Experienced Psychosocial Problems of Women with Spouses of Substance Abusers: A Qualitative Study

Abstract

BACKGROUND:

Substance dependence is one of the most important social issues in the world today, which affects not only the life of an addicted individual, but also the relatives of the substance abuser individual, and in particular their spouses and children are also exposed to multiple injuries.

AIM:

This study aimed to investigate the experiences of the women with the substance abuser spouse.

MATERIAL AND METHODS:

This study is a qualitative study. Sampling was done purposefully. The data were subjected to 25 participants with in-depth and semi-structured interviews (15 wives and 7 therapists and 3 officials dealing with family members of the substance abuser) and analysed using the qualitative approach of the conventional content analysis (Granheim’s method).

RESULTS:

Out of the results of the interviews, two main categories were extracted, including A) family psychological breakdown and B) Disadvantaged social status. The main category of family psychological breakdown including 5 subcategories: Psychological disadvantages, losing borders in the family, insecure space house for the family, turbulent family and Concern on spouses leaving. Category of disadvantaged social status is also including 3 subcategories: trying to preserve the family’s image, social stigma, and social isolation of the family.

CONCLUSION:

The families, especially the women with the substance abuser spouse, are severely vulnerable in various psychological and social dimensions. Therefore, the attention of the health cares to these families is important.

Introduction

Substance-dependence is one of the main problems of today’s societies that destroy the lives of millions, spending the high cost of the society on fighting, treating and harming it. Today, the problem of addiction goes beyond health care and has become a social crisis all over the world [1]. The World Health Organization in 2010 has estimated substance-dependent people to be about 230 million people around the world, accounting for about 5% of the world’s population [2]. In Iran in 2017, the exact number of the addicts has reached two million, eight hundred and eight people and people aged 15-64 are the most substance abusers [3].

Substance-dependence generally causes serious harm to oneself, family and society, and also creates a high cost for the family and the country [4]. In the family system, the negative effects of the abuse are especially on the spouses, parents, and children of the substance abuser [5], and the family members may feel angry, frustrated, anxious, fearful, worried, depressed, ashamed and guilty [6]. When an individual in the family begins to change habits, practices, interactions, the family members are unwittingly attracted to him. Also, the family members are often negatively affected by the addict lifestyle and feel unhappy, angry, frustrated and confused without knowing what happened. They worry why their loved one is acting differently, withdrawing, and does not his responsibility well. Therefore, it causes tension in the family and eventually, anxiety and depression in the family members [7].

Spouse of men with addiction is suffering about themselves, their lives, and the future of their family members. Their anxiety is the consequence of their mental occupation of the disintegration of their lives. They are anxious and depressed because of the pressures of homework, economic problems caused by addicted husband unemployment, and lack of intimate relationships. They are anxious and depressed because of the pressure of their housework, and the economic problems caused by the addicted spouse’s unemployment and the lack of an intimate relationship with each other. Studies have generally shown that higher levels of alcohol and drug use and higher levels of substance-related problems increase the risk for partner aggression [8]. There is a relationship between the men’s addiction and marital violence, and the substance provides a source of conflict and violence for the family members due to changes in the system [9].

Due to the stigma associated with substance abuse, most problems with substance abuse are hidden in the family. This not only worsens the experience of tension in the families but may also prevent the assistance and cooperation that the family can provide to improve the person with addiction [7]. People’s attitude towards the spouses of the addicted men is a blatant and humiliating one, and people consider them the cause of the addiction of their husbands [10]. Therefore, these women are not only a victim of the addicted person in the family but also suffer greatly from the community. This often leads to feelings of guilt, shame, depression, anxiety, isolation, and suicidal tendencies. On the other hand, man’s addiction makes the whole family more isolated and social relationships diminish. Relatives often do not come to their homes because of the poor economic situation and the unemployment of their husbands or the fear of their husband and son being addicted [11].

