Abstract
Background:
Substance use disorder is a major public health concern in India. Understanding social support among persons who were abstaining from substance use would help in promoting long-term abstinence.
Aim:
To examine perceived social support among abstinent individuals with substance use disorder
Methods:
Cross-sectional study design was used. Sixty subjects who were attending follow-up service were selected consecutively from out-patient specialty clinic (Addiction Medicine), tertiary care teaching hospital, Bangalore. Persons with SUDs between the age of 18–60 years with minimum abstinence period of three months and above were included. Exploratory analysis such as descriptive statistics, spearmen correlation was used. The study was approved by Institute ethics committee.
Results:
Mean age of the respondents was 39.6 (S.D ±9.5) years. Majority (60%) do not have peer pressure, majority (60%) had diagnosis of alcohol dependence and 80% had past history of abstinence, 40% were maintaining abstinence from three to six months. Majority (60%) were never hospitalized. Mean score of perceived social support among persons who were abstaining 90 days and above were 61.48 (±13.50) indicating high perceived social support.
Conclusion:
Perceived social support was higher among persons who were abstaining from substance use for three months and above.
Keywords: alcohol, drugs, social work treatment, abstinence
Introduction
Substance use disorder is a major public health concern in India. In India, about 14.6% of the people aged between 10 and 75 years of use alcohol. The prevalence of dependence pattern of alcohol use in the general population (10–75 years) is estimated to be 2.7%. Nearly one in five alcohol users suffer from alcohol dependence and needs urgent treatment [1].
Support from other people plays a pivotal role in dealing with life challenges. Social support serves as a buffer against life’s adversities. Perceived social support is conceptualized as the “cognitive appraisal of being reliably connected to others” [2]. It does not actually involve receiving any tangible support or assistance; it is a perception that support is available during times of stress[3]. Perceived social support serves both as instrumental and expressive functions in a person’s life, provides social links, nurturance, affiliation and guidance, and also develops self-value and intimacy [4].
Substance use disorder has a direct impact on the individuals, family and community. Social support helps to develop resilience in overcoming substance use disorder. The absence of social support leads to maladaptive coping such as substance use to deal with life adversities. Lower social support is linked with high lifetime alcohol, cannabis, and tobacco use [5]. Perceived social support was positively related to self-esteem and life satisfaction in drug dependents [38, 40–42]
Role of Social Support in Alcohol Use disorder
Better social support system, achievement orientation and intellectual cultural orientation in family environment, reinforcement, communication pattern in the family interaction pattern, adequate role functioning in marital quality life were the family factors predicts the abstinence among alcohol dependents [6]. Family social support was one of the reasons for natural recovery of persons with alcohol dependence syndrome (ADS) [7]. Well-motivated persons with ADS had more support from family and friends [8].
Persons with ADS showed more problems in the area of primary social support (family) [9] and there was higher degree of dysfunction in the domains of social support system [10]. Untreated individuals had significantly lesser social support than treated persons [11]. In the families of relapsed individuals, social support was found to be lesser [12], have strained interpersonal relationship with spouse and less supportive family environment[13]. The extent of social support from spouse was less in unemployed alcohol dependents [14].
There is positive correlation between family social support and marital quality among alcohol dependents [15]. Abstinent individuals in an industry setting had significantly more social support from family members. Factors responsible for their abstinence were support from their spouses, friends, and management [16]. Harmonious relationship and support in the family was one among the four family and social indicators responsible for predicting the better prognosis in alcohol dependence [17]. Family intervention was effective in improving the social support of individuals with ADS [18].
Perceived social support was more among people with high resilience than that of the group with low resilience. Positive affection, social support, and spirituality from families help increases the resilience among alcohol dependents [19]. The person who perceives high social support from family has fewer relapse to alcohol and drugs [20]. Fostering positive social support results in higher resilience and low levels of drug abuse[21]. Perceived social support was significantly related to the social domain of quality of life[22], higher self-esteem, lower depression and anxiety, and better sleep among individuals with substance use disorder[37].
Social Support and Abstinence
Higher level of social support has been associated with reduction of substance use and improved mental health[37], reduced rates of alcohol use and alcohol-related problems in non-treatment seeking adults[43]. Higher levels of social support have been linked to multiple addiction-related outcomes, including lower frequency of relapse (Atadokht et al., 2015)[44]. Perceived social support is inversely related to substance use frequency[5]. There is a positive relationship between social support and abstinence-specific self-efficacy [23–24] found that social support and social network size were inversely related to pretreatment days using drugs. The instrumental and emotional social support was most common form of social support perceived in both inpatient and outpatient settings. Participants most frequently mentioned social support was Alcoholics Anonymous [23].
