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Acceptability and applicability of an intervention program with substance addicts

Abstract
The complexity of the problems related to the harmful use of substances requires regular questioning of practices. This article aims to explore the acceptability and applicability of an intervention programme for patients with problematic substance use. Methods: Qualitative study. Data collection, through a focus group with 6 nurses and 6 semi-structured interviews with patients under treatment. We have used lexicographic textual analysis. From the focus group, 151 text segments were analysed, retaining 85.8% of the total for the creation of five classes. An analysis of similarity led to the formation of two central nuclei, represented by the words ‘Nursing’ and ‘Intervention’. From interviews, 252 text segments were analysed, retaining 71.83% for the creation of 5 classes. An analysis of similarity led to the formation of three central nuclei, represented by the words ‘want’, ‘programme’ and ‘see’. Nurses recognise the need for a more structured and flexible approach focused on people’s needs. Users also affirm the need for flexible interventions, without a pre-established time frame, that promote labour integration, therapeutic support for abstinence and management of comorbidities.
 
Introduction
About 1.2 million people in Europe are currently under treatment for illicit substance use 1. In Portugal, a policy was implemented in the year of 2000, aiming at decentralisation, national coverage, proximity responses, with a humanistic orientation of harm reduction and decriminalisation of public or private use, acquisition, and possession of any drug. This policy has contributed to the creation of many specialised outpatient support units with multidisciplinary teams, integrating a psychosocial support network articulated with basic health care. These public health policies have reduced the prevalence of problematic substance use, compared to other countries in Europe, lowered rates of infectious diseases, reduced penalties for drug-related crime and made it clear that this was a social problem of extensive impact2. Among the various outcomes associated with this approach, the users\' survival and consequent ageing stand out. From this perspective, and given the users\' complex health needs, the importance of nursing care stands out, since it has a key role in the development of structured responses to the problems caused by substance abuse. Users call for a more active role of nurses in their monitoring processes, that value their care and shared decision on care plans3. Nursing can play a leading role with interventions aimed at reducing stigma, increasing users\' knowledge, promoting recovery, responding to the needs of older people, and helping to empower them to self-manage their addictions. However, regarding "nursing intervention programmes" for patients with substance addiction, evidence is still scarce3. Nurses work closely with drug-based programmes4, through appointments and programme management. However, nurses should seek new systematised approaches in response to people\'s needs and increase the level of evidence of the interventions they perform, which should have a multidisciplinary matrix5.
In many chronic illness situations, such as drug abuse, people need programmes to train and develop a better capacity for self-management of their health situation6. It is for this reason that a set of interventions or strategies may be included in an "Intervention Programme", defined as a set of activities, structured in organized sessions, and aiming at a certain objective. Some authors place these programmes to develop social competencies and acquire confidence and should be supportive and stimulating contexts7. Many of these programmes differ in structure, content, target population and type of response8 and their indiscriminate use cannot be considered adequate. When opting to create a "new" programme, the cultural characteristics of the population, the health problem, the care to be provided and accessibility must be considered. Both professionals and experts by experience (people with experience of the health problem) should be heard, as they provide essential details about the need for it, comparing it with the existing ones, and adapting it to the context for its development, viability and effectiveness9.
In line with what some authors advocate10, this research intends to contribute to greater consistency in the way treatments are implemented, and to the identification of better settings for intervention programmes. Thus, the aim of this study is to explore the acceptability and applicability of an intervention programme for patients with problematic substance use.
Methods
Type of study
Exploratory study, with a qualitative approach, integrated into the development of a complex intervention. It is intended to structure the intervention and to perform the initial analysis of acceptability and applicability by the stakeholders (substance users and nurses) of the context where the intervention may be implemented9,11. Activities were defined for the focus group (FG) phases, planning, preparation, moderation (introduction, development and conclusion), data analysis and dissemination of results12.
Population, sampling and selection criteria
Convenience sampling. Inclusion criteria: nurses working in public health outpatient units, specialised in addictive behaviours and addictions (ABA), in different regions of the country, for more than 5 years; or in higher education institutions, with experience in ABA and in the development of complex interventions. Users were selected by nurses from a team with the aforementioned characteristics, integrated in a drug-based programme and followed in a nursing consultation; or people discharged from a drug-based programme in the last 6 months.
