Psycho Social Determinants of Relapse Among Patients Diagonised with Substance Use Disorder at Parirenyatwa Psychiatric Unit Annexe.

Psycho Social Determinants of Relapse Among Patients Diagonised with Substance Use Disorder at Parirenyatwa Psychiatric Unit Annexe

Rumbidzai Nzwenge, L. Chichevo

University of Zimbabwe

DOI: https://dx.doi.org/10.47772/IJRISS.2025.907000007

Received: 17 December 2025; Accepted: 30 December 2025; Published: 26 July 2025      

ABSTRACT

Substance abuse has become a substantial and growing problem in Zimbabwe that has resulted in a high number of admissions and readmissions, in public institutions; particularly at Parirenyatwa Annexe. Despite the available treatment, a considerable number of relapse cases have been recorded at Annexe, which has had to accommodate the cases due the shortage of rehabilitation centers in the country. The primary aim of the study was to explore the psychosocial determinants of relapse among people diagonised with substance use disorder. Additionally, the study sought to explore the risk factors for re-admission and the major substances used by the patients. A qualitative research design was utilised with the purposive sampling method. Ten participants took part in the study and data was collected through semi-structured interviews.  The thematic analysis identified the following themes as the psychosocial factors that led to relapse:  stigma, stress, dual diagnosis, family influence, work pressure, craving and availability. Furthermore, crystal methamphetamine, cannabis and alcohol were found to be the major substances used. The risk factors for re-admission were identified as unemployment, lack of social support and peer influence. The theoretical framework utilised to understand this study was the relapse prevention model developed by Marlatt. According to the study psychotherapy interventions may beneficial when focusing on the identification and management of high risk factors including the role of families as a part of treatment plans. Additionally, community awareness campaigns should be conducted to educate on substance use disorder and rehabilitation homes that offer treatment and skills training for those diagonised with substance use disorder should be established.

Keywords: Substance use disorder (SUD), psychosocial determinants, relapse, re-admission, triggers, high risk situations, coping mechanisms

INTRODUCTION

According to Hasin (2013) and the diagnostic statistical manual of mental disorders (DSM-5, 2013) substance use disorder (SUD) is characterised by maladaptive patterns of substance use leading to clinically significant impairment or distress. Substance use disorder occurs when one continues to use drugs even though it interferes with life at work home or other areas of functioning (Diagnostic and Statistical Manual of Mental Disorders; 5^th edition, 2013). Recent robust epidemiological studies have shown that substance use after successful treatment and rehabilitation is the biggest problem that requires effective preventive measures for relapse. 50% of persons with substance use disorder relapse after treatment (Chetty, 2011). Other studies have additionally documented that relapse rates following treatments are high and typically reach 40-75% in 3 weeks to 6 months periods following treatment (Moradinazar et al, 2020; Williams et al, 2010). The studies indicate that the brain is wired to repeat activities that are found pleasurable, thus, people become dependent and continue to crave substances even after successful detoxification. Staff, (2016) states that relapse occurs when one returns to drugs, alcohol, or other addictive behaviours after a long-term period of non-use which stems from a continued dysregulation of the brain. Drug and substance abuse has become a global pandemic affecting all races and nationalities (Anderson et al, 2020). Approximately 31 million persons suffer from substance use disorders throughout the world (World Health Organisation (WHO), 2019). A 2014 national survey on drug abuse reports that 21.5 million Americans over the age of 12 had a substance use disorder in the previous year which corresponds to 1 in 12 people (American addiction centers, 2022). After admission, more than 50% of persons with SUD relapse after treatment (Chetty, 2011). A study to find out about relapse triggers (Kwako et al,2016) concluded that stress and cues associated with past drug usage or exposure were the main cause.

In Africa, the highest prevalence and increase in substance use is being reported in West and Central Africa with rates between 5.2% and 13.5% (WHO, 2017).  This is due to the availability of cannabis and other hallucinogens and amphetamines (WHO, Africa, 2018). National medical facilities for treatment and rehabilitation are often seriously inadequate or non-existent. Frequently, only small numbers of drug-dependent persons can be accommodated in the psychiatric wards of general hospitals as is the case in Zimbabwe. This has been seen to be one of the causes of relapse because cases are not managed adequately due to a lack of resources.

Additionally, in Zimbabwe Substance abuse is a substantial and growing problem (Rudakatsira; Maphosa; Mukandavire; Muula & Siziya, 2009; Cubbins et al 2012; Duffy et al, 2015. Statistics derived from the Ministry of Health and Child Care Zimbabwe show that 57% of admitted cases in Zimbabwe’s mental health institutions in 2017 were drug abusers, in 2019 45% of admitted patients were youths and 60% of all inpatients for drug abuse were relapse cases (ZCLDN, 2019). The negative effects have been felt by the drug abusers as well as the community and nation at large (Chikoko, 2019). The ease of availability of substances, together with a lack of recreational activities for young people during lockdowns have both been cited as potential reasons for the increase (Mukwenha et al, 2021). However, even prior to the pandemic, drug use was already reported to be reaching crisis levels with young men being most implicated (Mhizha, 2010). Risk factors of substance abuse among young adult men in Zimbabwe have been found to be unemployment, low socio-economic and an unsupportive environment (Challier, Chau, Predine, Choquet & Legras, 2000). Given the contextual factors shaping engagement in substance abuse, recovery is complex and there are high rates among those seeking treatment (Luck & Beagan, 2015; Wasmuth & Scott, 2014). Due to high rates of drug abuse in Zimbabwe, it has also been noted that there is an increase in the number of SUD patients and readmissions after successful treatment, but little is known about the causes of relapse and the current study seeks to explore the psychosocial determinants of relapse among SUD patients.

AIM 

To examine the psycho-social determinants of relapse among Substance abuse disorder patients

Problem Statement

Relapse is when one returns to drugs, alcohol, or other addictive behaviours after a long- term period of non-use which stems from a continued dysregulation of the brain (Staff, 2016). It is a breakdown along the way to recovery, when one returns to the use of drugs, and alcohol after a long term of non-use (Department of Health, 2004). In 2011 a new organisation the Zimbabwe Civil Liberties and Drug Network (ZCLDN) was set up to advocate for effective strategies for addressing problems associated with drug misuse in the country. Drug abuse has led to substance use disorders and it has been noted that there is steep rise in the number of admissions due to the use of methamphetamine among adolescents and the youth among other conditions predisposing them to short- and long-term psychiatric conditions (UNICEF, Zimbabwe 2021). In 2019, 45% of admitted patients in mental health institutions across the country were youths who tested positive for drug use and 60% of all inpatients for drug abuse were relapse cases (ZCLDN, 2019). Despite successful admission and detoxification as well as psychotherapy intervention patients still relapsed still relapsed after weeks or months. This implies that the determinants of relapse may be unrelated to the treatment plan. The goal of recovery is to improve an individual’s quality of life, which intern benefits their family and society (Lowinson et al, 2005). However, this goal is hindered as persons with SUD find themselves back in the hospital due to relapse. Previous studies in Zimbabwe have focused on the risk factors for drug abuse (Rudakatsira et al, 2015) and there is no literature on the determinants of relapse among SUD patients. Without fully understanding the determinants most people will be unsuccessful in their attempts to remain sober hence the need to focus on the psycho-social determinants so as to come up with a solid plan and help in reducing the numbers of unsuccessful cases.

Rationale

The rationale of the study is to explore the psycho-social determinants of relapse.   Given that substance abuse is increasing in Zimbabwe and most patients are relapsing after successful treatment, it is essential to explore the reasons and evaluate the existing relapse prevention strategies and how they are implemented. In 2018, 57% of all admissions to mental health institutions were drug-related mental illnesses and about 60% of all inpatients were relapse cases (ZCLDN, 2019). The prevalence of substance use disorder is high and most treated patients come back again after weeks or months after relapsing, however there is limited data to support the causes of relapse which then motivated the researcher to explore the psychosocial determinants of relapse among substance use disorder patients. The research study will help set up interventions focused on relapse prevention in order to reduce the high prevalence of SUD relapse; included in this intervention would be information to the caregivers and community about psycho-social risk factors of relapse.

Objectives

1. To investigate common/major substances used
2. To explore the factors leading to relapse
3. To explore the risk factors for re-admission

Research Questions

1. Which substances are commonly used?
2. What are the factors which led to relapse?
3. What are the risk factors for re-admission?

METHODOLOGY

Research Design

Psychological research with a phenomenological strategy has been employed in the study to explore the psycho-social determinants of relapse among patients diagnosed with substance use disorder. Kumar, (2011) indicates that the main focus of qualitative research is to understand, explain, explore, discover, clarify situations, feelings, perceptions, attitudes, and values of a group of people.

Thus, a phenomenological study that attempts to understand people’s perceptions, perspectives, and understandings of a particular situation was deemed the most appropriate for this research study (Leedy & Omrod, 2010). The current study focuses on the participants as meaning makers, their perspectives, and their understanding of what caused the relapse after successful detoxification and rehabilitation.