Some studies (Moriarty et al., 2011; Salehi et al., 2012) have shown that the family members of alcohol or substance consumers have more psychological and social problems [12], [13]. Also, in these people, the medical cost increases compared to the family members without having a person drinking alcohol or drugs [14]. Not only are the lives of the addicted individual, but also the relatives of the addict at risk of multiple injuries to this social phenomenon. So far, there has been no research on the psychological and social problems of women with substance abuser spouses, although there has been a lot of work on the addiction, all of these studies have been about violence and addiction itself and addicts, and again, the problem is that most of the studies conducted in this area have done little with the methodology. Only a few variables are used in this methodology [9], and few studies of the exact and profound aspects of life with a substance-dependent partner have been considered from their attitude.

Given that such information is not available about the effect of spouse’s addiction on women’s lives, and our main goal is to clarify the profound aspects of this issue and to do this, the questionnaire may not elicit the desired information. In other words, one cannot get a complete picture of what is happening through quantities of study. For this reason, this study is aimed to explore the experiences of women with substance abuser spouses in a qualitative way.

Methods

This study is a qualitative content analysis study with a conventional content analysis approach aimed to explore the experiences of women with spouses with substance use. This conducted in 2018. This way, information is obtained directly from the study participants, without imposing predetermined category or previous theoretical views, and the knowledge generated is based on their unique viewpoints, and actual text data and codes and category are extracted directly and inductively from raw data [15].

The research environment included government and private drug treatment centres in Gorgan, the provincial well-being centre, the provincial health centre and the Counter-Narcotics Headquarters Consulting Center. These centres are the most important ones for providing services to the families of people with substance abuse. The participants included women with substance abuser spouses, therapists and officials dealing with family members of the substance abuser, and inclusion criteria included being completely alert, and being able to communicate and share experiences verbally

A sampling of the present study was purposeful. In purposeful sampling, the selection of the participants with two criteria was sufficient to have sufficient knowledge about the phenomenon under study and to obtain good information [16]. Thus, for sampling, researcher referred to the addiction-related centres and interviewed people who met the criteria for entry into the study, Consider also the distribution of age, education level, number of children, type of substance abuse, duration of spouse’s abuse, spouse’s job, and spouse’s leaving history for maximum variation.

Data collection continued to the phase of data saturation. This means that the new participants did not make any new issue, and the information provided by them seemed to be repeated [17], which data were collected for a period of 6 months. In this study, the data were saturated with 25 in-depth and semi-structured interviews with 15 spouses and 7therapists and 3 officials dealing with family members of the substance abuser.

Data Collection tool in this study was semi-structured interviews. The interviews were conducted in a private room in a secluded room and before the interview, the purpose of the interview, confidentiality of data, and the right to leave the interview at any time from the interview were individually explained to each participant. To create an open space and establish the right relationship, the interviewer first introduced himself and finally thanked the attendee for the interview. Oral consent was obtained from the participants.

The interview lasted from 25 to 100 minutes. During the interviews, spouses and staff were routinely asked: ‘What has it affected your life since your spouse became addicted? Express your experiences. What has been the impact on your social relationships? (For spouses). Express your experiences of women’s lives with spouses of the substance abusers (for therapists and officials).’ Then, we used pointed questions (such as can you provide an example? Or can you explain more? Or what do you mean by this?) According to interviews’ responses to add to the depth of the data.

The researcher allowed the participants to record the interview, and if they were not allowed to record, Interviews were written.

Data Analysis

Immediately after the interview, the participant’s comments were reviewed and, if necessary, completed and the interviews were attempted on the same day for typing and analysing. At the same time as data collection, the analysis was also carried out. The content analysis method was used to analyse the data from individual interviews and to extract key codes. As a result, the problems of the women with the spouses of the substance abusers were categorised.