Data collection and variables
Data collection from nurse participants was conducted through an online FG, using the Zoom platform for audio recording, in February 2021. The FG with 6 nurses was led by the main researcher, with a duration of 1h40min. Since the main researcher and the participants knew each other personally and professionally, due to their shared area of clinical practice and research, special attention was paid to explaining the study and obtaining consent. The FG was recorded, transcribed and the texts were analysed. The questions that guided the FG were: 1. Within the scope of drug support programmes, do you consider that one would benefit from a structured training programme for self-management of the consequences of substance dependence? 2. What should be included in such a programme (interventions, duration, objectives, participants)? 3. How can such a programme be made attractive to people? We also posed questions about age, level of education, profession, length of professional experience in the field of ABA, and previous experience in the development of intervention programmes.
Due to the Covid-19 pandemic, six semi-structured interviews were conducted, between June and August 2021, to collect data from users. The interviews were conducted at the premises of a specialised outpatient public unit in the Greater Lisbon region, recorded on computer in audio format and then transcribed. The interviews, transcription and text analysis were carried out by the main researcher (external to the team and without personal knowledge of participants) as well as by other researchers external to the unit\'s team. The average length of the interviews was 22 minutes. The interview questions were: 1. In what way have you been helped to cope with the consequences of your addiction? 2. How do you think teams could better help people coping with the consequences of their addiction? 3. Would you consider that a structured training programme for self-management/self-care of the consequences of substance dependence would be beneficial? In addition, participants were also asked about their age, time of substance use and time of follow-up in medication programmes.
Data processing, data analysis and conceptual framework
The analysis of the data that resulted from both the FG and the interviews were carried out using lexicographic textual analysis, the Descending Hierarchical Classification (DHA) and similarity analysis, through the software IRaMuTeQ - R Interface, following the recommendations of other authors13. This approach does not require any prior coding or classification of the content. No content was sent to participants for validation. The main researcher discussed the data, already anonymised, with the research team. COREQ recommendations regarding the design and reporting of qualitative studies were followed14.
Ethical aspects
The objectives were explained, doubts were clarified, and participants\' informed consent was obtained. This study received a positive review by the Health Ethics Committee of the Regional Health Administration of Lisbon and Tagus Valley (7211/CES/2020), and all institutional authorisations were obtained.
Results
Five nurses specialised in Mental Health and Psychiatric Nursing and one generalist nurse, aged between 35-54 years (mean 47.3, standard deviation (SD) = 7), three men and three women, two with a PhD in Nursing, two with a master’s degree and two with a Bachelor\'s degree, participated in the FG. The average time of experience with people with ABA was between 11 and 20 years (mean 18, SD=3.9). Of the 6 participants, 3 had previous experience in having contributed to the development of intervention programmes for people with ABA.
Concerning the interviews, participants included 5 men and 1 woman, aged between 45-63 (mean 58.4, SD=7.6); with a mean time of substance use of 27.4 years (SD=14.1) [9-43] and a mean time of permanency in the programs of 11 years (SD=8.8) [2-11]. 3 were working regularly, 1 had intermittent work, 1 was retired and 1 was unemployed. They all lived on their own or in rented accommodation, and none was homeless. Only 1 of the participants lived alone.
Regarding the lexicographical analysis, in the CHD the criterion used as a cut-off bridge for the inclusion of the elements in the dendrogram classes, was the value of X²≥ 3.84, the calculation being defined according to a significance level of 95%. All words included present an X2 higher than the reference value and a p-value <0.0001. In the analysis of the focus corpus and the interview corpus, it was not always possible to apply the criterion double the average frequency, possibly due to the number of texts (16 texts in the FG and 6 texts in the interviews). In the FG analysis, the double of the average frequency was 18 (2*9) and in the interviews it was 12 (2*6). The lexicographic textual analysis from the FG revealed 6381 occurrences of words, distributed by 715 forms, with an average of 9 words for each form.
Through the CHD, 151 text segments were analysed, retaining 85.8% of the total for the creation of 5 classes resulting from the participation of the content regarding the Nurses\' perception of the need and structure of an intervention programme (Table 1).
The vocabulary in class 1 allowed us to call it "Model of the intervention", being responsible for 15.9% of the text segments analysed in the corpus. The words ‘change’, ‘need’, ‘theoretical’, ‘status’, ‘nursing’, help understanding the vision shared by the participants, agreeing on the benefit of a change in the form of intervention. This intervention should be centred on people and their behaviour, based on nursing diagnoses and on a defined theoretical framework. The need to be able to perform a structured intervention focused on empowerment for self-management of the consequences of drug addiction achieved consensus and acceptability, and nursing knowledge was inherent.