The study employs purposive sampling with voluntary participants not more than 10 who have a history of substance use disorder guided by the DSM-V and have relapsed after leaving Parirenyatwa Annex psychiatric hospital. The study utilizes semi-structured interview questions. The researcher is guided by a set of questions rather than dictated by them (Smith& Osborn, 2003). These interviews allow greater flexibility of coverage and allow the interviewer to go into novel areas and they tend to produce richer data. Thematic analysis is used to examine the data. It is a technique for finding and examining patterns in the meaning and substance of qualitative data.

Ethical Considerations

The research participants will be requested to give consent before partaking in the research study. Informed consent is an ethical and legal requirement for research. It informs the participants about the purpose of the study and any pertinent information about their study, for example, the duration of the study, the extent of confidentiality, and anonymity. The research study will not harm participants either physically or emotionally.

Definition of Core Terms

Substance use disorder (SUD) is defined as maladaptive patterns of substance use leading to clinically significant impairment or distress (Hasin, 2013).

Relapse is when one returns to drugs, alcohol, or other addictive behaviours after a long-term period of non-use which stems from a continued dysregulation of the brain (Staff, 2016).

Psychosocial determinants refer to psychological and social factors that shape an individual’s beliefs, attitudes, behaviours and experiences ( Marmot,2005).

Conclusion

This chapter looks at the problem and its setting. Under this chapter, the following was covered: an introduction with the covered: an introduction with the background to the study, a statement of the problem,  rationale, objectives, sub-research questions, methodology, ethical considerations, and definition of terms.

LITERATURE REVIEW

This chapter reviews the literature relevant to the research. It focuses on the definition and phenomenon of relapse among patients diagnosed with substance use disorder.

What Is Substance Use Disorder

According to Hasin (2013), substance use disorder (SUD) is characterized by maladaptive patterns of substance use that cause distress or clinically substantial impairment. The Diagnostic Statistical Manual of Mental Disorders (2013) states that substance use disorder is characterised by failure to stop using substances like alcohol, illegal drugs, and tobacco to the point where the person’s capacity to function in day-to-day life is compromised, as well as by continued use despite known problems. Due to substance usage, people discontinue or minimize important tasks at work, school, social activities, and leisure time. Because their cognitive functioning is affected, people with substance  use disorders may have distorted thoughts  and behaviours that negatively affect or influence behaviour. The areas of the brain related to judgment, decision-making, learning, memory, and behavioral control exhibit changes in brain imaging studies (Blaine et al., 2020; Fischer et al., 1997). The drugs used modify how the brain works, and these changes may persist long after a person becomes intoxicated or develops a tolerance to the drug. According to the neuro-adaptation theory (Kobo & Le Moal, 1997), which describes changes in the brain that take place to counter a drug’s initial effects after repeated drug administration, substance use disorder leads to drug dependency. The alterations could take place at the drug’s site of action or in several mechanisms that are activated by the drug’s activity. Drugs alter the chemistry of the brain to counteract their effects when taken often; when used infrequently, they disturb the brain’s homeostasis. According to this view, neuro-adaptation is what causes both drug tolerance and withdrawal symptoms (Parsons et al., 1997). Stressful stimuli cause the dopamine reward system to be activated, making abstinence vulnerable to relapse, which leads to ongoing drug use to prevent withdrawal symptoms. In contrast to earlier conceptualizations of drug dependency, which concentrated on the physical symptoms of withdrawal, more contemporary formulations emphasize dysphoria, depression, irritability, and anxiety. According to Koob et al. (1997), these symptoms show signs of neurobiological alterations and may be a factor in relapse. Around 40% of patients with depression also have a substance use disorder, according to research, and depressed thoughts have been found to be highly correlated with cravings for drugs and alcohol (Brenner et al., 2020).

The National Institute on Drug Abuse (2021), states that people use drugs for a variety of reasons, including euphoria, experimentation, and stress relief. Addiction develops after frequent substance use, which results in a need to cut back or stop but failure. According to Kaplan et al. (1985), this addiction may result in physical, psychological, and interpersonal issues like arguments with family and friends. According to West (2006), the definition of addiction should refer to a reward-seeking behaviour that has outgrown its control since this better captures the observed rise in the want to engage in the addictive behaviour over time. Cannabis increases dopamine levels and improves brain activation, according to research. Addiction results from the reinforcing effects and elevated dopamine levels; more dosages of the drug may be needed to achieve the same amount of pleasure. The incentive and reward- preparatory components, which are felt as excitement, urgency, or yearning, are connected to the dopaminergic pathway. The opioid system, in contrast, is linked to consummatory components of reward like rest, happiness, and drowsiness (Di Chiara & North, 1992).

Alcohol usage causes both a direct stimulation of dopamine and an indirect increase in dopamine levels, which have been linked to the reinforcing effects of alcohol (Chen, 2007).Cannabis increases dopamine levels and improves brain activation, according to research. Addiction results from the reinforcing effects and elevated dopamine levels; more dosages of the drug may be needed to achieve the same amount of pleasure. Additionally, according to the Cognitive Affective-Pharmacogenetic Theory, the abuse process starts with people struggling to live up to their own or society’s standards, and anxiety is a side effect of conflict stress (Gold, 1980). The key to the theory is how an individual interprets their anxiety, not how they actually feel it. Drug addicts’ uneasiness is driven by the idea that they have no control over their surroundings. Low self-esteem and self-depreciation are the results of such strong emotions (Krystal & Raskin, 1970). Anxiety reduction, ecstatic feelings, and a heightened sensation of power, control, and wellbeing are some of heroin’s main pharmacogenic effects. Drug abusers can thereby achieve what they think they are unable to do for themselves through the use of drugs, including the elimination of anxiety, the development of positive self-esteem, and the perception of competence, control, and environmental mastery. People who struggle with anxiety often feel overwhelmed and turn to drugs or alcohol to calm themselves. About 75% of the time, anxiety disorders come first, but over time, they feed off one another in a vicious cycle (Smith & Book, 2008). The results of the studies are consistent with the idea that a person’s perception of their ability to control an event significantly affects their behaviour. A multimodal approach is necessary for the successful treatment of drug users because it may change flawed thinking, teach them new social skills, help them manage their pain and anxiety, and motivate them to stop using drugs.

Major Abused Drugs

Cannabis, amphetamines, and opioids are the three illicit drugs that are most often used worldwide (UNODC, 2013). In a study by Boys et al. (2000) on the common uses of drugs, it was discovered that cannabis was used for sleep, relaxation, and activity enhancement. Cannabis users are at risk of experiencing brief psychosis as well as chronic mental health conditions including schizophrenia (Volkow et al., 2016). According to Bloomfield et al. (2013), cannabis dependence is linked to the acceleration of psychosis in susceptible individuals. Cocaine is used to stay awake, boost self-esteem, get drunk, and feel better. Although it can result in psychotic symptoms such paranoia and hallucinations brought on by an imbalance in dopamine levels, depression, recurrent hospitalizations, aggressive behaviour, suicide, and homicide (Miller et al., 1991; Sherer, 1988 & Brady, 1991), it can also have negative effects. According to Restrepo et al. (2009), cocaine use is linked to cardiovascular problems, brain haemorrhage, stroke, and kidney failure. In the study, female participants reported using amphetamines to assist them lose weight in addition to using them to remain awake and increase activity and euphoria (Boys et al., 2000). The stimulant substance amphetamine has hallucinogenic effects, which can lead to a feeling of disconnection from oneself which results in distorted perception, delusions, ecstasy, paranoia, feeling powerful and confident. However when it wears off it can lead to feelings of depression, anxiety, distorted perceptions, fatigue and headaches (Bungay et al,2006 & Canadian Centre on Substance Abuse, 2005)and depression. Alcohol is consumed for euphoria, relaxation, and self-assurance. According to Darke et al. (2008), it is linked to heart failure and cerebrovascular accidents. The use of heroin has also been discovered to be widespread, however it carries a risk of early mortality from overdose, violence, suicide, and alcohol-related causes (Degenhardt & Charlson et al., 2014). Humans need to keep using the aforementioned substances in order to feel euphoric and relaxed since they are physiologically driven to seek rewards. Tolerance develops with repeated use, and unpleasant emotions may result from stopping the drug. A person will need to consume the drug or chemical again in order to have the intended result. In West and Central Africa, the prevalence of drugs has increased due to the availability of cannabis plants and other hallucinogens (WHO, Africa, 2018). According to research, cocaine, heroin, marijuana (cannabis), and tik were frequently used substances in South Africa that caused cases with substance use disorder to relapse (SADAG, 2016).

