Relapse among substance abusers after treatment is an old phenomenon that has always been the nemesis of nations all around the world (Golestan, Abdullah, Ahmad & Anjomshoa, 2010). For long, studies have found that through several generations, relapse to substance abuse after treatment remains one of the greatest challenges in the treatment of all forms of substance abuse including alcohol, marijuana, heroin and cocaine (Marlatt & George, 1984; Polivy & Herman, 2002; Witkiewitz & Marlatt, 2004).
Many a study posits that when people attempt to change an undesired or problematic behavior, there is a high possibility of an initial lapse (Golestan et al., 2010; Marlatt & George, 1984; Witkiewitz & Marlatt, 2004). Drug dependency has been typified as a persistent relapsing disorder (McLellan, Lewis, O’Brien & Kleber, 2000). In clinical terms, relapse is defined as a return to a maladaptive use of substance, such as marijuana, alcohol, tobacco, heroin, cocaine or other illicit psychoactive drugs after having been previously treated for the same substance abuse disorder (Witkiewitz & Marlatt, 2004).
Researches on the substance abuse phenomenon posit that on the average, within a year of receiving treatment, most patients revert to previous levels of substance use (Hall, Havassy & Wasserman, 1990; Witkiewitz & Marlatt, 2004). Substance abuse clients and counselors both consider relapse as a major challenge militating against substance abuse prevention strategies (Golestan et al., 2010). Global statistics on the rate of relapse to substance use is disturbing. Both counselors and clients admit that whereas it is tough for a client to quit the use of drugs, it is even tougher to stay off the drug after intensive treatment (Ducray, Darker, Smyth, 2012; Moeller et al., 2001). Notwithstanding the client-focused and intensive treatment modules available for substance abuse, most treated clients return to the use of the abused substance after a period of abstinence (Polivy & Herman, 2002).
Substance abuse is shrouded with personal and social problems including the health of society regarding its political, social, economic and cultural issues in various degree (Hendershot, Witkiewitz, George, & Marlatt, 2011). The price for using and abusing illicit drugs are weighty and incontestable. The attendant health complications, poor psychosocial functioning and adverse economic implications such as government’s expenditure on treatments and rehabilitation of substance abusers have all been well documented (Burger, 2008; Parrott et al., 2004; Pressley & McCormick, 2007; United Nations Office on Drug and Crime’s report, 2013). Piggot, Carson, Saha, Torbeyns, Stock and Ingenito (2003) have stated that relapse to substance abuse could lead to such consequences as cognitive impairment, non-adherence to medication, personal distress, imprisonment and hospitalization.
Decades of research on substance abuse have implicated psychosocial factors such as mental health, significant life events and social functioning as playing critical roles in influencing the relapse rates and the abuse of drugs among clients who have previously been treated for substance abuse disorders (Hammerbacher & Lyvers, 2006; Melberg, Lauritzen, & Ravndal, 2003). Contextual factors such as living and working environments have been considered as relevant when accounting for relapse precipitants in substance abusers (Reece, 2007). Consistently, researchers have identified psychosocial factors including self-efficacy, negative affects, ineffective coping responses and a host of high-risk situations as precipitating the relapse to substance use (Connors, Maisto & Zywiak, 1996; Larimer, Palmer & Marlatt, 1999; Marhe, Waters, Van de Wetering & Franken, 2013; Mattoo, Chakrabarti & Anjaiah, 2009; Reece, 2007).
Several other psychosocial factors including fights and interpersonal conflicts, peer pressure, divorce, strained relationship with friends, family and co-workers (Broome, Simpson & Joe, 2001; McLellan, Lewis, O’Brien & Kleber, 2000) have been found to increase the risk of relapse to substance abuse. Community supports (Ibrahim & Kumar, 2009), support from family and friends (Broome et al., 2001) and stressful life events (Wills, Vaccaro & McNamara, 1992) have also been found to determine clients relapse state after rehabilitation. Information about psychological and social (contextual) factors relating to relapse and substance abuse may both be critical and important for planning clinical intervention strategies as well as contribute to aftercare and community-based interventions.
Literature is replete with studies correlating cultural and religious variables to relapse to substance abuse. Ethno-cultural identity and religiosity have been found to moderate substance use among particular groups of people (Chen, Dormitzer, Bejaro & Anthony, 2004). In particular, there has been a significant negative correlation found among people with higher levels of religious practice (religious devotion) and substance abuse (Chen et al., 2004; Kliewer & Murrelle, 2007).
Since four decades ago when scientific approach into the study of relapse has started (Marlatt & Gordon, 1984), there has been ample evidence that suggest various relapse rates for various substances. In one earlier study, about 90% of alcoholics who received treatment experienced at least one relapse over a 4-year period (Polich, Armor, & Braiker, 1981). In another study, Cornelius et al. (2003) found that 66% of the respondents had resumed their drug use within six months after treatment. There exist various relapse rates for the various substances of abuse. Differences in these rates could be attributed to several factors including the definition of relapse, individual’s variables, characteristics of the addiction and the effectiveness and success of treatment (Connors, G.J., Maisto & Zwiak, 1996).