Need for the Study
In Indian context, there is dearth of studies examining perceived social support among abstinent individuals with substance use disorder. Persons with substance use disorder who seek treatment have better chances of abstinence; however relapsing nature of illness makes it difficult to attain. Examining perceived social support among persons who were abstinent from substance use disorder would help in promoting long-term abstinence. Hence, present study was carried out to examine role of perceived social support among abstinent individuals with substance use disorder and its relationship between clinical and demographic variables.
Methods
Cross-sectional study design was used. Sixty samples were selected from out-patient department using consecutive sampling technique during their follow-up. Male and female persons with SUDs aged between 18 and 60 years with minimum period of abstinence at the time of data collection were included and those who refused consent were excluded from the study. The data was collected from July 2017 to Nov 2017 at out-patient specialty clinic (Addiction Medicine), tertiary care teaching hospital, Bangalore. Interview schedule was used to collect data on demographic and clinical profile. Tools used: Multi-dimensional Perceived social support scale [25] 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 to 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. Higher score indicates higher perceived social support. All the subjects were screened, assessed by mental health professionals (psychiatrist, psychiatric social workers and clinical psychologist during the follow-up service) and abstinent individuals were referred to the researcher for data collection. All the participants in the study were underwent pharmacological and psychosocial interventions such as brief motivational intervention, relapse prevention. Informed written consent obtained from participants and the study was approved by the institute ethics committee prior to data collection. Exploratory analysis such as descriptive statistics, spearmen correlation analysis was used to analyze the data. First author BR collected the data. Software SPSS 20.0 was used for statistical analysis.
Results
Table 1 shows the socio-demographic characteristics of subjects. More than half of (57%) the recovering persons (those who maintain abstinence for a minimum period of three months) were in 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 senior secondary school level. Majority of the abstinent individuals were married (75%), employed (98%), daily wage earners (62%), Hindus (90%), living in nuclear family (67%), having monthly income between Rs.5000 and 10,000 (52%) and from urban background (58%).
Table 1:
Socio-demographic variables of the respondents
| Sl.No | Socio-demographic variables | Category | F | % |
|---|---|---|---|---|
| 1 | Age | 24–30 | 09 | 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 | Marital status | Single | 14 | 23.3 |
| Married | 45 | 75.0 | ||
| Divorced | 01 | 1.7 | ||
| 4 | Employment status | Employed | 55 | 91.7 |
| Unemployed | 05 | 8.3 | ||
| 5 | Domicile | Urban | 35 | 58.3 |
| Rural | 24 | 40 | ||
| Semi-urban | 01 | 1.7 | ||
| 6 | Family type | Nuclear family | 40 | 66.7 |
| Joint family | 20 | 33.3 |
Table 2 shows clinical profile of the abstinent individuals with substance use disorder. Most of them (63.3%) were started using substance before the age of 20 years, and 53.3% respondents were developed dependence before 25 years of age. Seventy eight percent were having diagnosis of Alcohol and tobacco dependence. Eighty percent of the respondents had past history of abstinence, half of the respondents (51.7%) attempted to abstain on their own. Nearly half of the (43.3%) respondents were abstinent after taking treatment. Physical health issues were the most commonly reported reason for abstinence (38.3%). Nearly half of the respondents maintained abstinence for three to six months (40%). Fifty seven percent of the respondent reported internal trigger was the reason for relapse and 45% respondents had relapsed once. One-third (32%) of them maintained abstinence from day one after seeking treatment. Mean score of perceived social support (61.48 ± 13.50) among persons who were abstaining three months and above were indicating high perceived social support.