According to studies, the most often used substances in Zimbabwe; include glue, bronchlee, mangemba, cane spirit, marijuana, codeine, and crystal meth (Zimbabwe National Drug Master Plan, 2020). Drugs like musombodia, a very intoxicated beverage made from ethanol and emerald powder, are produced in large quantities locally (Jakaza & Nyoni, 2018). In the past, substance use was a prevalent trait among homeless children who did this for a variety of reasons, such as to relax in difficult situations, build bravery for committing crimes, or to sedate. However, Zimbabwe’s extremely high unemployment rates, coupled with destitution and hopelessness, have led to a rise in the number of young people who use drugs for recreational purposes (ZIMFACT, 2021); this has been made worse by the readily available and affordable nature of these substances to young people and adolescents as they interact within their social circles. One possible explanation for the rise has been suggested as the absence of youth-oriented leisure activities during lockdowns (Mukwenha et al., 2021). However, drug usage was already reported to be at crisis levels before the pandemic, with young men being the most at-risk (Mhizha, 2010). The aforementioned substances also increase the risk of cardiovascular and neurological disorders, unsafe sexual behavior, and predispose to both short-term and long-term psychological issues such addiction, stress, depression, anxiety, and psychosis. Additionally, drug use has negative socioeconomic effects and is linked to an increased risk of violent crimes, robberies, unemployment, and the requirement for treatment services (Mukwenha et al., 2021).

Internationally, the World Health Organisation and the United Nations have been  at the forefront with many efforts in synthesizing evidence and guidelines in combating  this public crisis (Degenhardt,2010; WHO,2016).Following the African Union Plan Of Action 2021–2023, the Zimbabwe National Drug Master Plan was created in 2020  in response to the rise in drug use. It is an integrated and all-encompassing strategy that addresses a variety of drug-related issues with the goal of resolving and reducing the challenges associated with drug use in Zimbabwe. This action plan places a strong emphasis on the necessity of harm reduction, demand reduction, treatment and rehabilitation policies for drug users, as well as community reintegration. This was established after it was discovered that the lack of rehabilitation facilities in the nation and the likelihood of recidivism for addicts even after treatment makes illicit activity worse. The government is still constructing rehabilitation homes to offer assistance to drug abusers and alcohol addiction sufferers. The church, non-governmental organizations, the community, and public health institutions have all been invited to submit ideas on the drug master plan as part of this action plan by the Zimbabwean government. Instead of criminalizing drug use, the government implemented policies that will let drug users get treatment and rehabilitation at public health centers because they believe that doing so will make young people afraid to seek help for drug impacts ( National Civil Liberties of Zimbabwe, 2019).  The Ministry of Health and Child Care in Zimbabwe has made outstanding progress toward the mental health system because the drug master plan ensures that drug users receive the essential treatment and rehabilitation at an affordable cost (ZCLDN, 2020). People with substance abuse-related mental illnesses are put into mental health facilities where they participate in detoxification programs, receive medical attention, and receive inpatient rehabilitation such as cognitive behaviour therapy, family counselling, if appropriate, and occupational therapy (Nhunzvi et al., 2019). The problem is that Zimbabwe’s public health system does not offer rehabilitation programs for people who need them due to drug usage but have not yet developed mental health conditions (Nhunzvi et al., 2019). Law enforcement is also running awareness campaigns on drug misuse and its impacts on the community in addition to the Ministry of Health and Child Care’s efforts (Magaya, 2017). Frequently, families resort to the police for assistance in dealing with a family member who has become antagonistic as a result of drug misuse (Mafigu, 2018). Additionally, the police aid in the reunification and reintegration of young drug addicts and their families (Matunhu & Matunhu, 2016). The church in Zimbabwe has played a role in educating and preparing youth leaders to recognize teachings of drug usage among their peers and respond to it (Kumuterera, 2019).There is a need to create church-based programs for drug abusers given the church’s influence in the society (Chikwanha, 2019). Non-governmental organizations (NGOs) have also attempted with a variety of missions. One such organization is ZCLDN, which pushes for strategic planning to address issues related to drug misuse in Zimbabwe and southern Africa (ZCLDN, 2019). Additionally, drug abusers in Zimbabwe can receive spiritually oriented rehabilitation treatments from free walk-in rehabilitation facilities like Narcotics Anonymous (Batsell, 2018).

The above-mentioned initiatives demonstrate that the Zimbabwean government and its stakeholders have plans in place for combating drug abuse, providing rehabilitation, and preventing it. However more innovatiness is required in terms of drug abuse rehabilitation (Nhunzvi et al, 2019) as public mental health institutions in Zimbabwe focus on drug abuse related mental illness only. Drug abuse is growing, as is the number of people being admitted to and readmitted from hospitals after receiving successful treatment. There is need to find out why so as to evaluate the existing relapse prevention strategies and how they are implemented. This implies that intervention programs should be widened and also need to develop affordable rehabilitation as part of the drug master plan.  The research study will help set up a program for relapse prevention in order to reduce the high prevalence of SUD relapse, to inform the caregivers and community about psycho social risk factors of relapse. The study will help provide information to the Plan of Action in terms of treatment and rehabilitation guidelines for people who use drugs and also educate the community on the factors that cause relapse.

What Is A Relapse?

Relapse, which results from on-going brain dysregulation, is when a person uses drugs, alcohol, or other addictive behaviours again after a prolonged period of abstinence (Staff, 2016).The brain is programmed to repeat behaviours that are enjoyable. This also occurs with substance use disorders; after completing a complete detoxification, many still seek and become dependent on their usage, which is known as a relapse. Relapse occurs when a person resumes their prior levels of alcohol or drug use after failing to maintain their aim of abstinence or minimizing their use (Department of Health, 2004). It is the escalating return to drug usage following an attempt to stop. Relapse is a highly prevalent aspect of addiction, hence it is to be expected that those attempting to remove dependence would experience one or more relapses before completely quitting (Werner et al., 2021). The cycle of change model, however, which postulates that people go through a cycle of avoiding, allowing for abstinence, taking active efforts to stop, and then reverting, views relapse as a phase (Potik, 2020).

 According to the National Institute on Drug Abuse (2020), 40 to 60% of drug addicts relapse while undergoing treatment. The significant relapse rates following treatments have also been shown in other research (Moradinazar et al., 2020), and they often approach 40-75% in the 3–6 weeks following therapy (Williams et al., 2010). By investigating the link between different psychosocial factors and relapse, a research study can enhance our comprehension of the likelihood of relapse and detect specific areas that require attention in relapse prevention. Given that relapse is a complex and dynamic phenomenon influenced by biological, psychological and social factors  and their interplay, a study of this nature can provide valuable insights into managing and preventing relapse. Marlatt and Gordon’s (1985) model of relapse makes clear the significance of psychosocial factors in relapse. While in recovery, numerous circumstances can result in temptation. Anyone can experience a relapse due to two types of triggers: internal and external stressors.  External drug addiction triggers are things in their environment, like people, places, or things they come into touch with. Drug misuse internal relapse reasons are triggered by internal factors, typically one’s mental state or way of thinking. Once these triggers are recognized, preventing them might be easier. These cues may also be more likely to emerge subconsciously, making them crucial to recognize and avoid. Both types of reasons deal with certain issues that can thwart a stage of healing (Asensio et al., 2020). According to studies, those who struggle to cope with stressful situations such family conflict, peer pressure, financial hardships, or temptations are more likely to relapse (Brown et al., 2004). Relapse can be brought on by social support networks, psychological problems, stigma, and financial hardships (Brady & Sonne, 1996). Bandura (1970) explains how mental processes affect behaviour that is goal-oriented. Through reinforcement, a person will imitate any behaviour that rewards them; for instance, when using cocaine, they feel pleasure and a rush, while drinking alcohol, they feel less stressed and anxious. As the user seeks to replicate the effects they experienced while under the influence of substance usage, more substances are used, it becomes a habit and the sense of self-assurance results in dependence on the substance. According to research, using substances like amphetamine leads to a high rate of relapse (Thompson, 2010). This is due to the fact that methamphetamine is a member of a class of synthetic stimulants that are highly addictive and result in withdrawal symptoms when stopped. In the first week after stopping the treatment, craving comes before a methamphetamine relapse (Galloway GP & Singleton, 2009). People eventually use the drug again after being discharged because the withdrawal symptoms are unpleasant and can be avoided by doing so.

Higher levels of self-efficacy have been linked to longer periods of sobriety and a decreased chance of relapsing, according to research from the past (Hagman, 2004). Self-efficacy and results that lessen the likelihood of relapse are influenced by motivation to abstain (Miller & Rollnick, 2002). One of the mental factors that affects the success of a drug rehab intervention is the belief in one’s own ability to succeed (Warren et al., 2007). A cognitive-motivational power known as self-efficacy believe determines an individual’s appropriate level of coping when their skills and abilities are put under stress. A person’s ability to solve problems is undermined by low self-efficacy (Reeve, 2005).The effects of the substance and the anticipated results associated with drug use elicit desire, which can raise the likelihood of recurrence (Marlatt GA & Donovan DM, 2005). The risk of relapse and the length of abstinence periods are related to the coping mechanisms a client uses to deal with stressful life situations (Rohsenow et al., 2000). Relapse risk and the number of abstinence days after treatment are correlated with social support system presence and quality.