Substance abuse and relapse phenomenon have been conceptualized and explained through a number of theories. In particular, the Cognitive-Behavioral Model of Relapse Process (Marlatt & Gordon 1984, 1985; Witkiezie & Marlatt, 2004) and the Relapse Syndrome Model (Gorski & Miller, 1982; Gorski, 1990) have expansively explained the process and indicators involved in relapse to substance abuse. Other theories that explicate relapse to substance abuse include the Stress-diathesis Model (Gatchel, 1993), the Self-medication Hypothesis (Duncan, 1974; Khantzian, Mack, & Schatzberg, 1974), the Bidirectional Model (Biafora Jr. et al., 1994), the Psychological Distress Model (Mercier et al., 1992) and the Behavioral Choice Model (Bickel & Vuchinich, 2000). The Cognitive-Behavioral Model of Relapse Process and the Relapse Syndrome Model – the foundations of this study are discussed comprehensively in the next chapter.
In general, substance use is attributed to a number of factors, including, psychosocial, biological and contextual variables (Nordfj?rn, 2011). In particular, psychosocial factors have been known to be critical determinants of relapse to substance abuse. Significant life events, psychosocial distress and self-efficacy have all been identified as significant predictors of relapse to substance abuse (Hendershot, Witkiewitz, George, & Marlatt, 2011; Nordfj?rn, 2011).
Studies have found major positive and negative events, similar to those found in the general population, have significant influence in the lives of substance abusers (Melberg et al., 2003; Witkiewitz & Marlatt, 2004). Periods such as the loss of a loved one, or social occasions and events such as funerals, wedding celebrations, and birthday parties have been found to have influenced the return to alcohol and drug abuse (Melberg et al., 2003; Saunders & Kershaw, 2006). For instance, a client discharged from a substance abuse rehabilitation facility after treatment could remain sober for a long period only to lapse during a funeral or wedding celebrations.
Unquestionably, the role of psychological distresses, including depression, interpersonal conflicts, and anxiety in substance abuse and relapse have long been noted (Grant et al., 2004). Continuous interpersonal conflicts with a spouse or a co-worker, for example, could lead to depression, or outburst of anger and frustrations. The individual could revert to alcohol and drugs to either help take cope the situation or to empower him or her to face the perpetrator. Empirical supports linking psychological distress to substance use and abuse exist. In one study, clients with psychological distress were found to abused alcohol and drugs than those without any psychological distresses (Grella, Hser, Joshi, & Rounds-Bryant, 2001).
Self-efficacy, defined as one’s belief that a task can be carried out successfully to achieve a desired outcome (Bandura, 1997), has been associated with substance abuse and relapse (Nordfj?rn, 2011). Clients who show low levels of self-efficacy, for instance, have been found to have shown high levels of alcohol and substance abuse (Hendershot, Witkiewitz, George, & Marlatt, 2011). Individuals who lose confidence in themselves and in their efforts to succeed, no matter the venture, could for long remain depressed and frustrated. The individual may then resort to substance use, amid the frustration, to enflame some happiness. Gradually from a lapse, the substance abuse behavior may continue and become a full blown relapse.
1.1 Statement of the problem
Unquestionably, the abuse of alcohol and drugs remains problematic in most countries of the world. The 2013 World Drug Report by the United Nations Office on Drug and Crime (UNODC) revealed that over 35 million people, representing 0.8% of the adult population worldwide use heroin, cocaine or a combination of both. Of this population, it is estimated that 10-13% will become drug dependent and will forfeit their sobriety (UNODC Report, 2013). The UNODC’s statistics for 2013 on the worldwide estimate of substance abuse is even more frightening. The report revealed that in 2012, between 167 and 315 million people aged 15–64 were estimated to have used an illicit substance in the preceding year.
West Africa is not excluded from the problem of drug trafficking and abuse. About a decade ago the region was declared as a transit route for hard drugs (Drug News Africa, 2012). According to the Ghana Demographic Health Survey Report (GDHS) for 2009, the sub-region had become not only a transitory route, but more disturbingly, a consumer market of these illicit psychoactive drugs (GDHS Report, 2009). The report concluded that the abuse of hard drugs was on the increase and had attracted the attention of most health professionals in Ghana (GDHS Report, 2009).
The Out-patient Monthly Morbidity Returns (OMMR) records for 2012 from the Department of Psychiatric of the Regional Hospital, Sunyani, showed that of the 2,284 patients who accessed the facility for the year, about 596(26%) were alcohol and drug abuse related cases. In the same year, out of the 1,047 new cases seen, 413 were substance abuse related disorders, with 138 having been either re-admitted or treated on at least one other occasion for the same diagnosis. This statistics showed a 12% increase in substance abuse and relapse cases as compared to that of the preceding year (OMMR for Psychiatric Unit: Regional Hospital, Sunyani, 2012).