Table 2:
Clinical Profile of the Respondents
| Sl.No | Clinical profile | Categories | f | % |
|---|---|---|---|---|
| 1 | Age at initiation of substance use | 10–15 | 15 | 25.0 |
| 16–20 | 23 | 38.3 | ||
| 21–25 | 13 | 21.7 | ||
| 26–30 | 09 | 15 | ||
| 2 | Age at dependence | 15–20 | 15 | 25.0 |
| 21–25 | 17 | 28.3 | ||
| 26–30 | 15 | 25.0 | ||
| Above 30 year | 13 | 21.7 | ||
| 3 | Diagnosis | Alcohol Use Disorder | 11 | 18.3 |
| Alcohol and tobacco use disorder | 36 | 60.0 | ||
| Cannabis use disorder | 08 | 13.3 | ||
| Benzodiazepine use disorder | 01 | 1.7 | ||
| Inhalants use disorder | 02 | 3.3 | ||
| Opioid use disorder | 02 | 3.3 | ||
| 4 | Reason for abstinence | family issues | 13 | 21.7 |
| physical problems | 23 | 38.3 | ||
| Others | 24 | 40.0 | ||
| 5 | Number of relapse | none | 19 | 31.7 |
| 1 | 27 | 45`0 | ||
| 1–3 | 07 | 11.7 | ||
| 3–5 | 01 | 1.7 | ||
| more than 5 | 06 | 10.0 | ||
| 6 | Past history of abstinence | Yes | 48 | 80.0 |
| No | 12 | 20.0 | ||
| 7 | Duration of abstinence | 3 – 6 months | 24 | 40.0 |
| 6 months – 1 year | 13 | 21.7 | ||
| 1–2 years | 09 | 15.0 | ||
| Above 2 years | 14 | 23.3 | ||
| 8 | Reason for relapse | Internal trigger | 34 | 56.7 |
| External trigger | 14 | 23.3 | ||
| Others | 12 | 20.0 |
Table 3 reveals the results of spearman correlation analysis between relevant socio-demographic variables, clinical variables with regard to perceived social support and abstinence. Perceived social support is positively correlated with education (r=0.40, p= 0.001), income (r=0.24, p=0.02). Perceived social support negatively correlated with age at initiation of substance use (r= −0.24, p = 0.01). Abstinence is positively correlated with number of relapse (r 0.34, p=0.006), number of hospitalization (r = 0.26, p=0.04). Though there is no correlation between abstinence and perceived social support, however individuals with substance use disorder had higher mean score on perceived social support (61.48 ± 13.50).
Table 3:
Correlation between socio-demographic, clinical variables and perceived social support
| Sl.No | Variables | Abstinence | Perceived social support |
|---|---|---|---|
| 1 | Age | r =.150 p =.253 |
r = −0.06 p = .30 |
| 2 | Education | r = −0.05 p =0.33 |
r = .40** p =.001 |
| 3 | Income | r = −0.23* p = 0.03 |
r = .24** p = 0.02 |
| 4 | Duration of employment | r =0.17 p =0.09 |
r = − 0.22* p = 0.05 |
| 5 | Number of relapse | r =.349** p =.006 |
r =0.09 p =0.22 |
| 6 | Number of hospitalization | r =.262 p =.04* |
r = −0.05 p =0.33 |
| 7 | Age at Initiation of substance use | r =0.01 p =0.45 |
r = − 0.24** p = 0.02 |
p<0.05
p<0.01
Discussion
Social support has been well researched for its positive effect on an individual’s overall health and psychological well-being [45]. Social support has been linked with abstinence from substance use. Present study examined the role of perceived social support among abstinent individuals with substance use disorder. The results revealed that those who were abstaining for minimum three months were having higher level of perceived social support. This finding was in concordant with previous study finding where persons with high social support were maintaining abstinence [6–8], [16–17], [26], [27], [28], [29], [30] and had lower risk of alcohol relapse [19, 31, 32] and increased abstinence period [ 33 ]. Abstinent group perceived better social support than relapsed group[41]. This finding also provides possible insights for pathways to increase social support.
Studies have reported that characteristics of one’s social network have effect on substance use and its treatment outcome. Number of persons in the social network was a significant moderator of abstinence. Larger social networks showed a stronger improvement on abstinence. Previous studies also reported contrast finding that individuals with limited social support had higher abstinence.
The study examined the perceived social support among individuals with substance use disorder who were abstinent from substance use for three months and above. The results revealed that abstinent individuals were having higher level of perceived social support. In this study, average age of the abstinent individuals was 39 years. This finding was similar to previous study findings which reported mean age of the persons who maintained one year abstinence was 39 years and 41 years respectively [34, 35].
Present study revealed that there is an association between education, income, perceived social support. Higher education and income showed better perceived social support. In Indian context, spouse play vital role in seeking treatment for substance use, strengthening the family support system during treatment would help maintaining recovery or prevention in relapse in future. Abstinence is positively correlated with persons using single substance have better chance of maintain recovery than poly-substance user.
Limitations
Data collection was restricted to people achieved sobriety for more than three months and above. At time of data collection, those had relapse and delirium tremens who maintained abstinence for more three months were not included. Study was limited to people receiving treatment from clinical setting. Hence, generalization of results to those who achieved abstinence through other services may not be possible. Study findings are specific to men than women with substance use disorder as there was one women sample in this study. Larger samples are required to confirm the study findings as results were correlational and not causal relation. Lastly, data analyzed were without any corrections and did not consider confounding factors that may explain variation in results. Study findings provide evidence for an important link between perceived social support and abstinence.