Additionally, because drug addiction is a disease, those who suffer from it need socio-psychological care more than those who suffer from physical illnesses do.  After therapy, people with substance abuse should prioritize social and medical assistance in addition to medical and pharmaceutical care. Support from society plays a special role in sustaining withdrawal for drug addicts because the process of withdrawing and eliminating links with drug fellows involves socially supportive relationships and resources (Davis, 2005).It was discovered that personality factors can also contribute to relapse. According to a study by O’Leary (2000), personality qualities including neuroticism and conscientiousness can contribute to addiction relapse. According to Singh (2002), a combination of higher levels of neuroticism and lower levels of conscientiousness was associated with a higher risk of relapse while a lower likelihood of relapse was associated with a combination of higher levels of conscientiousness and lower levels of neuroticism. In addition to a lack of assertiveness and peer pressure, Hammerbarcher and Lyvers (2006) discovered that low mood or negative mood states were connected with relapse. Sadness, frustration, wrath, anxiety, and resentment were listed as examples of negative emotions. Avoiding unpleasant impact is the main cause of drug relapse, according to a study on the psychosocial factors contributing to opioid dependent relapse in India (Baker, 2004).  Additionally higher self-efficacy was associated with fewer chances of relapses. Developing holistic individualized plan aimed at improving self- efficacy, undesired stressful life events and negative affect can reduce relapse rates and improve management of patients with substance use disorder (Ambekar,2019).

Psychosocial Determinants Of Relapse

Worldwide, substance use problems affect 31 million people (World Health Organization (WHO), 2019). According to a 2014 nationwide study on drug misuse, 1 in 12 Americans over the age of 12 (21.5 million) over the preceding year had a substance use disorder (American addiction centers, 2022). More than 50% of SUD patients who are admitted relapse after therapy (Chetty, 2011). According to a study on relapse triggers (Brown, 1960), stress and cues from prior drug use or exposure were the main contributors.

After receiving successful treatment and detoxification, 59% of patients in Rwanda with substance use problems relapsed, according to a study on the factors that influenced this outcome, male participants made up the majority of the group. According to the study, those with SUD who lived only with their mothers were more likely to relapse than those who had both parents as caregivers. Patients who stayed in the hospital for less time had a higher risk of relapsing than those who stayed more than three months.  Relapses following treatment were common. Family disputes, psychological stress, peer pressure, and socioeconomic factors like drug availability and a lack of assertiveness were all recognized as risk factors. In order to prevent relapse, substance use management should focus on prolonged follow-up rather than only detoxification (Kabisa, 2021).

Similar to this, statistics from 2016 show that substance abuse is on the rise in South Africa, where at least 15% of the population is estimated to have a problem with it. According to the South African Depression and Anxiety Group (SADAG, 2016), some of the most often used substances in this nation are alcohol, marijuana (dagga), cocaine, tik, and heroin. According to SACENDU (2014), readmissions accounted for 22% of admissions in 2013. Young African adults may relapse in high-risk situations such as unemployment, rejoining drug-using social groups after receiving treatment, access to and availability of drugs, particularly in high-density areas, and a lack of infrastructure, particularly in terms of positive entertainment in communities (Bain, 2004).

Substance addiction is also a significant and developing issue in Zimbabwe (Rudakatsira, Maphosa, Mukandavire, Muula, & Siziya, 2009; Cubbins et al., 2012; Duffy et al., 2015). Since 2017, there has been a noticeable rise in drug abuse, with 45% of young people already abusing drugs (Zimbabwe Civil Liberties and Drug Network, 2018). In 2019, this further grew to 57%. According to statistics from Zimbabwe’s Ministry of Health and Child Care, 57% of patients admitted in the country’s mental health facilities in 2017 were drug addicts (ZCLDN, 2019). In mental health facilities across the country in 2019, 45% of patients admitted were young people. Drug users, as well as the society and country at large, have experienced negative repercussions (Chikoko, 2019).

the statistics on youth drug abuse in Zimbabwe increase yearly despite measures implemented by various stakeholders to fight the pandemic  (Chikoko  et  al., 2016;  Matutu  &  Mususa,  2019).  In commenting about drug and substances abuse statistics in Zimbabwe, Makande (2017) highlights that there is no accurate information on the magnitude of drug abuse  by the youth in Zimbabwe, hence the country relays on calculated estimates. Though there may be a short of exact statistics, this does not negate the existence of the problem of drug abuse by the youth in Zimbabwe (Mazuru, 2018).

One of the groups thought to be most negatively impacted by this growing issue is young adult men (Index Mundi Zimbabwe demography, 2012; Nhunzvi et al., 2019). Despite the fact that men are primarily active, a study by Box (2020) found that women are also involved in this because of Zimbabwe’s economic circumstances. Drugs like marijuana and broncheeler are used to support women engaged in sex work, including to ease their physical and mental suffering. According to Hamunakwadi (2019), using drugs is a talent for survival because it is difficult to engage in a private relationship with a total stranger. Young men and women engage in sexual activity after attending parties where various substances are consumed, increasing their risk of catching STDs.

Psychological Factors

Self Esteem

Two out of eight respondents, according to Nurhazlina and Azlinda’s 2009 research, relapsed into drug use after finishing treatment because they lacked the self-confidence and strength to maintain their drug-free lifestyles or were more obviously struggling with low self-esteem. According to Ibrahim (2009), most addicts lack the confidence to deal with the challenges that lie ahead; it is simple to give up and fail to deal with a situation in a constructive and intelligent way. As a result, individuals are susceptible to drug impact, which can cause relapse. Nine out of the 21 drug users surveyed by Cheung et al. (2003) were able to abstain from drug use due to their high levels of self-assurance, sense of fulfillment in their life, and stable income.

Stigma

Stigma can lead to feeling of shame, guilt and self -doubt which can increase the risk of relapse by triggering negative emotions and reducing self-efficacy (Hatzenbuehler et al 2013). Stigmatising attitudes can lead to internalized stigma which causes negative attitudes about the self, leading to negative self- concept and reduce the belief in one’s ability to recover. In addition stigma and discrimination can limit access to health care and social support, making it harder for people with substance use disorders to stay sober and maintain recovery (Livingston& Boyd, 2010). Corrigan, (2004) asserted that stigma can fuel addiction and undermine treatment effects as it can lead to loss of social support creating feeling of loneliness  and isolation which increase the risk of relapse. Several studies have documented the relationship between stigma and substance use disorder and its impact on the risk of relapse such as a study by (Room et al, 2005) which found that people with alcohol use disorder who experienced discrimination were more likely to relapse than those who did not. Similarly a study by Tucker et al, (2017) found that stigma- related stress was associated with a higher risk of relapse among people with opioid use disorder.

Stress

According to Conrad (2016), the majority of alcoholics in recovery think that drinking reduces stress, yet it   increases the risk of relapse. Stress causes depression, and there is evidence of a persistent link between alcohol use disorders and depression, according to Kendler et al. (1993) and Hill (1990). Stress increases cortisol levels in the body, which can worsen symptoms of anxiety and depression, stress is a major contributing factor to substance misuse. As a coping strategy to overcome these unpleasant feelings, some people may turn to drugs. Homeostasis is upset by stress, which also triggers physiological reactions and anticipatory behavior. An increase in impulsivity and a decrease in behavioral control are the outcomes of high stress, which causes the striatum to become more sensitive and the prefrontal cortex to become less active.  Chronic stress response activation also raises the risk  of psychopathology, including alcohol and drug addiction. The HPA axis is impacted by chronic stress, which may intensify the effects of drugs. Substance abuse disrupts this axis, making it difficult for people to cope with stress (Runyan, 2024).

 Yaqub (2013) suggested that global poverty is rapidly spreading and joblessness is rising, which causes many people to experience mental stress and worry as well as a lack of social networks, which prompts them to look for shelter in narcotic drugs and substances. Males are more likely to relapse following treatment than females are, and the primary risk factors include psychological stress, peer influence, a lack of assertiveness, conflicts, and peer pressure (Kabisa, 2021).

Negative Emotions

Negative affect which includes emotions such as sadness, anxiety and anger were a significant predictor of subsequent alcohol relapse among individuals enrolled in an outpatient treatment program (Daughters et al, 2005).Patients may use substances to alleviate negative emotions leading to a cycle of addiction that maintains the negative affect. In essence drug use may temporarily relieve emotional distress but ultimately will reinforce further use leading to relapse.. Avoiding unpleasant impact is the main cause of drug relapse, according to a study on the psychosocial factors contributing to opioid dependent relapse in India (Baker, 2004). The unpleasant feelings were commonly related to interpersonal relationships, financial problems and health issues. Negative emotional states from such situations increased the likelihood of relapse.