Analysis was done using the 5-step method for analysis of qualitative data described by Griesheim and Landman, as follows: 1. determining content of the analysis or unit of analysis; 2. determining meaning units; 3. condensed meaning units were abstracted and coded; 4. codes were compared based on similarities and differences and classified and subcategories5. Themes of the categories were specified and reflected the latent content of the text (main category).

The researcher immediately listened to the interviews several times after recording each interview, and after finding a general overview of them, the interviews were implemented and written in a word-for-word way, and handwritten notes were reviewed several times. Then the texts were read row by row, and the sentences and phrases were determined, and then the semantic units were extracted in the form of primary codes. In the following, the codes were categorised according to the semantic and conceptual similarity and compressed as little as possible, and the subcategory was formed, which were more comprehensive and abstract. The categorisation of the subcategories led to the formation of the main category [18].

The four criteria of credibility, dependability, conformability, and transferability, as described by Lincoln and Goba, were used for applying trustworthiness to the findings [19]. For this purpose, the researcher attempted to improve the credibility by remaining engaged with the participants and data collection process for a prolonged duration using various information sources, including spouses, nurses, doctors, psychiatrists and officers who were involved in the service centers of this group, also, after encoding each interview, a full version of the code, including the keywords and codes obtained to assess the compatibility of the codes with the participants’ experiences, was shared with some of the participants (check member).

Discussion of the research team on conflicting findings and the achievement of the final consensus was also one of the other ways to secure the findings. To provide dependability to the findings, the researchers coded the transcripts of the interviews a few days after the initial coding and compared the results with the first coding, confirmed by achieving similar results and data stability and coordination. In order to enhance dependability and conformability, a part of the interview, along with its analysis, was provided to two external observers who were well experienced in both qualitative research and the subject studied. In order to achieve transferability, the results of the research were shared with several therapists and women whose spouses were Substance users and did not participate in the research, and the extent to which they were matched with their experiences.

Ethics

Ethical considerations were also observed in this research. Among them, informed consent from the participants to participate in the research and recording their interviews, the secrecy and confidentiality of the information was observed, and the right to withdraw from the interview was given to the participants. The text and interviews were kept in a safe place. This study was taken from the approved common project of Isfahan University of Medical Sciences and Golestan University of Medical Sciences that was approved by the Medical Ethics Committee of this university.

Results

Twenty-five 25 participants including 15 women with substance use spouses and 7 therapists including 3 nurses, 2 psychologists, 1 physician and 1 psychiatrist and 3 officials dealing with family members of the substance abuser including 1 province mental health official, 1 province well-being director and 1 Head of Counter-Narcotics Headquarters Consulting Center, participated in in-depth and semi-structured interviews. The participants’ demographic characteristics are presented in Table 1).

Table 1.

Participants’ Demographic Characteristics

Participants	Number	Age Mean	Education
Spouses	15	36.6	Illiterate to bachelor
Service Providers and Officials	10	39.7	Bachelor to doctor degrees

Type of substances used by substance abuser was included: opium, drug Juice, crack drug glass drugs, and tramadol. Addiction period of substance abuser was approximately 3 to 20 years. Occupation of substance abuser was unemployed, worker, employee, self-employment and history of leaving of the substance abuse was approximately 0 to 5 times.

The results of 25 in-depth and semi-structured interviews of participant 121 initial (primary) codes, and 8 subcategories, finally 2 main categories were extracted, including 1) family psychological breakdown and 2) the disadvantaged social status shown in Table 2.

Table 2.

Main categories and subcategories of the study of Psychosocial Problems of Women with Spouses of Substance Abusers

Main category/Subcategory
A) Family psychological breakdown
Psychological Disadvantages
Losing borders in the family
Insecure space house for the family
Turbulent family
Concern on spouses leaving
B) Disadvantaged social status
Trying to preserve the family’s image
Social stigma
Family social isolation

The main category of the family psychological breakdown

Spouses of substance abusers participating in the study experienced widespread psychosocial fluctuations since their spouses’ Substance abuse, which included 5 subcategories: psychological disadvantages, losing borders in the family, insecure space house for the family, turbulent family, concern on spouses leaving. All of these subcategories represent a gap in the psychological and emotional dimension of the family, which were categorised according to semantic similarity and fit into a more abstract category of “psychological breakdown”.