Implications for Clinical Practice
Strengthening the social support among persons with substance use disorder may help in promoting long-term abstinence. Psychosocial interventions focusing on strengthening social support would help individuals with substance use order to maintain long-term abstinence.
Conclusion
Perceived social support was high among abstinent individuals with substance use disorder who were maintaining abstinence three months and above.
Acknowledgements:
This work was supported by India-US Fogarty Post-Doctoral Training in Chronic Non-Communicable Disorders across Lifespan Grant #1D43TW009120 (Sinu Ezhumalai, Post-Doctoral Fellow; LB Cottler, PI)
Funding:
National Institute of Mental Health And Neurosciences, Bangalore, Ministry of Health & Family Welfare, Govt of India under Human Resource Development Programme in Mental Health (2016–2018).
Footnotes
Conflict of Interest: Nil
Contributor Information
Mr. Bharath Rathinam, Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bangalore-560029..
Dr. Sinu Ezhumalai, Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bangalore-560029..
References
- 1.Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda RK. Magnitude of Substance Use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019. [Google Scholar]
- 2.Barrera M Distinctions between social support concepts, measures, and models. Am J Community Psychol. 1986;14:413–45. [Google Scholar]
- 3.Lakey B, Scoboria A. The relative contribution of trait and social influences to the links among perceived social support, affect, and self-esteem. J Pers. 2005;73:361–88. [DOI] [PubMed] [Google Scholar]
- 4.Cutrona C, Russell D. The Provisions of Social Relationships and Adaptation to Stress. Adv Pers Relatsh. 1983;1:37–67. [Google Scholar]
- 5.Rapier R, McKernan S, Stauffer CS. An inverse relationship between perceived social support and substance use frequency in socially stigmatized populations. Addict Behav Rep. 2019;10: 100188. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Dhanasekarapandian R, Ranganathan M. Family interaction pattern and Abstinence among persons with alcohol dependence syndrome. Int Res J Soc Sci. 2017;6(8):23–6. [Google Scholar]
- 7.Panditi K Natural recovery of persons with alcohol dependence syndrome. NIMHANS. 2004 [Google Scholar]
- 8.Lilly P Role of motivation in the treatment of alcohol dependence. NIMHANS. 2001 [Google Scholar]
- 9.Biswas G Family interaction patterns of persons with depression, alcohol dependence and obsessive compulsive disorder. NIMHANS. 2003 [Google Scholar]
- 10.Kumar D A comparative Study on the family functioning of alcoholics and non-alcoholic employees in an Industry. NIMHANS. 1996 [Google Scholar]
- 11.Shivakumar K Psychological distress and social dysfunctions among treated and untreated alcoholics. NIMHANS. 1997 [Google Scholar]
- 12.Yesudoss A Family interaction and self-concept of relapsed and abstinent alcohol dependents. NIMHANS. 1991 [Google Scholar]
- 13.Thirumoorthy A The experiences of wives of alcoholic abstinent and relapsed employees – A follow-up study. NIMHANS. 1995 [Google Scholar]
- 14.Mathew K, Bajumon. Violence in the families of employed and unemployed alcoholics. NIMHANS. 1997 [Google Scholar]
- 15.Vijayan TV, Reddy Krishna, Nirmala BP. Social support and marital quality among wives of persons with alcohol dependence. Indian Journal of Social Work. 2010; 71(3): 329–350. [Google Scholar]
- 16.Dias VM (1994). Understanding alcohol long-term abstinents and relapsers in an Industrial setting. NIMHANS. [Google Scholar]
- 17.Rajaram S Social Indicators in the prognosis of alcoholics. NIMHANS Journal. 1992;10(1); 61–63. [Google Scholar]
- 18.Mathew B Qualitative analysis of family intervention. NIMHANS. 1997 [Google Scholar]
- 19.Nikmanesh Z, Honakzehi F. Examining perceived social support, positive affection, and spirituality, as resilience factors, among boys of drug-dependent fathers. Shiraz E-Med J. 2016b. 10.17795/semj42200. [DOI] [Google Scholar]
- 20.Hajloo N, Karimi M, Narimani M. The Role of Family Expressed Emotion and Perceived Social Support in Predicting Addiction Relapse. Int J High Risk Behav Addict. 2015; 4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Mwebi Bantu, Onderi OKwara. Adolescent resilience, social support and drug abuse a case of Koboko District. Uganda: West Nile; 2014. [Google Scholar]
