Women and Substance Abuse: Examining the Factors Influencing Relapse

Introduction

The issue of substance abuse was once synonymous with men, but it is also a problem that increasingly affects women. Malaysia’s rapid economic and social growth has resulted in a transformation of women’s roles, including careers, responsibilities, and identity. The pressures on women as a result of these changes have, to a certain extent, contributed to an increase in social ills among women, particularly substance abuse. In addition, in this way of a lifestyle driven by materialistic desires, some women got carried away by the flow of this life and bargained their values and morals to achieve prosperity. Women are found to have a higher risk of drug dependence, drug overuse, and relapse (Addiction Center, 2019). This is very worrying, as women are an important national asset that should be optimally developed to allow them to actively and effectively contribute to national and societal development. Relapse occurs within the first three to six months after the end of treatment, and the period following the end of treatment can be an influencing factor in relapse among women. A further study shows that between 35% and 58% of women with substance abuse problems relapsed within two weeks of treatment, while a study by Campbell and Ettore’s (2011) found that addicts relapsed within six months of completing treatment and being rehabilitated, with the main causes being their response to pressure and their being too self-reliant to control their own desires.

Wasif et al., (2011) in their study on former women addicts that have completed their treatment and rehabilitation process, utilizing the Adult Substance Use Survey (ASUS), found that former substance abusers were positively expected to relapse within six to twelve months. Most previous studies have not identified the post-treatment period in their studies, although this factor is very important in the evaluation of relapse among former addicts, especially women. Research has shown that women are more successful at avoiding relapses than men. A study by Walton, Blow, and Booth, (2001) did not find a significant difference between men and women in regards to relapse. Previous findings have found that women often seek help from others, while men seem more reticent. Ibrahim et al., (2012) found that the risk of relapse among addicts is high, especially those with unstable emotions, prone to anger, have interpersonal conflicts such as family problems, marital issues, and divorce. The risk of relapse among female addicts without familial support is not surprising, as they usually have no motivation to adhere to the drug addiction rehabilitation process.

Women involved in substance abuse face challenges in staying drug-free, such as a lack of motivation, low self-esteem, interpersonal conflict with others such as family members, the inability to sever relations with their drug-using network, and an environment that could disrupt the treatment process. Compared to their male counterparts, women participate more in family affairs, and face the potential of more problematic interactions with their family members. They are more prone to stress and would return to drug use for a semblance of peace of mind. Joshi and Rathore (2017) in their study reported that substance abuse has consistently been seen as a male issue, particularly in India. Generally, women who use drugs have been the target of special opprobrium in Indian culture but, despite this fact, studies on substance abuse in recent years have shown a major change in this regard with a significant rise in substance abuse by Indian women. Women with addiction issues are labelled as failures, unable to fulfil the aspirations and expectations of female moral principles. They also faced societal stigma, as their actions contradict what is expected of a good woman, in conduct and behaviour (Ayyagari et al., 1999). This situation then leads to relapse. However, in recent years, the number of substance abuse cases in reports demonstrates the increasing number of female addicts in India.

National Council on Alcoholism and Drug Dependence (NCADD) has opted for a logical and open consideration on sexual orientation issues that contributes to substance abuse among women in India. Female addicts have experienced more symptoms of sickness and absence of pain than male substance abusers. Across societies and networks, the most critical natural factor that powers drinking in women was discovered to be domestic abuse, ill-treatment by a partner or by another close relative. Only a few studies showed that women turn to drug use to accompany their partner or companion and, subsequently became dependent on it. In the National Survey on Drug Use and Health (2017), the reason for the women began on the road to addiction due to influence by friends and companions.

Literature Review

The increased availability of drugs and the consequent drug abuse has been observed as a growing social problem in Malaysia. The increased availability of Opioid Agonist Therapy (OAT) has been observed as the first and foremost priority for the Malaysian Ministry of Health which provides government-funded free assistance for Malaysians in governmental selected medical clinics. In the present time, free methadone is being distributed among all the public clinics for harm reduction, comprising needle and syringe exchange programs in every state of Malaysia, but recent empirical shreds of evidence indicated that no statistics are available concerning women benefiting from OAT in the country, and that these programs proved to be inadequate as compared to the needs of the present. Wickersham et al., (2016) found that around 35% to 58% of women addicts relapsed within two weeks after treatment. Meanwhile, a study found that the period after treatment is an influencing factor in relapse among women. Another study by Wasif et al., (2011) also found that addicts relapsed within six months after the end of their treatment and rehabilitation period. It is due to their response to pressure and self-reliance to avoid drug use. This proves that drug users, even after following the treatment and rehabilitation process, still face a variety of psychological pressures such as desires, urges, signals, and thoughts of returning to drug use. This means the period before the inclination to relapse emerges varies and depends on the high-risk situations that they might encounter.