Psychological Disadvantages

Participants in this study stated stress, anxiety, and Depression, which primary codes of “stress”, “anxiety”, and “depression” considering their similarity and consistency in reflecting a Psychological and Emotional problem were placed in a more abstract subcategory of “psychological disadvantages”.

The participants in the study stated that due to their living conditions, they felt worried about their future and their children, that now their spouse is just thinking about their substance abuse, how the future of their children will be in terms of school and marriage. They also had stressed to carry out their activities and often felt as if they had the ability to work, and they were upset by the physical symptoms of stress.

“Sometimes, I’m always stressed, then what it will happen, and I’m worried, these conditions make me unable to do my daily tasks” (M-1 Spouse of the Family).

“ I’m worried about my children, that tomorrow they will grow up and one asks them that your father has such condition and that this will make them feel embarrassed” (M5-Spouse of the Family).

Most participants in the study stated that they were anxious due to the inappropriate behaviours of their husband with them and their children in the family. They stated experiences such as anxiety about a sudden occurrence, a feeling of fear of punishing the children by the father and the feeling of constant and unreasonable concern and the physiological causes of it.

“I’m always worried, and I’m always concerned, I say to myself what will happen. Because of this, my heart beats up; I sweat my hands and shake my feet” (M1-Spouse of the Family).

“I had a patient who always feared that she and her children behave and be beaten by her husband.” (M20-Psychiatrist Center).

Participants also reported that their husband’s addiction had a great impact on them psychologically. Shame, shyness, and social isolation were factors that caused depression in the women with substance abuse spouses.

“I was once depressed, I felt disappointed, I was sad, I was bored with everything, I had no motivation in life, I cried very soon, I did not bear anything, I went to the psychologist for this reason, I had been a bit overwhelmed for a while” (M3-Spouse of the Family).

“The spouse who stated said that she wanted to fire herself or eat a pill and wanted to kill herself. We even had a woman who had fired herself and fired her whole body and hands” (M21-Center physician).

Losing borders in the family

Most participants stated that the substance abuse had an effect on the behaviour of their husband, causing anger and lowered tolerance and aggressive behaviour (crying out loud, throwing things) which affected their spouses’ behaviours. These experienced concepts of participants based on their similarities, assigned to more abstract categories with” losing borders in the family” label.

“My husband was very brutal in the house, arguing for no reason and this was causing a seizure, he was crying out loud, he was throwing things” (M12-Spouse of the Family)

Participants also stated that these behaviours of their husbands led to aggressive behaviours in them.

“My husband’s behaviour has affected me so much; I’m nervous. I’ll go to the furnace soon … When I’m nervous, I’ll beat them “ (M7-Spouse of the Family).

“Here are women who take their husbands’ medication; they are very aggressive so that the morale of their husbands also affects them.” (M 19-Center Nurse).

Insecure space house for the family

Participants in this study stated lack of security, uncontrolled behaviour by substance abusers, getting hurt, beat up to death, being attacked with a knife, which was categorised according to semantic similarity and fit into a more abstract category of “Insecure space house for the family”.

“We have an axe in the house when we go to the forest; we will take it, he (my husband) had taken it and wanted to kill us, saying that I had seen you as the sheep and wanted to kill you” (M-12 Spouse the Family).

“A woman said that some days my husband imprisoned me in the closet and he went outside and how many days I was jailed there, and I did not feel safe at all, or some days to death he beat me “ (M 16-Center Nurse).

Turbulent family

The participants experienced very severe psychological stress, to be tormented and tire that this subcategory formed.