Table 1

The excerpts of the participants\' discourse, show that, by analysing their practices, nurses consider the discussion, construction, and creation of a structured model of intervention to be beneficial.
[…] They can serve as inspiration for the organisation of these stages, which will somehow correspond to what are the stages of a journey of change, i.e. of change of status, which is what is intended (nurse 5(e5)).
[...] there are interventions that I can do and measure and realise that after so many nursing appointments I achieve a gain in a certain area, a gain is a change, the change of status, of behaviour (e2).
[...] This is what bothers me, it\'s the fact that we are stuck in a type of work that we are doing and that there are a number of things that we even detect and feel that people need (e6).
In all classes, it was possible to identify words that appeared in 100% of the text segments of class 1, although with reference values without statistical significance (p>0.001), but with semantic proximity to those included in the class (significance to the lexical conception). In this class 1, the words ‘diagnosis’, ‘help’, ‘need’ may relate to an intervention model with a final focus on promoting well-being and meeting needs.
Class 2 was entitled "Participants" justified by 21.2% of the textual data analysed. The words ‘technician, ‘reference’, ‘person’, reveal the comprehensiveness of the participants’ reflection on the actors involved. Professionals with different disciplinary backgrounds such as facilitators/therapists, the people being cared for and the relationship as a bond emerged as the reference matrix to delimit the active actors in this process. The participants’ competence is perhaps the main reference for dynamization, in addition to the active role of the caregivers.
[...] that nurse will work with the person within the scope of his/her competencies. They will interact with other technicians according to the various needs people have (e5).
[…] Then there is the issue of the relationship and the link. Sometimes it is not because I am the user\'s reference technician that he is more attached, sometimes it is precisely to another technician that he will be attached (e3).
[...] individuals are unique, and the truth is that there must be a need, sometimes the need is not identified by the individual, but by us, the technicians, who in principle see things from another point of view (e3).
From the complementary analysis of the words that appeared in the text segments, the following words stand out: ‘therapist’, ‘psychologist’, ‘nurse’, ‘physician’, ‘competence’, ‘user’, ‘relationship’. They show a departure from the single concept of who is the most suitable professional for the intervention and suggest an association between different knowledge. The performance by only one nurse was unanimously considered possible, but the indication of a generalist nurse or a specialist in Mental Health and Psychiatric Nursing was questioned.
Class 3 was designated as "Structure of the intervention", totalling 25.8% of the analysed corpus, and the main words emerged as: ‘individual’, ‘group’, month’. When reflecting on such a complex issue, most participants had difficulties in being direct and objective in reflecting on the structure, which was observed in the lexical vocabulary of the class, since an intervention of this nature may have different structures.
[...] there are different issues of individual character that need to be worked on such as emotional management, anxiety, sadness, where many times they can be worked on in a group but need to be complemented with an individual approach (e3).
[...] about the durability of the 3 months, I have also worked in programmes where there was a limited time, 2 or 3 months, sometimes this time is not the time of the person (e6).
In addition, the words ‘durability’, ‘limited’, ‘integrate’, programme’, ‘intervention’, and ‘nursing appointment’ contribute to a reflection on the therapeutic integrality and intentionality of a program.
Class 4 represents 17.2% of the textual segments and was designated "Focus of intervention", as it contains the words ‘consequences’, ‘problem’, ‘training’, ‘self-management’, ‘approach’, ‘stop’, ‘consumption’. This class focuses on the need for help to deal with the consequences of drug addiction, the empowerment for self-management of the problem, and quitting the consumption, as can be seen in the following excerpts
[...] there is a problem associated with cocaine use that teams find difficult to deal with. Coming back to the issue of empowering self-management of consequences, what we want is to educate people for better health and we try to come up with strategies to meet this challenge (e4).
[...] each stage would have within it a certain objective and a set of activities, and the order of the stages is not necessarily rigid. I liked the systematisation of the factors that can contribute to greater effectiveness in the self-management of the consequences (e5).
[...] Often this is behind not stopping consumption. I can\'t stop using because I can\'t find work, because I am anxious, sad or because of family conditions (e1).
The word ‘advantage’ demonstrates the consensus in the creation of an intervention model. The words ‘addiction’ and ‘structured’, are related to the focus of the intervention, orienting towards the structure adapted to the focus and present a significance to the lexical conception. The word ‘familiar’ broadens the view of the client who is the target of care.
