medium repertoire and 30.6% (n = 19) reported quite elaborate repertoire.

Subsequently, when comparing the sociodemographic, clinical and related to the use of drugs characteristics in the aggressiveness self-control score, it was identified lower scores on aggression self-control in women with the following characteristics: women who did not work before hospitalization, who had involvement with trafficking. sustaining drug use had Major Depressive Episode and Personality Disorder, as can be seen in Table 1.

Table 1: Comparison between aggressiveness self-control in psychiatric comorbidities, interaction contexts and drug-related situations 

The variables that showed statistically significant differences in Table 1 were submitted to a multiple regression analysis (Stepwise method), which identified that the involvement with drug trafficking and the Major Depressive Episode were predictors of low scores in aggression self-control, as can be seen in Table 2. Such procedure provided an explained coefficient of variance (R2) of 0.193, which determines that the selected independent variables explained 19.3% of the low scores on aggression self-control. The variables “having personality disorder” and “working before hospitalization” were not statistically significant, in other words, they did not provide an explanatory power for aggression self-control in the participants of this study.

Table 2: The impact of psychiatric comorbidities, interaction contexts, and drug-related situations on self-control of aggression in crack users 

Discussion

It was identified, from the proposed objective, characteristics of the participants who presented lower scores on aggression self-control (not working before hospitalization, engaging in drug trafficking to afford the use, presenting Major Depressive Episode and Personality Disorder). From these characteristics, only two presented an explanatory value of the low scores on aggression self-control: involvement with drug trafficking and the Major Depressive Episode, as it will be discussed below.

Engagement with drug trafficking and the criminal network are violations that relate to impulsive and aggressive behavioral characteristics (^{Almeida et. Al, 2014}). Antisocial Personality Disorder, for example, is a psychopathology that has poor impulsivity control and aggression self-control (^{APA, 2014}) and is closely related to the deficit in aggression self-control and consequent violation of social rules. According to a study with 1052 substance abusers in Sweden, Antisocial Personality Disorder and stimulant drug use were predictors of criminal behavior, including drug trafficking (^{Fridell, Hesse, Jæger, & Kühlhorn, 2008}).

In the Brazilian context, a study carried out in a unit of the Foundation of Socio-Educational Assistance in the metropolitan region of Porto Alegre (RS), with 83 young men, identified similar results (^{Davoglio & Gauer, 2011}). The use of psychoactive substances correlated positively with the infractions for which young people were complying with socio-educational measures, including drug trafficking, which acted as a catalyst for violence and corresponded to 6% of the crimes committed by these adolescents. Still in this context, ^{Guimarães, Santos, Freitas and Araujo (2008}) found the presence of criminal records (40% of the surveyed sample) in crack users admitted to the Detoxification Unit of the São Pedro Psychiatric Hospital of Porto Alegre (RS).

Facing the data presented in this study, it is understood that in addition to typical behavioral characteristics of offenders (such as impulsive deficit and aggression self-control), the use of drugs itself contributes to criminal involvement. In addition, by inserting themselves in drug trafficking, female users expose themselves to risks and violence that hinder the self-control of aggression, lacking contexts that promote social skills (^{Limberger & Andretta, 2017}).

In addition to involvement with drug trafficking, the major depressive episode also presented an impact on low aggressiveness self-control scores, acting as a predictive factor. This data corroborates the perspective of ^{Caballo (2003}), who states that depression hinders the practice of social skills. ^{Segrin (2000}) also points out that depressed people can distort their social skills in self-report instruments, judgind themselves as less socially competent than they really are.

Also in this context, the relationship between drug use, social skills and depression was also investigated in a Brazilian study with 179 nursing students, mostly women (88.6%). The data showed that students using licit or illicit drugs were more likely to have depressive symptoms, which increased the probability of drug use (^{Botti, Monteiro, Benjamim, & Queiroz, 2016}). In its turn, when social skills are satisfactorily developed, and this includes improved aggressiveness self-control, depressive symptoms tend to diminish by modifying the subject's behavior and contributing to interpersonal relationships, as pointed out by a systematic literature review. (^{Campos, Del Prette & Del Prette, 2014}).

Considering that depressive symptoms can negatively influence interpersonal relationships (^{Feitosa, 2014}), interventions such as Social Skills Training can contribute to treatment with depressed patients. The skills practiced in training can be incorporated into the participants' social repertoire, maintaining more satisfactory social relationships and increasing the sense of mastery and pleasure, contributing to the reduction of depressive symptoms (^{Andretta, Limberger, & Schneider, 2016}).

The other characteristics investigated (not working before hospitalization and having personality disorder) presented lower scores on self-control of aggressiveness, but have no explanatory value. It is understood that the work context plays a role in the development of aggressiveness self-control and that in its turn other characteristics may be involved in the group of women who did not work before hospitalization, such as the degree of severity of the type of disorder related to crack use (light, moderate, or severe).

Considering that in this study only four personality disorders were evaluated for a population of 62 women, the enlargement of the sample and evaluation of the other disorders would enhance other possibilities of analysis. The data from this study also need to be analyzed with caution, as it is about a specific population of the northwest and metropolitan region of the state of Rio Grande do Sul/Brazil, not being possible to make generalizations for the country. It is also believed that it is relevant to investigate the predictive factors of other social skills factors, such as coping with risk; self-affirmation in the expression of positive affect; conversation and social resourcefulness and self-exposure to strangers and new situations. Research in the area of social skills needs advances in the field of crack users, in order to understand this phenomenon and to develop interventions based in empirical evidences.

Conclusion

Self-control of aggression is a fundamental skill both in the treatment and psychosocial rehabilitation of crack users, because the assertive management of aggression contributes to satisfactory interpersonal relationships and reduction of future problems. From this study, it was found that involvement with drug trafficking and depression were predictors of low scores in aggression self-control. Thus, it is understood that health professionals and researchers may be more aware of such characteristics in the treatment of female crack users. Knowing this, the union of factors (change in lifestyle, without exposure to risks such as trafficking, appropriate treatment for depression integrated with Social Skills Training and specifically the improvement of aggressiveness self-control) may contribute to the development of a repertoire of social skills with effective results, reducing risk factors for drug use.

As a specific contribution of this study, it is observed a deepening of a specific social skill, the self-control of aggression. It is noticed that studies of social skills, as they are a set of behaviors, must consider the specificities of social skills classes, identifying their repercussions in the lives of individuals whose repertoire has losses.

It is understood that the phenomenon of crack use in women is complex, and there is a need for further studies that include other aspects, such as factors that contribute to motivation and permanence in treatment, more effective forms of access to treatment, among others. In addition, it is suggested that future studies evaluate the effects of Social Skills Training with female crack users.