“I was so stressed out in this short period of my life that even when my dad I loved so much and lost him; I didn’t feel so pressured.” (M15-Spouse of the Family)

“I had been a bit overwhelmed by the severity of my discomfort, and I get worn very soon “(M3- Spouse of the Family).

Concern on spouses leaving

The participants were concerned about the fact that their spouses did not leave successfully and that they increased their medication dosage, instead of reducing their drug use, and they were concerned while meeting with their old friends. These experienced concepts of participants based on their similarities assigned to more abstract categories with “Concern on spouses leaving “label.

“Then, after a while, they were taking drugs, they increased their drugs a lot, instead of reducing their drug, which made it harder for anyone to take” (M-16 Center Nursing).

“The cases that a woman said her husband would leave ten times for the slave to leave, but her husband would not leave” (M-23 Mental Health Official).

B) The main category of disadvantaged social status includes 3 subcategories: trying to preserve the family’s image, social stigma and family social isolation. All of these subcategories were categorised according to semantic similarity and fit into a more abstract category of “disadvantaged social status”.

Trying to preserve the family’s image

The participants stated that they had to conceal the problem of their spouses’ addiction because if anyone knew that their spouse was a substance abuser, they would no longer trust them to work outside the house. And that they were trying not to notice their neighbours or relatives that their husband was addicted and because of the fear of dishonour, they did what their spouses wanted and tolerated their spouse. These experienced concepts of participants were categorised into a more abstract category of “Trying to preserve the family’s image”.

“I’m honest; I have to keep my appearance. I care about dressing myself because I work outdoors” (M 13-Spouse of the Family).

“My husband tells me to call Moslem (agency driver) to give me my drug. Now you want to make everyone understand that you are taking my drug” (M 2-Spouse of the Family).

Social stigma

For the vast majority of the women, people’s attitude towards the spouses of the addicted men is blamed, and people have a negative attitude and different viewpoint on them, and cases like embarrassment from abnormal behaviours and the physical condition of a spouse are the fingerprints of the people. They expressed a small sense of humiliation and distrust of the people.

These experienced concepts of participants based on their similarities assigned to more abstract categories with “social stigma” label.

“Most of the time he is sleepy, or we go somewhere, we get embarrassed, and when we have some guests, he is in a nap. I always tell him that no woman likes to be less likely than another woman because when people realise that their husband is an addict, they ask many questions, they humiliate, they have a different look”(M-Spouse of the Family).

“The clients are upset that no one trusts them, and they say that when we borrow money, they are not guaranteed to us, maybe because of the label that always has them.”(M22-province well-being director).

Family social isolation

From the viewpoint of most interviewees, relationships with relatives and acquaintances after men’s addiction have declined, and even cut off in some cases. Participants expressed the lack of male presence at parties and the late attendance of men when accompanying them, limiting the woman’s relationship with relatives due to the instability of her husband’s behaviour. These experienced concepts of participants categorised according to semantic similarity and fit into a more abstract category of “Family social isolation”.

“My husband does not tend to be in contact with others due to his substance abuse. When he does not accompany us, most of the time, I do not like to go along with the children, I’m bored” (M-12 Spouse of the Family).

“Since my husband was sometimes talkative and he said unnecessary words, and others thought that he was in another phase or very frustrated and went in his phase, made me not be in touch with others and get away from others” (M11-Spouse of the Family).

Discussion

The results showed that most women with substance abuser spouse had experienced extensive psychological fluctuations since their spouses used the substances. In this regard, Nikbakht et al., (2016) also stated in a phenomenological study that psychological vulnerability is the consequence of addiction to the family so that these women suffer from a lot of distressing feelings such as anger, sin and frustration. They are affected by these emotions along with many problems. Having an addict, especially spouses, can lead to an experience of life in a world of anxiety, worrying and confusion [9]. Along with this result, Chapsman et al. (2011) also stated in Australia that the addict’s spouse faces multiple experiences. In the early stages, her spouse’s addiction is unbelievable. After being confident in the addiction, the husband enters the resistance stage. She is blaming herself; she is gradually depressed and hates being alive. She hides her husband’s addiction from others and always fears to disclose it among friends and relatives and is worried about being rejected by others. And even lose hope for life [20]. Kishor et al., (2013) also found that over 65% of the women with drug use spouses had mental disorders, and early mood and anxiety disorders and about 43% of them had severe mood disorders [21].