Class 5 was assigned the name "Indicators for the operationalization of the programme", covering 19.9% of the analysed corpus, with the words ‘difficulties’, ‘create’, ‘assess’, which are articulated in process and result indicators, essential for the creation and how the programme is run:
[...] To make a programme appealing to users, it must have good adherence. It is necessary to take into account the characteristics of our users because there is difficulty in adhering to psychotherapeutic and pharmacological monitoring (e2).
[...] needs to be systematised within a programme. These are interventions, if they are systematised, they end up being organisational and allow us to evaluate in a different way from what has been done until now, which is that there is nothing (e6).
With this class, it became clear that there is a need for indicators for this intervention and that participants have difficulty in anticipating the scope and course of implementation of this program, as suggested by the words ‘be’, ‘systematise’, ‘predict’ and ‘intervention’.
The analysis of similarity, referring to the FG data analysis, led to the composition of two central nucleus (Figure 1) represented by the words ‘intervention’ and ‘nurse’. The interconnection between these two concepts is strong, and their connection with the word ‘think’ reveals the exploratory nature of the FG but reinforces the conviction that intervention should and can be led by nurses, and that needs can be advantageously met by nurses. In the nucleus of ‘intervention’, the branches with greater connectedness are: ‘focus’, ‘want’, ‘consumption’, ‘stop’, ‘area’, ‘help’, ‘different’, ‘important’, ‘thing’, which, as mentioned in classes 1 and 4, the focus of the intervention should consider people\'s multiple needs. There is also connectedness with class 5 and the difficulties inherent to an implementation. As for the nucleus of ‘nurse’, the branches with greater connectedness are ‘technician’, ‘user’, ‘work’, ‘need’ and ‘change’, which refers to class 2 and the role of the various professionals\' skills, together with the users, in the development of a change approach. This connection extends to classes 1 and 3, with the reflections on the added value of the individual or group approach. With less connectedness emerges the need for change.
Figure 1 -Tree of co-occurrence between the words of the FG text corpus. Portugal. 2022

The textual analysis performed with the corpus that resulted from the 6 interviews revealed 8836 word occurrences, distributed by 1509 forms, with an average of 6 words for each form. Through the CHD, 252 text segments were analysed, retaining 71.83% of the total for the creation of 5 classes resulting from the participation of the content, as shown in Table 2, regarding the users\' perception of the need and structure of an intervention programme. The vocabulary in class 1 allowed us to name it "Expectations regarding the programme", being responsible for 14.4% of the text segments analysed in the corpus.
Table 2

The excerpts from the participants’ interviews show that the expectation towards a capacity-building programme will depend on the option for change, between what the person wants in their current reality, and what they want to change in their life (represented by the word ‘door’). They reveal the need for people to be helped to clarify what they want, after confronting their present situation, and demonstrate the need to respond to the users\' instability.
[...] if I come here just to keep score because it\'s convenient or even worse I only come when I feel like it maybe I\'m not very interested there has to be a control to see if I want to quit drugs (p1).
[…] inside here sometimes I can be very strong and face the world, but maybe in other situations I\'m like a pack of cards and you\'re strong and I\'m all scattered (p5).
[…] What helps most are the counselling, having a door that I can turn to in a situation where I have difficulty being in a group to talk about their problems. (p3).
Complementarily, the words ‘see’, ‘situation’, ‘counselling’, ’ask’, refer to the consensus on the added value of a programme, the difficulty of setting time rigidly and the need for advice in response to requests and needs.
The words ‘programme’, ‘certainty’, and ‘want’ led to the denomination of Class 2 "Programme’s link" with 21.55% of the analysed data. Analysing, it was found the need for the effective bond of users with a structured program, with which they agree and that should be focused on meeting their needs. They consider it necessary that participants have reflected deeply on their option, wanting to effectively change.
[…] I think counselling was good to be in this programme (p5).
[…] the programme must first focus on work and on the person feeling integrated and then, little by little, opening horizons (p1).
[…] the control has to be yours with so many uncertainties and so much blame and that is where I want your help you understand (p3).
The words ‘must’, ‘really’, good’, ‘believe’, reinforce the class designation. They are associated with the need to be supported in clarification. They also refer to the recognition of the benefit when linked to a structured programme.
Class 3, entitled "Articulation with a drug-based programme" accounts for 28.18% of the text segments and focuses on the answers provided to people\'s concrete requests when they need help. For this population, the articulation with a drug-based programme is considered essential, as can be seen in the following statements:
´[…] what happens is that there is this, it\'s a snow roller here, there are many people who are here because they are in a system of life that leads precisely to this (p6).