- 22.Ates N, Unubol B, Bestepe EE, Bilici R. The effect of perceived social support on quality of life in Turkish men with alcohol, opiate and cannabis use disorder. J Ethn Subst Abuse. 2019;5: 1–21. [DOI] [PubMed] [Google Scholar]
- 23.Stevens E, Jason LA, Ram D, Light J. Investigating social support and network relationships in substance use disorder recovery. Subst Abuse. 2015;36(4):396–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Zywiak, et al. The important people drug and alcohol interview: Psychometric properties, predictive validity, and implications for treatment. J Subst Abuse Treat. 2009;36(3):321–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Zimet GD, Dahlem NW, Zimet SG. The multidimensional scale of perceived social support. J Pers Assess. 1988;52:30–41. [Google Scholar]
- 26.Kumar Arul (1992). Factors associated with relapse and abstinence in the families of alcohol dependents. NIMHANS. [Google Scholar]
- 27.Ashok Kumar H (2008). Social support among abstinence and non-abstinence alcohol dependents. NIMHANS. [Google Scholar]
- 28.Beattie MC, Longabaugh R. General and alcohol-specific social support following treatment. Addict Behav. 1999;24:593–606. [DOI] [PubMed] [Google Scholar]
- 29.Moos RH. Theory-based processes that promote the remission of substance use disorders. Clin Psychol Rev. 2007;27:537–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Anthony Sojan, Dhanasekarapandian R, Murthy P. Two year abstinence from alcohol among persons with alcohol dependence: An in-depth psychosocial analysis. NIMHANS. 2012 [Google Scholar]
- 31.Chen G Social support, spiritual program, and addiction recovery. Int J Offender Ther Comp Criminol. 2006;50(3):306–23. [DOI] [PubMed] [Google Scholar]
- 32.Westfall KK Exploration of the relationship between resilience, social support and formal help seeking, and evaluation of Guelph’s 1 in 5 mental health awareness initiatives. 2014;87. [Google Scholar]
- 33.Yamashita A, Yoshioka SI. Resilience associated with self-disclosure and relapse risks in patients with alcohol use disorders. Yonago Acta Med. 2016;59(4):279–87. [PMC free article] [PubMed] [Google Scholar]
- 34.Nattala P, Leung KS, Murthy P. Family member involvement in relapse prevention improves alcohol dependence outcomes: a prospective study at an addiction treatment facility in India. J Stud Alcohol Drugs. 2010;71(4):581–7. [DOI] [PubMed] [Google Scholar]
- 35.Sinu E, Muralidhar D, Murthy P. Family centered social casework intervention for persons with alcohol dependence syndrome. NIMHANS. 2011 [Google Scholar]
- 36.Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosoc Rehab J. 1993;16:11–23. [Google Scholar]
- 37.Birtel MD, Wood L, Kempa NJ. Stigma and social support in substance abuse: Implications for mental health and well-being. Psychiatry Res. 2017;252:1–8. [DOI] [PubMed] [Google Scholar]
- 38.Cao Q, Liang Y. Perceived social support and life satisfaction in drug addicts: Self-esteem and loneliness as mediators. J Health Psychol. 2020;25(7):976–85. [DOI] [PubMed] [Google Scholar]
- 39.Dixit S, Chauhan VS, Azad S. Social support and treatment outcome in alcohol dependence syndrome in armed forces. J Clin Diagn Res: JCDR. 2015;9(11):VC01–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Hagen E, et al. One-year sobriety improves satisfaction with life, executive functions and psychological distress among patients with polysubstance use disorder. J Subst Abuse Treat. 2017;76:81–7. [DOI] [PubMed] [Google Scholar]
- 41.Laudet AB, Morgen K, White WL. The role of social supports, spirituality, religiousness, life meaning and affiliation with 12-step fellowships in quality of life satisfaction among individuals in recovery from alcohol and drug problems. Alcohol Treat Q. 2006;24(1–2):33–73 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Chou KL. Assessing Chinese adolescents’ social support: The Multidimensional Scale of Perceived Social Support. Personality and Individual Differences 2000;28:299–307. [Google Scholar]
- 43.Brooks TA, Miriam Magaña Lòpez, Alexandra Ranucci, Michael Krumlauf, Wallen Gwenyth R. A qualitative exploration of social support during treatment for severe alcohol use disorder and recovery. Addictive Behaviors Reports. 2017; 6: 76–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Atadokht A, Hajloo N, Karimi M, Narimani M. The role of family expressed emotion and perceived social support in predicting addiction relapse. Int J High Risk Behav Addict. 2015; 20;4(1):e21250. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985; 98(2):310–57. [PubMed] [Google Scholar]