Resilience among Abstinent Individuals with Substance Use Disorder

Abstract

BACKGROUND:

Understanding resilience among abstinent individuals with substance use disorder would help in enhancing recovery.

AIM:

To examine the resilience among abstinent individuals with substance use disorder.

METHODS:

The study used a cross-sectional research design. Sample size: 60 samples were selected using a consecutive sampling procedure. Using interview schedule, data was collected from abstinent individuals receiving follow-up services at the out-patient department, government-run de-addiction centre, tertiary care teaching hospital, Bangalore. Persons with SUDs aged between 18–60 years with a minimum abstinence period of three months and above were included. Those who were refused consent for the study were excluded. Statistical test: Descriptive statistics, Spearmen correlation and logistic regression analysis were used to analyze the data.

RESULTS:

Mean age of the abstinent individuals was 39.6 (S.D ±9.5) years. Majority (75%) were married, employed (98%), having diagnosis of alcohol dependence (60%). Majority (80%) had past history of abstinence, 40% were maintaining abstinence more than three months. Most (60%) were treated on out-patient basis and they never hospitalized. Mean score of resilience among abstinent individuals was 75 (±9.94) which indicates high resilience in them.

CONCLUSION:

Social work interventions focusing on enhancing resilience among person with substance use disorder would help in maintaining long-term abstinence.

Introduction

In India, about 14.6% of the people aged between 10 and 75 use alcohol. There are about 16 crore persons who use alcohol. The prevalence of alcohol use disorder in the general population (10—75 years) is 5%. Alcohol use is significantly higher among men (27.3%) than women (1.6%). About 19% of current users of alcohol drink in a dependent pattern. About 5.2% of the people (more than 5.7 crore individuals) are affected by the harmful or dependent pattern of alcohol use and need treatment for their alcohol use problems. Nearly one in five alcohol users suffer from alcohol dependence and needs urgent treatment[1]. The burden of substance use disorders contributed by alcohol and tobacco, was more in middle-aged (40–59) individuals (29%), among males (35.6%) and in rural areas (24.1%). Treatment gap is more for tobacco use (91.8%) and alcohol use disorder (86.3%) followed by depression (85.2%), and other common mental disorders (84%). Majority of the persons with alcohol use disorder (68.5%) were treated by a government doctor in the recent past than any other mental illness[2].

Resilience

Resilience may be defined as ‘positive adaptation’ despite significant adversity[3]. Resilience is considered as a trait, outcome, and process. In this study, it is conceptualized as an outcome measure. Resilience is a process that mediates the harmful effects of a stressful or adverse experience through the interplay of biological, psychological, and social resources. Resilience involves mechanisms that are in place before, during, and after a traumatic or adverse event and may be present in some areas of an individual’s functioning, but not in all spheres[4]. Several studies concluded that resilience is a common outcome of normal human development and adaptation[3][5]. Resilience denotes a process signifying coping competence in the face of adversity, while the term resiliency refers to a discrete personal attribute[6].

Resilience reflects the interplay between risk and protective factors that consist of personal and social elements[7–8]. Protective factors that are associated with resilience are categorized as (a) individual dispositional attributes, (b) family support and coherence, and (c) external support systems[9]. Resilience improves self-confidence, helping seeking behaviour and use of the support system in adverse situations. It enables individuals to think about the personal and social strength to rely on the crises, preventing the lapse or relapse with substance use. Social work interventions explicitly focus on the individual strength and resources to tap and enable the person to overcome the difficulties. Intervention focusing on resilience-building may result in preventing relapse. There is substantial research that examines recovery from substance addiction as a form of resilience. Studies that thoroughly investigated resilience in substance use disorder is limited[10].

Substance use and Resilience

Increased psychological resilience is inversely related to alcohol misuse and is protective against alcohol misuse over time. It would be beneficial for clinicians to evaluate resilience as part of alcohol use history taking as such assessment could provide relevant information for treatment planning. It may be helpful to include resilience enhancement treatment components in treating alcohol misuse[11]. Resilience and adaptive motivation were inverse predictors of substance abuse. Men with less ego identity, self-efficacy, and resilience tend to get re-hospitalized for substance use disorders than women [12]. Individual with high resilience had lower risk of alcohol relapse and deeper self-disclosure[13]. Faith communities that supports prevention programs increase resilience and reduce risk of substance use disorder[14]. Perceived social support was more among people with high resilience than those with low resilience[15].