Depression

Depression is a determinant of substance use relapse. Individuals in treatment of substance use disorder with higher levels of depression were at higher risk of relapse following treatment (Tang et al,2015).  The study also found that patients who had higher levels of support from friends and family were less likely to relapse if they had higher levels depression. This suggests that social support may be an important target for intervention in substance use disorder. The severity of depression was highly linked with the likelihood of relapse (Pierog et al, 2017) thus the management of depression in substance use disorder is a crucial step for relapse prevention. In a study conducted in Latin America 54.8% of illicit drug users had depression( Ferigolo et al,2009), the comorbidity of depression and substance use disorders suggests that as the person indulges in drug use personality factors such as behaviour change, social disinhibition and other psychotic symptoms come to the front while depression is at the background and untreated which then contributes to relapse if untreated(Pradhan et al, 2013). Hasin, 2002 found that major depressive disorder during sustained abstinence predicted dependence relapse and substance use after hospital dis-charge compared with those without abstinence major depressive disorder.

Dual Diagnosis

Patients with a dual diagnosis of psychosis or manic symptoms had a greater probability of readmission. The likelihood of readmission is increased by co-occurring SUD and schizophrenia, according to Thomsen et al.’s 2018 study. Disorders of the mind were another factor in readmission prediction. It is generally known that long-term SUD users run the risk of developing additional psychiatric or mental health issues (Winkelman et al., 2018). As a result, patients with a second diagnosis seemed to require lengthier hospital stays and re-admissions than those without mental health conditions.

Cravings

As individuals progress through recovery, they often experience intense cravings for the substance they have been using, which can be triggered by a variety of internal and external factors (Budney & Hughes, 2006). These cravings can be so hard to resist leading many individuals to relapse even after prolonged periods of abstinence. Research found that Individuals who experienced strong cravings for drugs or alcohol were more likely to relapse than those who experienced weaker cravings (Witkiewitz, Marlatt &Walker, 2005). Smith, Williams and Jones (2021) study demonstrated the potential of cravings to be a significant challenge in sustained recovery from substance misuse. Individuals who experienced greater cravings were at risk of relapse. The study highlighted the need for targeted interventions aimed at reducing cravings and urges to use drugs. The findings have implications for the development of personalized treatment plans tailored to an individual’s specific needs and challenges. According to Chen et al, (2016) cravings were a more significant predictor of relapse than depression, anxiety or stress as a result coping strategies for cravings were deemed important to manage and reduce the risk of relapse.

Social Factors

Lack of Social Support

According to Chen’s research from 2002 on social support, spirituality, and addiction recovery programs, social support from the local community through former drug users’ meetings in conjunction with programs promoting integration into society and spirituality are crucial to minimizing the negative effects of the formation pressure experienced during the recovery process. This has shown that society should give drug users unequivocal social and physical support, as well as, if required, jobs, in order to give them the courage to keep changing and, eventually, stop using drugs. Researchers Fauziah Ibrahim and Naresh Kumar (2009) revealed that society in Malaysia does not acknowledge relapse as a possibility.

When a theft occurs and they continue to act under their label, people frequently suspect them as well.  Support from society plays a special role in helping drug addicts maintain their withdrawal (Davis & Jason, 2005). Opportunities in life and personal desire might be hampered by stigma. It may make it more difficult to get employment, look for housing (Matsumoto et al., 2021), get compensation, or receive medical care (Corrigan & Wassel, 2008; Link & Phelan, 2001). Lack of social support from within the family can also lead to relapse. Patients who have limited social support are more likely to relapse and require re-admission. These individuals may not have a supportive network of family or friends to lean on during recovery making it more challenging to maintain abstinence (NIDA, 2016).

Family

Families are the variables that most influence people toward drug addiction relapse, claims Noor Zalifah (2007) in his case study on cases under the supervision of the National Anti-Drug Agency (NADA), which studies the reasons of addiction relapse. They forgot the fee for the immediate pressure due to pressure from family who want addicts to rehabilitate and turn immediately. A family history of drug addiction is connected with a high likelihood of relapse, according to Mattoo, Chakrabarti, and Anjaiah’s (2009) research of 30 male addicts to determine psychosocial factors related with relapse. According to a study by Ross, Hall and Boscarino, (2021) family factors can be a determinant of relapse among patients with opioid use disorder. The research found that patients who reported poor family functioning and support had a higher risk of relapse.it was suggested that family interventions should be considered as a part of a comprehensive treatment approach to promote sustained recovery.

Relapse in substance abuse patients is significantly influenced by family members’ emotional expression. Three to five factors—criticism, aggression, emotional over-involvement, and positivity and warmth—are evaluated to gauge the home environment. In many illnesses, high EE levels are strong indicators of relapse and can impair the prognosis. While hostility is a negative attitude toward a patient, frequently blaming them for their issues, criticism is a complaint about a patient’s behavior. The feelings and actions of a family member toward the patient that show excessive praise or blame, self-sacrifice, and overprotectiveness are known as emotional over-involvement. Patients who experience high levels of emotional engagement may come to believe that they are powerless to solve their own issues and that they are caused by outside forces. Though it shows a different side from hostile and critical attitudes, emotional over-involvement is comparable to the negative effect that triggers a relapse, which causes the patient to revert to their sickness as a coping technique. Warmth and positive reinforcement are crucial in creating a supportive environment for addicts. Warmth increases motivation, self-esteem, and the therapeutic partnership while decreasing shame and stigma, whereas positive evaluations recognize progress and accomplishments (Shanmugam et al., 2021)

Peer Influence

Due to the potentially vast array of settings including friendships and social networks, peer influence is a challenging subject. According to earlier research, 50% of former SUD patients’ old acquaintances persuaded them to start using drugs after they were released from treatment facilities [Broom, 2002; Hasin et al. 2013]. The same author also found that 76% of old friends help recovering addicts obtain the substances they require. The social setting was shown to have the potential to help or hinder a patient’s ability to change their behaviour after therapy. Negative peer impacts, for instance, have been linked to the emergence of substance use behaviours and the encouragement of relapse (Sapkota, 2019). The author also discovered that patients were helpless against others’ overt or covert attempts to get them to drink. Additionally, they stated that because the substance is regarded as the preferred recreational drug in their society, it is challenging for patients to maintain abstinence (Hendershot et al. 2011 & San 2013).Young people’s drug and alcohol usage is significantly influenced by their fear of social rejection and peer rejection, according to Arteaga, Chen, and Reynolds (2010). This is especially true in situations where substance abuse is accepted as normal in young people’s culture.

Unemployment

Sacks et al, (2014) found that unemployed patients with SUDs were more likely to be re-admitted within thirty days of discharge than their employed counterparts. The study suggested that job training and placement programs could be effective interventions to reduce the risk of re-admission. Individuals who are unemployed are at a higher risk of relapse and re-admission due to financial stress, lack of social support and exposure to high risk environments (Bezerra et al, 2018). Financial stress can due to the cost of treatment and the inability to work leading to substance use as a coping mechanism to this burden. Bray et al (2000) found that patients with SUD frequently struggle with unemployment. Adult patients receiving SUD treatment had low employment rates, according to the alcohol services information system (Substance Abuse and Mental Health Services Administration Office of Applied Studies, 2008). Unemployment was discovered to be a major predictor of SUD-related readmission in a cohort study by Ramadan et al., 2022 in Saudi Arabia, to evaluate characteristics linked with readmission and length of hospital stay among SUD patients.

Availability

Due to the availability of the cannabis plant together with various hallucinogens and amphetamines, West and Central Africa have the highest prevalence and increase in substance use, with rates ranging from 5.2% to 13.5% (WHO, 2017). Hartney and Gunn, (2017) examined the relationship between socio economic status and repeated treatment episodes for substance use disorders  and found that availability of substances was a significant factor in relapse and relapse treatment episodes. It was noted specifically that individuals with low socioeconomic status were more likely to live in areas with high levels of substance availability which in turn increased their risk of relapse. According to Cedra eta l, (2013), availability of opioids in a community was positively associated with the likelihood of opioid relapse. Schubart (2001) added, merely going back to the location where the drugs are can cause relapse. According to Hyman & Malenka (2001:697), environmental signals increase the chance of relapse when addicts come into contact with individuals, locations, or objects connected to prior drug use. As noted above high density areas may trigger a relapse because of the availability of the substance. Research found that individuals with a history of alcohol dependence who were exposed to alcohol related cues showed increased activity in the brain regions associated with cravings and reward seeking (Bottlender et al, 2017).this suggests that individuals with a substance use disorder maybe more susceptible to the lure of substances when they are readily available. According to Cami & Farre (2003), in the absence of the medication, environmental cues linked to the substance might cause withdrawal and yearning. Individuals who experience severe withdrawal symptoms are more likely to relapse( De Martini et al.,2014).

Conclusion

The chapter discussed the definitions of substance use disorder and relapse as well as the causes of relapse in prior research. The availability of drugs, dual diagnosis, stress cravings, peer pressure, family influence and stigma were some of the identified psychosocial variables leading to relapse, according to a literature analysis that revealed that males worldwide suffer more from substance use disorders. Peer influence, unemployment, and availability have all been identified as readmission risk factors. As was already indicated, no studies on the psychosocial causes of relapse in people with substance use disorders have been conducted in Zimbabwe. Prior studies have concentrated on the danger signs of drug abuse (Rudakatsira et al. 2015). Given that substance use disorder and drug abuse are both prevalent in Zimbabwe and that the majority of patients relapse after receiving successful treatment, it is important to assess the effectiveness of the current relapse prevention techniques. In order to lower the high frequency of SUD relapse and educate caregivers and the community about the psychological risk factors of relapse, the research study may assist establish a program for relapse prevention.