Best et al., (2010) in their study on former women addict that have completed their treatment and rehabilitation, utilizing the Adult Substance Use Survey (ASUS), found that former addicts positively expected to relapse within six to twelve months. This means the period for the inclination to relapse among addicts varies and depends on the high-risk situation that they might encounter However, most previous studies did not highlight the post-treatment period in their studies, although this factor is very significant in evaluating relapse among former addicts, especially women (Hughes, Wilsnack, & Kantor, 2016). Women were reported to be more successful in restraining themselves from relapsing compared to men (Sklar, Annis, & Turner, 1999). However, the fact that an increasing number of women are involved in drug abuse is very worrying, as women are an important national asset that should be optimally developed to allow them to actively and effectively contribute to national and societal development. This drug problem is a huge obstacle to the career development and progress for women. Therefore, identifying the relapse trigger among women addicts could not only prevent relapse, but also determine the key influences in their lives that drive them to relapse. This study aims to determine the factors influencing relapse among former women addicts. Women’s involvement in drug abuse not only affect other social issues such as the decline in morality, prostitution, and breakdown of marriages, but also the physical and mental well-being of these women.

Mohaddes et al., (2021) suggested that five themes correlate to the global theme of the antecedents of relapse of high risk. These themes are: craving for use, physical issues, mental stress, family factors, and social factors that might affect the patient’s treatment. Social support, self-efficacy, and situational perception are vital contributing factors that determine relapse among female addicts. Amat et al., (2020) found the risk factors of relapse are internal to the drug addicts: weak willpower, lack of personal interest, irritation, lack of religious support and prior knowledge, anger, and hatred. In addition, some external factors of relapse include insufficient family support, financial troubles, a weak peer circle, and social rejection. Furthermore, the influential role of social media and lack of proper living space after treatment are also major factors of relapse. A lack of family support and social rejection also majorly contribute to relapse. Therefore, identifying the relapse trigger among women addicts could not only prevent relapse, but also determine the key influences in their lives that drive them to relapse in the first place. This study aims to determine the factors influencing relapse among former women addicts.

Method

A cross-sectional study was conducted on patients with substance use disorders six months after treatment at the Cure & Care Rehabilitation Centre (CCRC) in Bachok, Kelantan. This rehabilitation centre is chosen because this CCRC is for women involved in substance abuse in Malaysia. According to the statistics published by the National Anti-Drug Agency (NADA) in 2019, 81 women with substance abuse were being treated at the CCRC. In this study, purposive random sampling was used to select the respondents. The purposive sampling technique is used in this study as the research sample is not selected randomly, but determined by the researcher through set criteria, and these criteria have to be met by the research samples. This means only the population that meets the criteria are chosen as research samples that could fulfil the research objectives. The researcher decides what needs to be known and sets out to find people who can and are willing to provide the information by virtue of knowledge or experience (Bernard, 2002; Lewis & Sheppard, 2006).

A total of 50 women addicts from diverse backgrounds were selected to participate in this study. The result was evaluated using Statistical Package for the Social Sciences (SPSS) version 17.0. A Problem Recognition Questionnaire (PRQ) with a 24-item inventory was used to measure recognition of their substance abuse using a five-point Likert scale, as follows: always, 1; very often, 2; sometimes, 3; almost never, 4; and never, 5. Perceived Social Support (PSS) is used to assess perceived social support from family and friends respectively, using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). In this study, the 10-item version of the PSS has Cronbach’s alpha values of 0.81 and 0.76 for the PSS-FA and PSS-FR subscales respectively. The Rosenberg Self-Esteem Scale (RSE) was developed by Rosenberg (1965) for the self-evaluation of positive and negative feelings in adolescents and adults. All items were assessed on a four -point Likert scale from 1 (strongly agree) to 4 (strongly disagree). In this Malay version, the Cronbach alpha coefficient was between 0.70 and 0.88, whereas the reliability and validity coefficients were estimated at 0.82 and 0.85, respectively.