Resilience as Mediator

Lower resilience, younger age, unmarried, higher stressors, being male was associated with severe alcohol-related consequences. Resilience mediates the relationship between stress and alcohol-related consequences[16]. Resilience mediates the development of depression or alcohol use disorders following trauma exposure[17]. Perceived social support partially mediate resilience[18–19] and improve the self-efficacy and life satisfaction in persons with Substance use disorder[20].

Persons with substance use disorder who seek treatment have better functioning, but the relapsing and complex nature of the illness makes it difficult to maintain sobriety. Understanding resilience among persons who were abstaining from substances would help in enhancing recovery. There is a paucity of literature in the area of resilience and substance use as well. Hence the study aims to examine the resilience among abstinent individuals with substance use disorder.

Methods

The study used a cross-sectional research design. Sample size: 60. A consecutive sampling procedure was used for the study. Using interview schedule, data was collected from persons receiving follow-up services at the out-patient department, government-run de-addiction centre, tertiary care teaching hospital, Bangalore. Persons with SUDs aged between 18–60 years with a minimum abstinence period of three months and above were included, and persons with delirium tremens at the time of data collection and who were refused consent for the study were excluded. Tools used: RS-14 resilience scale[21] was used to measure the resilience among persons with SUD. It is a shortened version of the resilience scale that consists of 14 items. Total scores of the RS-14 range from 14 to 98. The scale has good internal consistency and reliability .90 and .87. Perceived social support was measured using Multi-dimensional Perceived social support scale[40]. This tool examines the perceived availability of different types of support using a 12- item questionnaire. Three dimensions of support – emotional (showing concern, listening), informational (giving suggestions, advice, and guidance), and instrumental (financial or physical aid) were assessed. Each item is rated on a 5 point Likert type scale ranging from 1 – 5 (1 = available none of the time, and 5 = available all the time). Cronbach’s alpha for the scale was 0.89 and test-retest reliability (Pearson’s r) = 0.74. In both the tools, higher score indicates higher resilience and higher perceived social support. Descriptive statistics, spearmen correlation were used to analyze the data. Informed written consent was obtained from participants, and clearance from the institute ethics committee was received before data collection.

Results

Table 1 describes the socio-demographic variables of the respondents. More than half of (57%) the participants were in the age group of 31– 45 years, and their mean age was 39.6 (S.D ±9.5) years. Nearly half of them were studied up to 12th std, the majority (75%) were married, employed (98%), 62% were daily wage earners, 52% were having income ranged between Rs.5000–10,000, were Hindu (90%), living in a nuclear family (67%), more than half of them (58%) were from an urban background.

Table 1:

Socio-demographic variables of the respondents

Sl.No	Socio-demographic variables	Category	f	%
1	Age	24–30	9	15
		31–45	34	57
		46–60	17	28
2.	Education	Illiterate	09	15
		Primary school	12	20
		High school	26	43.3
		Higher sec level	04	6.7
		Diploma	03	5.0
		Graduation level	06	10.0
3.	Income in Rs (per month)	Less than 5000	2	3.4
		5,000 – 10,000	31	51.7
		10,000 – 20,000	19	31.7
		20,000–40,000	06	10.0
		Above 40,000	02	3.3
4	Religion	Hindu	54	90
		Muslim	04	6.7
		Christian	01	1.7
		Others	01	1.7
5	Domicile	Urban	36	60
		Rural	24	40
6	Family type	Nuclear family	40	66.7
		Joint family	20	33.3
7	Marital status	Unmarried	14	23.3
		Married	45	75.0
		Divorced	01	1.7
8	Employment status	Employed	55	91.7
		Unemployed	05	8.3

Clinical profile of the respondents revealed that most of them (63.3%) were started substance use at the age between 10–20 years, and 53.3% of respondents became dependent before 25 years of age. Seventy-eight percent were diagnosed with Alcohol and tobacco dependence. Eighty percent of the respondents had a history of abstinence, half of the respondents (51.7%) attempted to abstain from substance use independently. Nearly half of them (43.3%) respondents were taken medical treatment. Physical health issues were the most commonly reported reason for abstinence (38.3%), followed by family issues in one-fifth (21.3%) of the respondents. Less than half of the respondents (40%) maintained abstinence for less than six months duration, more than one-third (37%) of the respondents maintained abstinence from 6 months to 2 years in the past. Fifty-seven percent of the respondent reported internal trigger has a reason for relapse, and 45% of respondents relapsed once. One-third (32%) of them maintained abstinence from day one after seeking medical treatment.