Theoretical Framework

Introduction

Long term health outcomes are linked to substance use disorders. The management of alcohol dependence is a complex process, with relapse being a major challenge. Most patients with substance use disorder tend to relapse within a year of starting treatment, and the first three months are the most critical period(Hunt et al, 1971).Relapse  is driven by a combination of biological, psychological and social factors, with an intricate interplay among them. The model of relapse described by Marlatt and Gordon, (1985) clearly describes the significance of psychosocial factors in relapse, hence a study of association of various psychosocial factors of relapse will help in understanding the psychosocial determinants and identifying specific areas to be addressed in relapse prevention and management. A relapse prevention model was utilised in this research study to explain and understand the psycho social determinants of relapse among patients diagnosed with substance use disorder at Parirenyatwa Annex. In this chapter the aspects of a relapse model are explained.

Rationale for using relapse prevention model by Marlatt and Gordon (1985)         

The relapse model by Marlatt and Gordon 1985 was deemed important for the current study because it takes a comprehensive approach to identifying the psychosocial determinants of relapse.it recognizes that relapse is a complex process influenced by various factors including high risk situation, cognitive and emotional states, social support and coping mechanisms. By considering these factors, the model effectively addresses the multifaceted nature of relapse. Marlatt’s model is evidence based, has been shown to be effective in clinical setting and has been shown to be effective in preventing relapse. The study will be conducted in a clinical setting with substance use disorder patients who have relapsed. The model provides an understanding of the individual’s thought patterns, emotions and behaviours that led to relapse. By helping patients develop coping skills and self-control during high risk situations, the model promotes a sense of control and empowerment which can be beneficial in managing cravings and preventing relapse. This will help come up with a relapse prevention plan, helping patients on how best they can manage themselves after treatment after identifying high risk factors that may lead to relapse. The wide recognition and applicability of the relapse prevention model, combined with evidence based effectiveness and comprehensive approach to addressing both cognitive and behavioural aspects of relapse are some of the reasons why this model was preferred over other relapse prevention models.

Relapse Prevention Model (Marlatt & Gordon, 1985)

Relapse Prevention Therapy (RPT) is a cognitive-behavioral method for treating addictive behaviors. It focuses on the nature of the relapse process and offers coping mechanisms for maintaining change (Marlatt & Gordon, 1985). Once relapse triggers and high-risk situations have been identified, cognitive and behavioral techniques are used to prevent lapses or manage them when they do occur. These techniques also address lifestyle balance, cravings, and cognitive distortions that may lead to exposure to high-risk situations where relapse is most likely to occur. High-risk situations and the drinker’s reaction to them play a key part in the cognitive behavioral model of the relapse process.

High Risk Situations Of Relapse

The emotional, environmental, and interpersonal elements of circumstances that lead to relapse were categorized by Marlatt (1996). Negative emotional states, also known as intrapersonal high-risk situations, such as anger, anxiety, despair, frustration, and boredom, are said to be related with the highest rate of relapse in this taxonomy (Marlatt & Gordon 1985). These emotional states may result from reactions to environmental events (such as feeling upset about an upcoming layoff at work) or solely intrapersonal assessments of particular conditions (such as feeling bored or lonely after returning home from work to an empty house).Conflict with family members or other interpersonal interactions, for instance, might cause unpleasant feelings and lead to relapse (Marlatt, 1996). Additionally, Marlatt also discovered that social factors such being among other drinkers, experiencing happy emotions like joy or being around stimuli related to alcohol or advertisements for the drug can actually cause a relapse. A person’s response to high-risk situations determines whether they will experience a relapse. People who can execute effective coping strategies are less likely to relapse. People who have coped successfully with high-risk situations are assumed to experience a heightened sense of self-efficacy, while those with low self-esteem are more likely to relapse.

Expected Outcomes

According to research, those who consume alcohol more frequently tend to have higher expectations of its positive effects (also known as outcome expectancies). They may also expect only the immediate positive effects, ignoring or discounting any potential negative effects of binge drinking (Carey, 1995). When a person thinks that drinking will help them deal with difficult emotions or conflict (i.e., when drinking is used as “self-medication”), such positive outcome expectancies may become especially salient in high-risk settings. When this happens, the drinker tends to prioritize the anticipation of immediate benefits, like stress relief, and ignores potential long-term negative effects (Marlatt & Gordon 1985)

Lifestyle Factors

The degree of balance in a person’s life between perceived external pressures (or “shoulds”) and internally fulfilling or joyful activities (or “wants”) has been postulated by (Marlatt & Gordon 1985) as the covert antecedent most strongly connected to relapse risk. (“I owe myself a drink”). The individual may believe that drinking is the sole way to experience pleasure or flee discomfort in the absence of other enjoyable non-drinking activities.

Urges And Cravings

A hunger or impulse to consume alcohol may be one of the numerous manifestations of the desire for instant fulfillment (Marlatt& Donovan, 2005).Despite the fact that many scientists and doctors believe impulses and cravings are largely physiological states, the RP model contends that both desires and cravings are triggered by psychological or environmental factors. As the client’s need for instant fulfillment grows, persistent cravings may weaken the client’s resolve to maintain abstinence. An urge, according to Marlatt and Gordon (1985), is a relatively rapid impulse to carry out an action, such drinking alcohol, whereas a craving is an irrational desire to feel the results or consequences of that action. However, the same mechanisms might mediate both urges and cravings. Two of these procedures are conditioning elicited by stimuli associated by past gratification and cognitive processes associated with anticipated gratification.

Specific Intervention Strategies

Identifying And Coping With High Risk Factors.

 The first strategy involves teaching the client to recognize the warning signals associated with imminent danger—that is, the cues indicating that the client is about to enter a high-risk situation. The second strategy, which is possibly the most important aspect of RP, involves evaluating the client’s existing motivation and ability to cope with specific high-risk situations and then helping the client learn more effective coping skills (Daley & Marlatt, 2006). Relevant coping skills can be behavioural or cognitive in nature and can include both strategies to cope with specific high-risk situations (e.g., refusing drinks in social situations and assertive communication skills) and general strategies that can improve coping with various situations (e.g., meditation, anger management, and positive self-talk).

Lifestyle Balance

Balance in one’s lifestyle is crucial for avoiding relapse. The client is more prone to turn to alcohol in an effort to relieve stress if stressors are not balanced by enough stress management techniques. High-risk conditions, which are the key determinants of a relapse, can be triggered by two cognitive processes that help with covert planning for a relapse episode: rationalization and denial, as well as decisions that appear unimportant (AIDs). A person’s high-risk circumstances can be determined through self-monitoring, behavior assessment, analysis of relapse fantasies, and reports of previous relapses. A person who lacks coping skills to address these situations experiences reduced confidence in their ability to cope (Bandura, 1977). Moreover positive expectations regarding alcohol may anticipate only the immediate positive effects while ignoring or discounting the potential negative consequences of excessive drinking (Carey 1995). Specific intervention techniques (such as skill development, relapse rehearsal, education, and cognitive restructuring) and general techniques (such as stress management, imagery that increases efficacy, contracts that limit the amount of alcohol use, and reminder cards) can be used to reduce the determinants of relapse.

Enhancing Self Efficacy

The use of efficacy-enhancement procedures is an approach to preventing relapse and promoting behavioural change (Marlatt & Donovan, 2005).The client is encouraged to adopt the role of colleague and become an objective observer, which allows them to view their alcohol use as an addictive behaviour and accept greater responsibility. Additionally, the therapist provides simple written instructions that reiterate the importance of stopping alcohol consumption and leaving the lapse inducing situation. Additionally, the client is encouraged to break down the overall task of behavior into more manageable subtasks that can be addressed one at a time, such as coping with an upcoming high risk situation or making it through the day without a lapse (Bandura, 1977) Therapists also can enhance self-efficacy by providing feedback concerning their performance on other new tasks such as showing up for appointments on time can greatly enhance a client’s feelings of self-efficacy.

Eliminating Myths And Misconceptions

Therapists use standardized questionnaires or clinical interviews to elicit positive expectations of alcohol’s effects in order to contradict false judgments of its effects (Archie, 2005). Positive expectations of alcohol’s benefits are often based on untruths or placebo effects, and research has shown that the perceived benefits of alcohol on social behavior are often mediated by placebo effects. This suggests that the perceived benefits of alcohol are often mediated by placebo effects (Levine &Pittman, 2015) resulting from expectations and the environment in which drinking takes place (Marlatt and Rohsenow 1981).