[…] but the follow-up is not only psychological because when you arrive at the table, and you don\'t have a plate to eat you have to go and get it from somewhere (p1).
[…] I am taking the methadone. Tt has been the help I have had and that I needed (p2).
The words ‘safety, ‘nice’, ‘appointment’, ‘listen’, reinforce the characteristics recognised and necessary in this articulation, for the safety it provides, related to the medication support and the therapeutic space that can be created.
In class 4 entitled "Needs-based support" (20.99%) emerges the expression of support considered fundamental to the needs expressed by the interviewees, related to what they feel helps them the most. From listening to their problems, to help to meet more objective needs.
[…] the help to deal with the consequences of addiction meant a lot, first they knew how to listen (p6).
[…] one has to occupy one\'s time the fundamental issue was an extra support service to find a job according to one\'s capabilities of occupation work because one has to sort it out (p5).
[…] a programme should have a time for the person to talk to the psychologist a time for counselling to talk about the consequences of the effect of alcohol consequences of other diseases (p1).
The words ‘handle, ‘big’, ‘need’ and ‘service’, indicate the challenging way users look at the need they have, the help they need to cope and the huge commitment of professionals to articulate with different related services.
Class 5, called "Pillars of dignity" (14.92%), represented by the words ‘home’, ‘receive’, ‘money’, income’, allows to verify a more objective relationship to class 4. The analysis allows to uncover the needs considered most pressing, such as having a home and an income, considered factors of individual dignity, essential in the roadmap of a program.
[…] many lack housing for basic needs (p3).
[…] basically work is in the centre of everything (p3).
[…] then when there is unemployment people have to go somewhere to get money (p5).
[…] my mother worked, and my wife works to support me. It was my luck, if not maybe I would be talking differently. I receive my pension (p6).
In this class, the words ‘retirement’, ‘mother’, ‘living’, salary’ are important because they are recognised as sources of financial support, sustenance, fundamental for personal dignity and quality of life. They show the economic dependence on parents and the added value of autonomy is pointed out by all.
The similarity analysis also led to the composition of 3 central nucleus, as observed in Figure 2, represented by the words ‘programme’, ‘want’ and ‘see’. In the programa (programme) nucleus, the associated words: ‘help’ and ‘must’ sustain the pressing need for a response of support to people, with the commitment of all actors in the duty to intervene and refer to class 2. In this nucleus there is also a connection with the word ‘think’, revealing the uncertainty about the intervention in response to the consequences, then the word ‘speak’ as a necessary and fundamental vehicle, which refers to class 4. We also highlight the connection with the word ‘really’, as the motivational positioning to change many variables related to the person\'s condition. In the nucleus of ‘want’, the branch of ‘walk’ stands out, which is associated with a behavioural change related to consumption and the word ‘work’, a need pointed out as essential for the improvement of the quality of life and facilitator of the motivational wanting, which is connected to class 5. The connection with the word ‘take’ refers to the need for adherence to drug-based programmes, which emerged in class 3. This nucleus is strongly connected to the nucleus ‘see\', which refers to class 1, i.e. about the expectations of a programme with these characteristics. It is interpreted that there are more people in the same situation who need a more structured help (refers to class 2).
Figure 2 - Co-occurrence tree between words from the interviews\' text corpus. Portugal. 2022



Discussion
This study sought to contribute to the identification of better settings for intervention programmes that meet people\'s needs.
The substance-using population, especially those dependent on opiates and alcohol, are often integrated into drug-based programmes, and followed by multidisciplinary teams. These programmes try to respond to health needs, related to the severity of comorbidities such as hepatitis C, HIV, and diseases resulting from years of consumption and natural ageing, whether heart, gastric or respiratory4,15. The aim of the program is to help with situations of poorer mental wellbeing, such as depression, anxiety, distress, low self-esteem, cognitive decline16, and to promote a reduction in consumption and control of risk situations17. The programmes use different cognitive behavioural based interventions18 with reinforcement of the motivational structure, individually or in groups 19, in-person or remotely 20.
In this study there was consensus among nurses and users on the benefit of a new structured programme, with moments focused on topics that empower people, as advocated by some authors6,21. The classes found in the textual corpus, and the words that integrate and specify their aggregation, reinforce this perspective, which is verified in the relationship between the classes that emerged from the FG and the interviews. There is an approximation in the benefit of a programme, with its actors well defined, with the necessary bond and motivation, centred on basic needs, in order to provide dignity. Flexibility is an essential condition for both groups of participants. This combination may help to build a programme that effectively pays attention to needs, as it is based on a common perspective.