Participants on resilience measure had mean score of 75.78 (±9.94) indicating moderate level of resilience and on perceived social support mean score was 61.48 ((±13.50) revealing higher perceived social support among abstinent individuals with substance use disorder.

Table 2 reveals the Spearman correlation analysis carried out among socio-demographic variables and clinical variables about abstinence and resilience. Abstinence is positively related to income, several hospitalizations (r=.21) and several relapses (r=.34). Resilience is not associated with any of the socio-demographic, clinical variables. Resilience is strongly associated with education (r = 0.21) and perceived social support from the family and significant others (r = 0.29).

Table 2:

Correlation between socio-demographic variables and Resilience

Sl.No	Variables	Abstinence	Resilience
1	Age	r = 0.00	r = 0.03
2	Education	r = −.05	r = 0.21*
3	Income	r = −0.23*	r = 0.19
4	Number of relapse	r = 0.34**	r = 0.00
5	Number of hospitalization	r = 0.21*	r = −0.05
6	Resilience	r = 0.08	1
7	Perceived social support	r = 0.02	r = .29*

Discussion

The study examined the resilience among persons with substance use disorder who were abstinent for three months and above. The results revealed that those who were abstaining for three months and above had a higher level of resilience. This finding is in concordance with the previous study where persons with high resilience had a lower risk of alcohol relapse[13]. Individuals with resilience were less likely to involve themselves in drug abuse[22].

The present study showed that perceived social support is strongly associated with resilience among abstinent individuals. This finding was concomitant with the previous study[23]. Social support is associated with resilience to psychopathology[24], directly influences resilience[25], and increases resilience to drug abuse [15]. More social support from others increases resilience among persons with substance use disorder. Social support is necessary for resilience to occur, indicating that social support is positively correlated to resilience[26]. There is significant interaction between social support and resilience in mental health. Resilience is positively correlated with mental health, and social support reduces the negative effect of low resilience on mental health[27]. Social support and resilience protect individual mental health during crises, and it is essential to resilience[28]. Social support and resilience act as protective factors on mental health [29]. Resilience and social support predict the quality of life of patients with chronic illness. Studies have shown that resilience helps in recovery during adversities[30]. Resilient individuals maintain physical and mental health during difficult circumstances [31–32]. A meta-analysis revealed that resilience protects mental health, accelerates recovery, and mitigates the adverse effects of a crisis[33]

The present study showed no relationship between resilience, age, and income. This was finding was in contrast with previous studies which suggest that resilience may vary according to age. Resilience increased from young adults to older adults. Older adults are reported to have higher resilience. Resilience is indispensable for across age groups to recover and ‘bounce back from substance use disorder [34].

The present study revealed that education is positively correlated with resilience. This findings consistent with previous study findings. Adults with a professional education were significantly more likely to be resilient[35].

Although present study showed that the most abstinent individuals had a higher level of resilience score, however, abstinence was not correlated with resilience. This finding can be interpreted in the limelight that resilience can act as a mediator than directly associated with other variables as reported by several studies. This study also revealed no relationship between social support and substance abuse, resilience and drug abuse, which means that fostering more positive social support could result in high levels of resilience and low levels of drug abuse.

Social work methods may be used to increase individual resilience focuses explicitly on life skill development. There is ample evidence that an effective way to increase resilience is to focus on individual well-being. Social support from one’s community helps in nurturing resilience in the individual. Communities can enrich resilience in the individual through public health policies and programs that promote safe neighbourhoods, affordable housing, food and employment stability, access to healthcare, effective schools, emergency and disaster preparedness, and public spaces for relaxation and exercise[36].Developing the ability to regulate and manage emotions was important for the development of resilience in recovery[37]. Psychosocial interventions strengthening resilience results in enhancement of social support thereby helps people to cope with stress and prevents relapse and onset of substance use[38].Recovery oriented services need to focus on strengthening resilience and employment support for the person with substance use disorder to maintain long-term abstinence[39].

Limitations

Data collection was restricted to people who achieved sobriety for more than three months and above. During data collection, relapsed persons who maintained abstinence for more than three months were not included. The study was limited to people receiving treatment from a clinical setting; hence generalization of results to person achieved abstinence through other services may not be possible.

Conclusion

Resilience is high among persons with substance use disorder who were maintaining abstinence three months and above. However, abstinence is not associated with resilience in this study. Social work intervention should focus on enhancing resilience among people with substance use disorder to maintain long-term abstinence.