Cognitive Restructuring

One of the key components of Marlatt’s (1985) relapse prevention paradigm is cognitive restructuring, which involves helping people recognize and alter unfavorable attitudes and beliefs that can lead to substance use (Morgenstern et al., 1997). With the aid of cognitive restructuring, clients are able to alter how they see and attribute the relapse process. Clients are subsequently taught to reframe their perception of slip-ups, to perceive them instead as errors or learning blunders that signify the need for increased planning to cope more effectively in similar situations in the future (Witkiewitz & Marlatt, 2004).

Global Lifestyle Self Control Strategies

Marlatt and Gordon (1985) developed techniques that offer the client a variety of avoidance tactics for declining invitations, leaving dangerous situations, or generally avoiding troublesome locations or activities that serve as stimuli control measures that may assist prevent a slip. This is accomplished by keeping track of everyday tasks and categorizing each one as should or want.

Urge Management Techniques

The majority of individuals seeking treatment are prone to experiencing alcohol cravings or urges. As a coping mechanism, they are trained to identify and acknowledge these urges as an emotional or physiological response to environmental stimuli previously linked to heavy drinking. This is analogous to Pavlov’s dog which salivated at the sound of a bell that had previously signaled food (Marlatt& Gordon,1985).

Finally therapists can help patients create relapse road maps, which are cognitive behavioral evaluations of high-risk scenarios (Marlatt &Donovan, 2005). The therapist can assist the client in outlining various scenarios, including the possibility of provoking an argument. At each stage of the conversation, the therapist can help identify coping mechanisms that can be applied to prevent a lapse.

SUMMARY

The relapse prevention model explained the triggers associated with relapse, clients own motivation to change, enhancing self-efficacy and assertiveness so as to improve coping strategies with high risk situations. In addition this model provides an understanding of client’s own perception of the relapse process. Further the model provides an approach to prevent relapse and promoting behavioural change through enhancing self-efficacy and cognitive restructuring. Through an analysis of global lifestyle self-control strategies clients can unlearn behaviours associated with heavy drinking and choose a way of coping with stressors or situations. Psycho social determinants of relapse among patients diagonised with substance use disorder can therefore be explored using the relapse prevention model by (Marlatt and Gordon, 1985).

METHODOLOGY

This study sought to explore the psychosocial determinants of relapse among patients diagnosed with substance use disorder (SUD) at Parirenyatwa Annex psychiatric unit. The chapter includes research design, sampling, data collection, data analysis and ethical considerations.

Research Approach

The study employed a qualitative research approach. The adopted approach uses an inductive way of processing data. It allows for a subjective way of analysing and interpreting themes as it focuses on human experiences.  According to Kumar (2011) the main focus in qualitative research is to understand, explain, explore, discover and clarify situations, feelings, perceptions, attitudes, values beliefs and experiences of a group hence exploring the psychosocial determinants of relapse among SUD patients. Qualitative analysis allows for in depth interviews which provide insights into describing the phenomenon under study. It makes claims about how something happens or what it is including people’s thoughts and feelings, their actions and practices, the way they make sense of the world and the discursive resources they deploy and how they deploy them (Willig, 2019). This process produces thick data which is defined by (Ponterotto, 2006) as understanding the phenomenon under investigation in terms of its meaning rather than simply recording observable facts about it. Qualitative approach was employed in this study because it builds on knowledge, as it informs theory development both through the generation of new theoretical formulations as well as providing an opportunity to revise existing theories in the light of new data. The researcher seeks to find out the psycho- social determinants of relapse among patients diagnosed with substance use disorder it will allow for the emergence of new theories that are grounded in the data and reflect the detail and particularies of human experience in context. This approach allows the researcher to make sense of participant’s actions and to understand how they journey through a process that culminates in the phenomenon of interest (Josselin & Willig, 2015). This applies to the phenomenon of relapse as the researcher seeks to under the factors influencing relapse.

Research Design

Psychological research with a phenomenological strategy has been employed in the study to explore the psycho-social determinants of relapse among patients diagonised with substance use disorder. Kumar, (2011) indicates that the main focus in qualitative research is to understand, explain, explore, discover, discover and clarify situations, feelings, perceptions, attitudes and values of a group of people.

Thus, a phenomenological study that attempts to understand people’s perceptions, perspectives and understandings of a particular situation was deemed the most appropriate for this research study (Leedy & Omrod, 2010). The current study focuses on the participants as meaning makers, their perspectives and understanding of what caused the relapse after successful detoxification and rehabilitation

Sampling

Sampling is the process of selecting a small number from a large group or population (Walliman, 2011). Researchers select samples to find out more about populations of interest, an accessible population called the sampling frame could be a portion of the target that may be clearly identified and directly sampled from (Privitera, 2015). Participants are chosen based on their fit with the purposes of the study (Strydom & Delport, 2011). The study employs purposive sampling with voluntary participants not more than 10 who have a history of substance use disorder guided by the DSM-V and have relapsed after leaving hospital at Parirenyatwa Annex. Purposive sampling is a sampling procedure in which participants are selected from the target population based on their fit with the purposes of the study and specific inclusion and exclusion criteria. Good interviewees are those that are available, willing to be interviewed and have lived experiences and knowledge about the topic of interest (Hatch, 2002). Participants are chosen because they illustrate some features that are of interest for a particular study (Strydom & Delport, 2011). In this study participants chosen have a history of SUD and have relapsed after leaving hospital. Purposive sampling provides in-depth and detailed information about phenomenon under investigation.

Data Collection

The study utilises semi structured interview questions. These are in depth interviews conducted once only with an individual or a group (Strauss, 2008). The researcher is guided by a set of questions rather than dictated by it (Smith and Osbarn, 2003). These interviews allow greater flexibility of coverage and allow the interviewer to go into novel areas and they tend to produce richer data. The interviews should elicit data that provides insight about the phenomenon under study. The interviews will be conducted at Parirenyatwa Annex with patients who have been diagonised with substance use disorder and have a history of relapsing using semi- structured interviews. Semi structured interviews are an effective method of data collection when the researcher wants to collect qualitative, open ended data, explore  participant’s thoughts, feelings and beliefs about a particular topic and to delve deeply into personal and sometimes sensitive issue ( Dejonckheere, 2018)

Data Analysis

Thematic analysis is used to examine the data. It is a technique for finding and examining patterns in the meaning and substance of qualitative data. The study will use an inductive approach which allows the data collected to determine themes. A theme is a particular pattern of meaning present in the data (Joffe, 2012). It organizes and describes potential observations while also interpreting various facets of the phenomenon. Thematic analysis involves a search of themes that emerge as being important to the description of the phenomenon under investigation. The task of the researcher is to identify a limited number of themes which adequately reflects their textual data. According to Braun and Clarke (2006), there are six steps involved in thematic analysis namely familiarisation  with the data, coding, searching for themes, reviewing themes, defining and naming themes  and write up which involves an attempt to capture and account for thematic patterns in the data and also try to theorize them.

Familiarisation involves reading over the data, transcribing audios, skimming the text, making quick notes, and generally perusing the material to become acquainted with it (Brown & Clarke, 2006). The next phase is coding, which entails underlining specific text passages and creating labels or codes that define the material. All phrases or sentences that match the codes must be highlighted. Each code describes the thought or feeling represented in that particular section of the text. These codes give the researcher access to the key ideas and recurring meanings in the data. A theme is a pattern that encapsulates something important or fascinating about the investigation ( Brown & Clarke,2013.

The researcher generates themes by recognising patterns among the data, it can be combining codes into a single theme that has a meaning about the purpose of the researcher. The review of themes, which involves comparing the themes produced with the data set gathered, comes next. This stage helps determine whether any data points are missing, whether the themes accurately represent the data, and whether any adjustments are necessary to make the themes more effective. The researcher can separate, combine, dismiss, or develop new precise and practical ideas by reviewing existing themes (Caulified, 2022). Once the researcher gets a list of themes, the next step is to define each one by stating what it means, taking into account subthemes and other factors (Clarke & Brown,2013).

Ethical Considerations

The study was guided by several ethical considerations. Research participants were requested to give consent before partaking in the research study. An informed consent is an ethical and legal requirement for research which briefs participants about the purpose of the study and informs them that participation is voluntary and that they are free to withdraw at any point. The informed consent also entails the duration of the study, extent of confidentiality and anonymity. Participants were assigned to a number before the interview which they used throughout the research study to safeguard confidentiality and anonymity. Participation will not exploit participants in any way. Since the participants are inpatients their refusal to participate, participation and answers will not influence the care they receive or their relationship with care providers. The research study did not harm participants either physically or emotionally. The participants will have psychological sessions at Parirenyatwa Annex psychology department under Dr Farzana. During the interview participants may withdraw their consent if any psychological harm they may have a session at Annex psychology department, they may contact the researcher to book their sessions if they experience any psychological harm after the research study.

Conclusion

The aim of this chapter was to explain the methodology used in carrying out the study. Qualitative research approach was used to generate more data and phenomenological approach was also adopted since the focus of the study was on exploring the psychosocial determinants of relapse among patients diagonised with substance use disorder at Parirenyatwa Annex. The chapter also explained sampling technique as well as the method of analyzing the obtained data.