The Drug News Africa states that about 1.25 million Ghanaians in 2012 had drug addiction problems, mostly marijuana (Drug News Africa, 2012). Studies on substance abuse in Ghana (Affinnih, 1999a Lamptey, 2005; Redvers et al., 2006) estimate more worrisome statistics. In no doubt, more people may be abusing drugs in Ghana than is estimated. This is very disturbing since the rates of relapse to substance abuse after treatment remain high. For instance, Brandon, Vidrine and Litvin (2007) noted that the relapse rates for most individuals after the cessation of alcohol or tobacco for a year ranges from 80 – 95%. Notwithstanding the type and frequency of the drug in use, the penalties are always grave. Witkiewitz and Marlatt (2004) noted that violence, legal problems, depression and suicide attempts are some of the adverse consequences of substance use. The availability and the increasing use of these illicit psychoactive drugs results in its dependence with its attendant psychosocial adverse effects.
Undoubtedly, substance abuse has profound health, economic and psychosocial consequences to the individual, family, community and nation. Studies (Berk, 2007; Large, Sharma, Compton, Slade, & Olav, 2011; Witkiewitz & Marlatt, 2004) have shown a number of physical, psychological and health-related consequences following the continuous use and abuse of substances. At the personal level, substance abuse has been associated with adverse biopsychosocial consequences, including heart failure, erectile dysfunction, hypertension, cancer, stroke and capillary haemorrhages, irritability and restlessness, mild paranoia, physical exhaustion, mental confusion, loss of weight; fatigue or depression and unemployment (Davison, Neale, & Kring, 2004; Kring, Davison, Neale, & Johnson, 2007). Similarly, the families of substance abusers also share in the consequences. In particular, the loss of productive hours in care of the substance abuser and the cost of treatment have been documented (Moos, 2007; Redvers et al., 2006). A number of social and economic implications have also been noted at the community and national levels. Increase in crime rates, unemployment, poor academic or job performance, school dropout, divorce and the diversion of scarce national resources for treatment and rehabilitation of substance abusers have been associated with substance abuse (Burger, 2008; Parrott et al., 2004; Pressley & McCormick, 2007).
1.2 Aim and objectives of the study
Willig (2008) argues from a pragmatic viewpoint that the aim of research is not about generating abstract truth free from the experience of people but rather to provide insight that will inure to the benefit of humanity. Hence the aim of this study is to explore the psychosocial precipitants of relapse and the rate of relapse among substance abusers in the Sunyani Metropolis. More specifically, the objectives of this study are:
To explore the various psychosocial factors that contribute to relapse of substance abusers in the Sunyani Metropolis
To estimate how often respondents return to pre-treatment levels of substance abuse after treatment
To explore the role of the family, culture and religion in relapse or abstinence among respondents.
To explore the preventive/coping strategies clients use to prevent relapse.
To explore the psycho-socioeconomic consequences of relapse to the respondents, their families and society.
1.3 Relevance of the study
In 2005, a total of 86,003 outpatient attendances were recorded by the three psychiatric hospitals in Ghana (Ofori-Atta et al., 2010). Substance abuse disorders were among the top psychiatric diagnoses for the attendance, accounting for about 22.8%. Even more frightening was the number of substance abusers projected to develop psychological disorders in the course of time.
The passage of the Ghana Psychological Bill and the Ghana Mental Health Law in 2012 mandates the Ghana Health Service to employ Clinical Psychologists to all regional and district hospitals in the country to treat and manage the myriad psychological problems faced by clients. In no doubt, substance abuse and relapse would be one of the major clinical diagnoses these clinicians would encounter. Reece (2007) has postulated that contextual and environmental factors are critical determinants of relapse among substance abusers. Certainly the environmental conditions of Europe and elsewhere are significantly different from those in Ghana and the rest of Africa. Consequently, one cannot readily attribute the factors found to have precipitated substance abuse and the resultant relapse of a different context to that in Ghana.
More widely, findings from this research would aid Clinical Psychologists, Psychiatrists, Psychiatric Nurses, policymakers and relatives of clients to better understand the psychosocial factors that precipitate the relapse phenomenon and the rates at which relapse to substance abuse occur when deciding how best to offer treatment options to develop effective relapse preventive strategies which are contextual in the management of the relapse phenomenon.
Furthermore, although there are studies on substance abuse in Ghana (Affinnih, 1999a Lamptey, 2005; Redvers et al., 2006), there is a paucity of data regarding the psychosocial factors that influence relapse to substance abuse. The rates of relapse to substance abuse among substance abusers have also not been well documented. Of equal importance, the findings from this study would add to the literature on the relapse