Reasons for Help-Seeking and Associated Fears in Subjects with Substance Dependence

Abstract

Background:

Patients seek treatment for substance use disorders because of certain reasons that they consider significant and important, but on the other hand, they do have various fears or apprehensions about the treatment, which act as barriers for treatment-seeking. In this study, we aim to assess their reasons for seeking treatment, the associated fears about treatment, their social support and locus of control, and also to find the relationship among these variables.

Materials and Methods:

One hundred subjects attending the Drug Deaddiction and Treatment Center, Postgraduate Institute of Medical Education and Research (PGIMER) were prospectively recruited, with purposive sampling from 15 June to 14 July, 2011. The sociodemographic and clinical variables were ascertained through a semi-structured performa. The PGI Locus of Control Scale, Social Support Scale, and Reasons of Help-seeking and Fear Questionnaire were applied.

Results:

The common reasons for seeking treatment were — having become a habitual user, taking substance for a long time, and a need to take it every day. The common fears about treatment were the fear of disappointing others, loss of secrecy of substance use, and being considered a failure in life. The locus of control was primarily internal. Certain reasons like taking substance for a long time, feeling ill, and feeling sad were associated with a lower social support. Social support was not associated with the locus of control. The most affected areas of impairment were finance and health.

Conclusions:

Certain reasons and fears regarding treatment are more common than others. It is important to look into reasons and fears that are related to better treatment outcomes.

INTRODUCTION

Substance use disorders represent a major public health challenge worldwide.[1] Treatment of these disorders is fraught with many challenges, including, high dropout rates, occurrence of comorbid illnesses, and difficulties with social support.[2–4] Yet, despite these adverse circumstances the patients are impelled to seek treatment due to certain reasons, which they consider significant and important. Conversely they may be wary of the treatment process due to certain fears.

There have been studies looking at the reasons for seeking treatment in the substance-using population. Ludwig (1985) reports that ‘hitting the bottom’, alcohol-induced physical problems, allergy or physical aversion, change in lifestyle, and spiritual-mystical experiences can trigger the initiation of abstinence in alcohol dependents.[5] Oppenheimer et al. (1988) has used the ‘Reasons’ questionnaire in drug users and found that life being out of control, needing drugs every day, and becoming addicted to drugs, are the most common reasons for seeking treatment.[6] Brooke et al. (1992) has indicated that seeking help is related to the experiences of addiction, loss of control over life, and financial and family difficulties.[7] Chung and Shek (2008) have found that heroin users came for treatment when they ‘hit the bottom’ in their lives[8] and the same was reported for alcoholics by Ludwig (1985).[5] Cunningham et al. (1994) has found that weighing the pros and cons of drinking or drug use and warning from spouse are the most often reported reasons for persons seeking treatment for substance use.[9] Smith et al. (2010) have reported self-control reasons to be the major reasons for quitting substance use.[10]

Brooke et al. (1992) have reported that the main fear of treatment is failing the treatment process,[7] while Oppenheimer et al. (1988) have stated that it is the fear of disappointing others and the fear of failing treatment.[6] Rapp et al. (2006) have highlighted certain fears of treatment as barriers to treatment in the substance-using population, such as, having a bad experience with treatment, uncertainty of treatment, embarrassment, and being afraid of seeing someone in treatment.[11] In another recent study, the most common fears reported have been fear of disappointing those who are trying to help and psychological dependence on drugs.[12]

The concept of locus of control holds importance for substance users, as it determines their view of whether extraneous circumstances or they themselves control the continued substance use behavior. The concept of locus of control had been introduced by Rotter (1954) and refers to the extent to which individuals believe that they can control the events that affect them. There has been some endeavor to find the association of substance use with the locus of control.[13] Researchers have found the internal locus of control to be negatively associated with substance use in adolescents.[14] The internal locus of control has been found as a mediator for substance abstinence and health-promoting behavior in the 12-step model.[15] This suggests that the external locus of control is related to more severe drinking patterns.[16]

Social support too has been found to be an important factor in the treatment process,[17] including treatment engagement of the substance users.[18] Furthermore, social support after inpatient treatment has been found to be an important factor predicting long-term abstinence in alcoholics.[19] High perceived family support has been found to be negatively correlated with concurrent substance use in a study of opiate-dependents in China.[20] Social support thus needs to be considered when attending to substance users, because it contributes to both reasons of seeking treatment and as an outcome moderator.

Looking at studies from India, Arun et al. (2004) noted that one of the most common reasons for seeking treatment was a wish to improve oneself and the availability and awareness of treatment.[21] A study from India sought to assess the barriers to treatment implying fear of treatment as a major barrier in the treatment of substance users.[22] Earlier studies from our center explored the reasons for help-seeking and fears about treatment in psychoactive substance users[23] and relapse into alcoholism.[24]

There has been a dearth of studies looking at the association of reasons for seeking treatment with social support and the locus of control of a patient, but none are available from India. Hence, this study was conducted to study the relationship of the reasons for seeking treatment for substance dependence with perceived social support and locus of control.