The result of this study showed that most women with addicted spouses experienced some degree of “anxiety”, “depression” and “stress”. Along with this result, Mancheri et al., (2013) also in a descriptive study of 400 addicted people showed that 36.4% of the spouses had moderate anxiety, 36.8% had moderate depression, 36% had low aggression, and 35.8% had a moderate interpersonal sensitivity [7].

When an individual addiction is identified in the family, the family members are affected by the function of the addict, and they experience high levels of stress and anxiety, which affect the lives of the members in all aspects. The family members are responsible for the addict and try to save, protect and control him. This leads to fatigue, anxiety, fear, feelings of guilt and anger in them[7], and because the person using the substance does not do well for his addiction, responsibilities and activities, communication problems and anger among family members are increased [22].

Regarding the worries that exist, Sharifi (2006) states that worrying about the problems of their lives and their future and their children is one of the issues that involve the minds of these people more, and this factor reduces self-confidence in these people [23]. The results showed that most participants were concerned about the failure of their spouses to leave. In this regard, Raibero et al., 2007 in a study found that 75-80% of the self-referral to addiction treatment centres had a history of failed treatment[24]. Hajian et al., 2013 also reported that 72% of the addicts had a history of the failed treatment [25]. This failure rate of the addiction treatment could justify the concern of the participants.

Our participants noted that they had a “turbulent family”. In this regard, Penn Hire and colleagues quoted Ahani as saying that families that had a dysfunction or severe Substance use dependency were more turbulent than other families. The association of such families is very turbulent [26].

The disturbance is a kind of negative excitement that encountering a change in the process of life that sometimes affects people with some emotional responses. Humans, when confronted with phenomena that conflict with the culture and the family system, sometimes experience severe psychological pressures [27].

Another result of the study was the social isolation of the family. Together with these results, Malayeri Langroudi Khah et al., (2008) in Tehran showed that one of the social problems of the spouses of the addicted men is “social viewpoint,” and stated that most of these women had social repressions and were trying their best to hide the addiction of the spouse. They attend parties without the presence of their husbands, and visiting is more limited to people admitted to the husband, including the addicts and drug dealers. These women think that everyone knows about their spouses’ addiction and chooses to stay away from the community [11].

Another common issue that has been acclaimed in most interviews is “social stigma”. Along with this result, Nikbakht et al., also stated in their study that the addiction stigma tended to hurt the personal and social identity of the substance abuser spouse, and the negative attitude of the community toward the addiction would restrict social communication[9]. This reduces self-esteem, social isolation, and inefficiency in the Substance user’s spouse [28].

In families where the head of the addicted family is an addict, he usually dominates his behaviour and anxiety. Excitement, concern and justification are observed in his words. Mutual respect disappears within the family system, and as a result, the level of incompatibility among the members of the family is increased, and the substance abuser’s absences gradually emerge, and the set of these behaviours has a destructive effect on family relationships and relationships, so that the spouse and children do not feel comfortable and secure in the sociability that accompanies him. Thus, in families where the head of the household is an addict, the social relations of the family members are impaired. Because, Violence reigns instead of affection and also in the sociability that he has, Family members feel more ashamed and embarrassed. Instead of feeling comfortable and proud [29].

In conclusion, families, especially women with the Substance user spouse, are subject to severe psychosocial vulnerability and need to have comprehensive understanding and support. Therefore, nurses can develop education programs for people at risk by increasing awareness and changing their behaviour in the process of preventing addiction problems.