Pearson’s correlation and regression analysis was used as the data analysis technique in this study and Pearson correlation coefficient was calculated to describe the strength and direction of the relationship between each independent variable and the dependent variable (Pallant, 2011). Meanwhile, the regression analysis was applied to test the hypotheses of this study. This technique is a powerful tool designed to explore and analyse the relationship between a single dependent variable and several independent variables. It is important to know that when the case involves an independent variable, the technique here is called simple regression. However, if it is more than one independent variable, the technique is known as multiple regression (Pallant, 2011). Multiple regressions were applied to assess the effect of factors such as family, friend support, motivation, and self-esteem on relapse

Results

Socio-Demographic Characteristics

Table 1 reports the socio-demographic data for the group. The majority of respondents were women between the ages of 21 to 40 (84%); 48% were married, 46% did not earn a monthly income, 68% showed “not applicable” to the question of taking drugs after treatment, and 78% admitted to a temptation to relapse. Table 1 shows the demographic findings of the study participants.

Table 1

Demographic Characteristics of the Study Participants(n = 50)

Correlation of Personal Factor and Interpersonal Factor with Relapse

As the Pearson correlation table indicates, there is a positive and significant relationship between family support and relapse (r = 0.183) and a positive and significant relationship between friend support and relapse (r = 0.009). We also see a significant, but negative relationship between motivation and relapse (r = 0.387) and between self-esteem and relapse (r = -0.035). Table 2 shows the relationship between personal and interpersonal factors and relapse.

Table 2

Pearson Correlation Coefficients Between the Study Variables

Predictor of Relapse Score

As presented in Table 3, the results of the multiple regression analysis were done by considering a total relapse scores as dependent variables, with personal and interpersonal factors as independent variables. The results also show that the independent variables of motivation, self-esteem, family support, and friend support are significant. Table 3 shows the regression results for the study respondents.

Table 3

The Results of Multiple Linear Regression of Relapse

Through this stepwise method, only significant independent variables are included in the regression model and selected as the main factors that influence the temptation to relapse. If a variable is significant, it is included in the regression equation This means the stepwise method selects the main predictor, followed by a second predictor, and so on. Based on Table 3, the stepwise regression analysis results show that the regression model is significant [F (5.921), p < 0.05)]. The results show family support (β = .348, t = 2.507, p = 0.030), friend support (β = -.286, t = -2.738, p = 0.40), motivation (β = .580, t = 2.050, p = 0.50), and self-esteem (β= .523, t = 3.659, p = 0.001) toward relapse was supported. It could be concluded that the temptation to relapse decreases with the corresponding increase in support from family and friends, motivation, and self-esteem.

Discussion

This study aims to determine the factors influencing relapse among former women addicts One important finding of the present study shows that both personal and interpersonal factors can lead to relapse. These findings are in accordance with previous studies (Greenfield et al., 2007; Walitzer & Dearing, 2006) which show low level of motivation among former addicts as contributing to relapse, especially in the early stages post-treatment. Consider the fact that most previous studies found that both men and women go through the same risk of relapse post-treatment and rehabilitation. Women are more likely to relapse compared to men due to the lack of motivation in addressing their drug problems (Martino et al., 2000; Goodwin, 2000). The reported difference between men and women are the factors related to relapse, the reports being that it happens without a clear motive, and is more related to negative effects such as physical and sexual abuse among women. Stigmatization, such as being labelled “addict” can have a lasting impact on their self-esteem. This is because women use the same problem-solving approaches in stressful situations, and women are more likely to either seek out social support, accept responsibility, or run away. According to the results, women face different barriers and obstacles compared to men. Women are more likely to relapse compared to men due to the lack of motivation in addressing their drug problem (Stotts et al., 2001).

Women require internal support in order to be motivated in the process of making changes for a better life (Dascal et al., 2020; Itai et al., 2019). Lack of motivation has been used to explain the failure of individuals to begin, continue, and succeed in treatment. Motivation can reduce the urge to use and the likelihood of using among women addicts. Motivation may be especially beneficial in reducing substance abuse and help women avoid relapse (Oveisi et al., 2020). As a result, women who use drugs require internal motivation to help them quit and move on to a better life. In addition, women are more inclined to seek social support from others to overcome their problems (Van Der Westhuizen, 2007).

The above findings show the contribution of the four predictive variables (family support, friend support, motivation, and self-esteem) toward relapse. The findings are in line with the correlation analysis results that show the relationship between these independent variables, which have both positive and negative relationships with relapse. This means the results of this study, i.e. the social support factor is the main predictive factor for the temptation to relapse, confirm the researchers’ findings. Furthermore, most previous studies show social support to be the main determinant of the temptation to relapse among substance abuse.