MATERIALS AND METHODS

The study was conducted at the Drug Deaddiction and Treatment Center (DDTC), Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh — a multispecialty tertiary-care teaching hospital providing services to a major area of north India. Most DDTC patients come via family- or self-referral, and some are referred from other hospitals or other departments of our Institute. The services are run by a team of psychiatrists, social workers, clinical psychologists, and nurses. The services include Outpatient, Inpatient, Basic Laboratory, active and passive aftercare / follow-up, and liaison with governmental and non-governmental agencies and self-help groups. The assessments include comprehensive physical and psychosocial evaluation, including for physical and psychiatric comorbidities. The treatment modalities used include pharmacotherapy, psychobehavioral therapies, and social-occupational rehabilitation.

The study had the approval of the institutional research ethics committee. The data collection lasted from 15 June, 2011 to 14 July, 2011. A cross-sectional design was used. The sampling was purposive, in that, based on the availability of the investigator (NN), the study subjects were recruited as new registrants from the DDTC outpatient service. A written informed consent was obtained from the patients taken up for the study. The inclusion criteria comprised of patients who were substance users and who gave valid informed consent. Those patients who were having any chronic physical illness / organic brain syndrome / mental retardation, who were not taking any substance, and who refused to give informed consent were excluded from the study.

After enrollment into the study, a semi-structured proforma was used to assess the demographic and substance use details. The overall impairment was explored in seven domains: health, occupation, finance, legal, family, marital, and social. Thereafter, the self-rated Hindi translated version of the following instruments were administered: Reasons for Help-seeking and Fear Questionnaire,[23] Social Support Scale,[25] and PGI Locus of Control Scale.[26]

Reasons for Help-seeking and Fear Questionnaire[23]: This was a self-rated instrument, which looked into the reasons for seeking treatment and the fears associated with the treatment in the substance users. The original questionnaire[27] comprised of 54 reasons and 27 fears of treatment. The Hindi adaptation[23] was used in the present study, which comprised of 40 questions for the reasons of treatment and 23 questions regarding fears about treatment. Each item could be scored from 1 to 3 in decreasing order of importance (applicable and important, applicable but not important, and not applicable). The instrument was used previously in our work, in our center.[24]

Social Support Scale[25]: It is a scale developed as an Indian adaptation of the social support questionnaire, developed by Pollack and Harris (1983).[28] This scale is available in Hindi and is self-rated. The scale gives a measure of social support in the subjects and has been validated in the Indian population. It is a short, simple, easy-to-score test, and consists of 18 questions, each question is rated on a four-point scale. Seven of the questions are positively worded and 11 are negatively worded, and require reverse scoring. The overall score can vary from 18 to 72. A higher score suggests that more social support is available to the patient. The test-retest reliability of the modified version is 0.91, with high concurrent validity with the Social Support Questionnaire. The scale has been used in many studies[29,30] and has been found to be a reliable and valid measure of social support.

The PGI Locus of Control Scale[26]: It is a quick, reliable, and valid scale to measure the internal–external locus of control. The scale has been developed for the Indian population. The scale is administered in the form of a semi-structured interview. It consists of seven items in Hindi, each item having three choices. Two of the items are worded beginning with internal control, while the remaining five are worded beginning with external control. The maximum score is 14 and minimum score is 0, with higher scores reflecting higher internal locus of control. The test–retest reliability has been found to be 0.77 two weeks apart, while inter-rater reliability has been found to be 0.95.[26]

Descriptive statistics were used for the demographic and clinical variables. Non-parametric tests were applied to see the relationship between nominal and ordinal data. Parametric tests were applied for the continuous variables. Analysis was done using SPSS version 14.

RESULTS

Demographic details

A total of 100 patients were recruited in this study. The mean age of the sample was 32.9 years (SD 11.1 years, range 17 to 73 years). The demographic data is presented in Table 1. The majority of the sample was married, employed, and belonged to an urban background.

Table 1.

Sociodemographic data

The substances being commonly used were opioids (43 patients), alcohol (31 patients), both alcohol and opioids (15 patients), and other substances (11 patients). Diagnoses were made as per ICD-10.[31] The mean duration of substance dependence was 7.04 years (SD 5.65 years). Additional psychiatric or physical diagnosis was present in about one-fourth of the sample (23 patients). Dysthymia, recurrent depressive disorder, and mixed anxiety and depression were present in one patient each. Among the physical disorders, the commonly presenting disorders were hypertension (nine patients), diabetes (six patients), seizure disorder (three patients), and hepatitis (two patients). Major substance-related impairments were found in the domains of finances, health, and family life. The lesser affected domains were those of legal issues and occupation.

Reasons for help seeking and fears about treatment

The most common reasons for seeking treatment were, becoming a habitual user, taking substance for a long time, and the need to take it every day [Table 2]. The common fears about treatment were a fear of disappointing others, loss of secrecy of substance use, and being considered a failure in life [Table 3]. The other reasons of coming for treatment and fears about treatment are mentioned in Tables 2 and 3, in decreasing frequency.