A recent study, which listened to nurses and people undergoing treatment, about an intervention model in ABA found, similarly to this study, that integrated people recognise nurses as not only providing interventions for their physical care, but also as an essential source of psychological support. They also expressed the desire to see their role expanded in the management of methadone treatment and the possibility of nurses articulating and facilitating the connection to other necessary services3.
From the words that were extracted from the participants\' discourse, we can highlight several that provide guidelines for intervention, such as ‘support’, ‘listening’, ‘social support’, ‘money’, ‘want’, which were also the target of attention in other studies, focusing on a more adequate social interaction, less drug and alcohol use, less psychological distress and increased motivation for therapeutic adherence 19,20.
The greatest advantage of a group intervention, mentioned as positive by the participants of this study, is the promotion of rehabilitation and social reintegration, as the exchange of experiences is seen as empowering to face factors that promote relapse 22. The need not to stipulate fixed times of duration is identified, but it is recognised as one of the most effective in promoting capacity for reflection and self-knowledge 23.
There is a need to articulate professional support, with the support of peers with experience of addiction, which has been demonstrated to be effective 24. The difficulty in finding work is one of the factors pointed out by users as a problem for treatment adherence and quality of life. They consider it essential to receive help getting a job, as found in previous research with people in drug-based programmes25.
The relationship between the findings reinforces what has been found in other studies on the opinion and acceptability of interventions implemented in this area of addictions, where this exercise was carried out during the implementation of the intervention 26 or, in a construction phase through participatory research27. We found no other studies of prior collection of the opinion of professionals or experts by experience in this area of health care. This practice is not widely used in the construction of complex interventions 11.
This study contributes to strengthening of the knowledge in the area of health and the specificity of nursing interventions, alerting to the satisfaction of complex needs and refocusing on the need to meet the most basic needs. The flexibility pointed out by nurses, but mainly by users, is a remarkable contribution to the construction of a new programme and challenges the foundations of previously defined interventions / programmes with mandatory contents and sessions for everyone.

Conclusion
This study aimed to listen to participants’ voices - expert nurses and experts by experience - in a drug addiction follow-up process. People with ABA, assisted in specialised units, have an increasingly higher average age, with several physical and psychological comorbidities and polysubstance use, which reveals the severity of the consequences of drug addiction, with impact on several areas of life.
Based on the assumption that people followed in nursing consultations have benefits from this follow-up, we questioned nurses and users about the added value of a structured intervention programme. The acceptability and agreement to its applicability became clear, flexible, with no set time at the beginning, enabling moments of individual and group interaction, initially focused on the satisfaction of basic human needs and with an emphasis on support to get a job. The spaces for venting emotions and the help to cope with day-to-day situations were also among the most consensual strategies
The users\' expectations are in line with those of the nurses. They welcome a constructive idea of a programme, recalling the need to create an effective bond with this intervention proposal on the part of the people included. They also stress the need to provide medication-based programmes articulated with this proposal. They indicate the benefit of focusing and centring the programme first on the most fundamental needs, with the subsequent offer of other interventions promoting well-being and less emotional suffering. They also point out that it is a basic human need to have a house to live in, preferably a house where the person can be autonomous and, complementarily, to have a job and an income. The challenges pointed out are enormous, due to the complexity of people\'s life situations and the consequences of the problematic use of substances. There is a consensus on the need for and the benefit of a flexible therapeutic structure and strategies of attachment. It is highlighted how everything is articulated in the capacity to communicate and to help the other, listening, interpreting their signs of anguish, uncertainty and difficulty in making decisions. We believe that this perspective may be innovative, responding in a more individualised and holistic way, as opposed to interventions/programmes with modular sequences formatted in a stricter way.

Collaborators
All authors made substantial contributions to the whole research process. Paulo Seabra and Carlos Sequeira came up with the idea for the research project and the article. Paulo Seabra, Inês Nunes, Rui Sequeira, Ana Sequeira, Ana Simões, Paula Amaral carried out the bibliographic research and data collection. Paulo Seabra, Rui Sequeira and Ana Brantes did the data analysis. Paulo Seabra, Inês Nunes, Ana Brantes and Carlos Sequeira drafted and critically revised the work. Finally, all are responsible for drafting the article. All authors approved the submitted version.

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