The regression results are also seen to support previous studies such as Campbell and Ettore (2011); Daley, (2013) and Maehira et al., (2013), which found family support allows addicts to accept positive changes in their healing process and build up their self-esteem. Had the family fail to provide support, the addicts would turn to other support systems that can address their needs. Family plays an effective role as the main support group in someone’s life. Women substance abuse with a supportive family can resist relapse, compared to those without family support. There are also issues related to social support to prevent relapse, with men being more inclined to receive more social support at home and work, while women are more inclined to be isolated from their friends in their decision to relapse. It is this situation that increases the risk of the temptation to relapse. Also, women with addiction problems suffer from a greater stigma compared to their male counterpart and when combined with a lack of social support, this means isolation and higher risk, and the healing process for women is lower than men (Feltenstein & Henderson, 2011).

Aside than family support, friend support is also seen as a predictive factor in the temptation to relapse among addicts. Women are more inclined to seek social support from others to overcome their problems (Van Der Westhuizen, 2007). This has been highlighted in previous studies such as Kopetz, and Kruglanski, (2011). which found that friends have an effect on the temptation to relapse among former addicts. Most of them are at risk of being influenced by their friends and join them in deviant behaviors. A study by Carver & Scheier, (2011) found that the friend factor shows a high predictor in individual involvement in the drug problem. They likely relapsed into drug use due to a feeling of failure and self-guilt. This shows friends play an important role in increasing the temptation to relapse among former substance abuse post-treatment. It has been shown that women are most likely to relapse into drug addiction (Kuhl, 1986).

As an alternative, women might have a higher sensitivity towards stress or signals related to drugs, as relapse can be triggered by these variables. All these factors have been reported as being related to relapse in studies among male and women addicts trying to quit. Some studies confirmed the effectiveness of self-esteem and motivation in reducing the temptation to relapse among drug addicts; similar studies are also suggested in regards to relapse cases in Malaysia (Ibrahim et al., 2012; Ghani et al., 2017 & Mohd Ghazalli et al., 2017). The motivation concept has been instilled to explain why people do what they do, and what drives an individual to shift from one behavior to another. They set their goal, identify a suitable method, and eliminate distractions and conflict. The results are similar to the findings by Carver, Scheier, & Weintraub (1989) and Greenfield et al., (2007) that show women drug addicts have a higher motivation to report their efforts to restrain themselves from relapsing. In addition, compared to men, women report a higher level of motivation, preventing them from relapsing. The present study shows that self-esteem could improve the motivation to prevent relapse.

This finding is in line with the results of a study by Becker and Hu (2008). Moreover, the results of the present study show that lower self-esteem can lead to relapse, which is consistent with previous studies. According to various studies, self-esteem serves as a predictor of the inclination to relapse. This was acknowledged by Chie et al., (2015) and Gillani et al., (2020) in their studies. Their studies found that self-esteem is the most important component that influences relapse. Self-esteem may affect their cravings, like their expectation and belief in their ability to not relapse. Conversely, if they have a negative perception of drugs, they would try harder to keep themselves from relapsing.

Conclusion

In conclusion, personal and interpersonal factors are significant in determining the temptation to relapse among former CCRC substance abusers in Malaysia. Based on the findings, addicts in high-risk situations are more tempted to relapse, and they find it difficult to handle this situation. Women involved in drug problems face multiple pressures and high-risk situations and are more at risk of relapse. They need help from their family, friends, and important social support to ensure they could resist partaking in drugs again. Furthermore, policymakers should pay more attention to this issue. Their use of motivation and self-esteem to avoid this situation is at an average level. An improvement in their motivation and self-esteem could therefore help them resist relapses. Their use of motivation and self-esteem to avoid this situation is at an average level. Improving their motivation and self-esteem skills can help them to resist relapse. Besides, it is hoped that the results of the study will not only help provide input from women’s addiction experience to drug rehabilitation counsellors, but will also help drug rehabilitation institutions to strengthen the treatment and rehabilitation process more comprehensively, especially to women addicts who are undergoing drug treatment and rehabilitation programs in Malaysia. Moreover, the results of the study on the experience of substance abuse among women should provide new input to for rehabilitation institutions to design and make improvements to rehabilitation treatment modules for women’s substance abuse. The results of this study are also expected to provide specific awareness to family institutions about their important role in jointly assisting NADA in combating addiction and rehabilitating drug addicts, especially among women in Malaysia. The continued social support of families can help substance abuse continue to live healthy lifestyles, free from the influence of drugs, and help reduce the recidivism rate among substance abusers in Malaysia.

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