Table 2.

Reasons for seeking treatment

Table 3.

Fears of treatment

Locus of control and social support

The mean score on the locus of control scale was 11.02 (SD 2.39). Ninety-two patients had internal locus of control, six had external, and two had both, reflecting a preponderance of the internal locus of control. The mean score on the social support scale was 50.8 (SD 6.6, range 34 to 65).

Association of reasons for help seeking and fears about treatment with locus of control and social support

Table 4 shows the significance values of the association of reasons for seeking treatment with locus of control and social support. Only the associations found to be significant by using the Mann Whitney U test have been depicted in the table. The table also shows the significant association of the fears about treatment with the locus of control and social support. The reasons for treatment associated with poor social support included taking substance since a long time, being almost bankrupt, feeling sad, feeling ill, difficulty in managing finances of the home, and being dismissed from job due to substance use. The fears associated with poor social support included being considered a failure in life, fear of failure of treatment, and an inability to complete treatment due to withdrawals. Spouse leaving due to substance use and fear of being sent elsewhere against his / her wish were associated with the locus of control.

Table 4.

Reasons and fears found to have a significant association with locus of control^a and social support^b

DISCUSSION

The study found that the most common reasons for seeking treatment were the fear of becoming a habitual user, taking substance for a long time, and needing to take substance every day. The common fears about treatment were a fear of disappointing others, loss of secrecy of substance use, and being considered a failure in life. The social support has been found to be good and locus of control was found to be primarily internal.

The findings of the study concur with those studies by Oppenheimer et al. (1988)[6] and Chung and Shek (2008).[8] Certain reasons and fears of treatment are more common, and reasons involving long-term dependence figure prominently. As in the present study, loss of control over the substance-using behavior and physical harm due to substance use have been reported quite frequently as the reasons for seeking treatment, by earlier studies.[5,6] Familial factors too have had an important role in the cessation of substance use,[8,9] as has been reflected in the reasons of treatment in our study. Similarly, fear of disappointing others and fear of failing treatment have been reported as important fears against seeking treatment as in other studies.[7,9,12] An earlier study from our center has found that the most common reasons for seeking treatment are: a need for drugs daily, drug problem becoming chronic, feeling ill much of the time, and a realization of having no self-respect.[23] The main theme of the reasons for help-seeking in the alcohol group were life getting out of control, becoming dependent, and rejection by significant others,[23] which were quite similar to the findings of Brooke et al. (1992) on drug abusers.[7]

A recent study from India[22] reported common barriers in the treatment of substance abuse as, time conflict, absence of a problem, and fear of treatment. Another study from our center showed that spousal discovery of substance use, starting the use of a harder substance, chronic alcohol problems, and inability to do any job properly were the major reasons for seeking treatment; while fear of disappointing others who were trying to help and being considered a failure in life were the major fears of the treatment.[24]

The social support reported by the substance users in this study seems to be fairly good when compared to other studies using the same scale in the psychiatric population.[29,30] This can be attributed to the fact that most of the patients who presented for treatment to seek help were accompanied by their families. The level of social support was found to be somewhat higher than in other studies from different part of India, using the same scale.[32]

The locus of control did not have a significant relationship with any particular reason or fear of treatment, except inability to get the substance. One of the reasons could be a small sample size in certain categories of reasons and fears, thus not yielding significant results. However, the endorsement of certain reasons was associated with low social support in our study. The reason of seeking treatment may have a bidirectional association with social support; low social support predisposing to a reason like ‘dismissed from job due to substance use’ and the same reason predisposing to low social support. Many of these relationships may be complex and interdependent.

This study presents a look into the reasons for seeking treatment and fears of treatment of substance users in India — a part of South East Asia where such studies are few. The study also delves, for the first time, into the issue of the role of social support and locus of control in their relationship with reasons and fears about treatment.

The major limitations of the study included recruitment of the subjects through purposive sampling and a limited sample size. The subjects were not explored about their prior treatment contacts as well as differences in responding to the items on the questionnaire with regard to their state at the time of intake, that is, during regular drug intake, withdrawal or sobriety. Furthermore, the social support questionnaire used in the study reflected global social support, and did not categorize it into further domains like emotional support and esteem support. The information collected was based on patients’ self-report, raising the possibility of individual patients over-reporting or under-reporting. However, it was seen that the self-reports of substance users were fairly acceptable.[33] The present study represents a sample of patients seeking treatment at a specialized addiction center and cannot be generalized to the primary care or a community setting.

It is important to assess the reasons for seeking treatment, as it may effectively help in modifying the management plans to patient needs. Also tackling the fears of treatment may make the patient more comfortable in the treatment process. Further studies need to be conducted to assess the relationship of these reasons and fears and the outcome with treatment, to implement such findings in formulating management plans in the future.