Apter 5: Data Presentation And Analysis

Introduction

This chapter seeks to present and analyse the results of the study using the qualitative research method. The data was collected using semi-structured interviews. The study adopted thematic method of analysis to bring out the results of the study.

Table 2: Presenation Of Themes

Objective                                                                     Emergent themes

Major Substances Used

The results of the study show that major substances used are crystal methamphetamine, cannabis, alcohol, and cigarettes.

8 participants used crystal methamphetamine

10 participants used cannabis

6 participants used cigarettes

6 participants confirmed using alcohol

Participant 1 reported that:  

“I started with alcohol but now I have advanced to other substances such as crystal meth, cannabis and cigarettes although i still take my alcohol”

Participant 2 added that:

 “I take alcohol, cannabis, cigarettes and bronchlear but I started with alcohol and later got addicted to cannabis and cigarettes

Most participants use more than two substances as evidenced by the table above. The most used appeared to be crystal meth, cannabis, cigarettes and alcohol. There is an element of advancing where an individual starts with one as they get used more substances come into the picture out of experimentation. There is evidence that often the least addictive substance such as alcohol is the one a person begins with. From the major substances discovered above, cannabis and crystal methamphetamine seem to be on every participant’s list. It is also noted that gender does not influence the type of substance as shown that females are taking same substances used by men and more than two at the same time.

Psychosocial Factors Leading To Relapse

Theme 1: Stigma

The results of the study show that stigma is a contributing factor to relapse. Stigma can lead to feelings of shame limiting recovery and leaving one prone to relapse. Two participants commented on this:

 Participant 1 reported:

“I could not tell my wife that I was once admitted at Annex because it’s a psychiatric hospital, she would think that I was insane and refuse to get married to me, who wants to get married to a mad person? I also thought that her family would disregard me as their son in law if they knew I was psychiatric patient”

Participant 4 reported that:

“I just didn’t like the way my mother and the neighbours looked at me after discharge it was like I am insane so when I confronted them they began calling me names after that I then went and took substances just to forget about it

Stigma emerged as a factor leading to relapse. Fear of being judged and rejected because of being previously admitted at a psychiatric hospital due to a substance use disorder led to a relapse when the spouse found out. It seems self stigamatisation can hinder treatment as one tries to hide their condition from another member of the family who could be a support system. This is brought up by feeling of shame, doubt and fear of being rejected by a partner or the family at large. Stigma from family seemed to bring out negative emotions as it also paved way for people outside family to begin stigmatizing the patient. This brings up negative thoughts about the self as well as negative emotions which can trigger a person to relapse back into the substance as a way of coping with the stigma.

Theme 2: Dual diagnosis

Results of the study show that dual diagnosis of mental health conditions leads to relapse. The conditions identified in this study were Bipolar Affective Disorder, depression and schizophrenia. Three participants commented

Participant 5 with Bipolar Affective Disorder conveyed that:

 “Most of my relapses occurred when I was in manic phase that’s when I tend to spend a lot, when I’m too excited I spend a lot on substances”

Participant 3 with comorbid schizophrenia added that

“I usually take cannabis and alcohol when I start hearing voices because when I’m home so as to silence because when I am high I don’t hear them,”

Participant 8 reported that:

 After my first discharge from SUD I was later diagonised with depression after my husband had left me dealing with separation was not easy therefore I sought help but I defaulted medication and stopped coming for psychology sessions whenever I felt low I would use cannabis or crystal meth to a point where I got admitted”

Dual diagnosis of mental health disorders together with a substance use disorder can lead to relapse. The results show that substances may be used as form of self-medication to the mental health condition. Additionally the nature of some mental health conditions leave patients prone to engaging in substance use such as bipolar a condition in which when one is in a manic phase they tend to engage more in pleasurable activities which can be substance use. Evidence above shows that in trying to deal with depression, substances are used to escape the feelings of sadness associated with depression. A dual diagnosis of depression and SUD leads to relapse as one uses drugs as a way of dealing with negative emotions associated with separation as noted above. The effects of cannabis and crystal meth were noted as beneficial to a person experiencing depression; however it was also noted that the negative effects will lead to admission because of the impairment caused. This shows that another condition may be a trigger to substance use which then contributes to relapse.

Theme 3: Stress

 Dealing with stressful events in life led to relapse. Five participants reported that stress led them to relapse, three voices are transcribed below:

participant 1 remarked:

 “I got stressed after my wife left me and in order to cope with this I began using crystal meth again because it made me feel good and forget about it”

Participant 7 reported that “ I got really stressed after my husband beat me up and left for South Africa after I had come home late from work, it hurts so much to beaten in front of children up to this day I’m still hurt”

Participant 8 reported “dealing with the separation was not easy for me especially after discharge whenever I felt depressed I would take the substances”

Stress is a state of worry caused by a difficult situation. Losing a loved one can be a cause of stress and because it’s an unpleasant feeling people want to do away with it. In order to achieve this, drugs to forget or feel good at any moment can be taken as evidenced above. People may turn to drugs as a way to cope with stress in their lives, and the feelings of relaxation and pleasure that substances provide can be very appealing in the midst of a stressful situation. Stress evokes negative emotions; these can be anger, sorrow. For people who have engaged in substance, it becomes easy to rationalize the behaviour and continue use to cope with the difficult situation that has evoked negative emotions in them.

Theme 4: Family

Family plays a role in the relapse of SUD patients. This can be caused by stigma within the family, conflicts resulting from continued use, domestic violence and sibling influence where provision of the substances is done within the family. The statements below support the contribution of family in relapse cases of SUD patients. Four participants commented on this. “Participant 1 reported that:

“I relapsed after I had a major conflict with my wife after she found out that I was once admitted at Annex a psychiatric hospital, according to her I was insane and she packed all her belongings and left..because I couldn’t cope with the stress of losing a loved one I began using again. My family was also blaming me for keeping it a secret”

Participant 4 reported that

“People are always talking about me at home… how bad I am and useless since I’m not contributing anything… my mother actually bad mouths me with neighbours  and every time I come across that I always leave and come back drunk, recently this has necessitated my re-admission”

“After sharing the incident with friends re-taking the substances seemed to be the only solution for me to cope as I could not think of anything else but her”

Participant 7 reported that:

 “Fighting with my husband is the reason I relapsed, the same day I visited my friends whom I take drugs with and I used a lot of crystal meth until I burnt my mouth”

Participant 3 reported that:

 “Another factor which led to relapse is that my sister is the fact that I was taking with my little sister when I told her that I wanted to stop she brought in cannabis and that’s how I began using again… participant 8 the sister reported that “it feels good to take with someone and since her brother is the one who introduced her to drug use they usually use together”

Family conflict cans actually a relapse. Substances are used as a way of coping with family pressures as evidenced above. People who have been into drugs lack confidence and strength to face and solve problems in their lives and resort to substance use because of the reinforcing effects of the substances which they believe will make them forget about the stressful event. The above responses also show that stigma within the family can lead to relapse when one is judged and rejected because they once got treatment for SUD… When family members become too involved in a patient’s life showing doubt, discriminating, limiting autonomy they feel unwanted and in trying to cope and live up with that they are prone to relapse as they seek comfort from substances again. Family can also contribute to relapse if another family member is involved in substance use disorder as noted above that when one thought of stopping another member still taking would influence another to take again. Family conflict contributing to relapse is also resulting from issues of domestic violence. One tries to deal with domestic violence by taking substances so as to forget about it although the scars still remain, Women are mostly affected by domestic violence as shown by the results of the study.

Theme 5: Work pressure

Work pressure emerged as a contributing factor to relapse. In trying to cope with pressure people may end up re-taking substances after a period of non-use. Five participants alluded to this.

Participant 7 reported that:

“My job requires a lot of energy, I have two children already to look after in order to cope with the energy I need something to boost my energy initially after discharge the first time I thought I was going to cut down but I failed until my family noticed that there was something going on and got me re-admitted”

Participant 10 reported that:

 “I thought I had it under control until I needed more clients for survival and had to use drugs again to get energy”

Participant 9 reported that:

“I relapsed because of work pressure… I sell these drugs for a living hence I felt pressured to use”

Participant 6 reported that:

 “Using drugs gives me energy to load up the car fast…i work from 5am up to around 11pm sometimes I don’t even get enough sleep yet I have to wake up and carry on the next morning so it’s the energy

Participant 2 added that:

 “I work as a carpenter when there’s a lot of work I take crystal meth to gain a lot of energy so that I can complete the work on time, however when it’s low I still take it because it keeps me happy I won’t stress about the work pressures”

Work pressure emerged as a major theme influencing relapse among patients diagonised with substance use disorders. Work pressure refers to the demands of work that strain people as described by respondents .Work pressure leaves no gender behind but affects all. In order to earn a living some are doing jobs that they are not even proud of such as sex working where one is forced to stay awake the whole night so as to catch as many clients as they can. In order to have the energy to continue there is need to take substances to enhance activity as well as energy. Touting has become a job that feeds people, however a lot of energy is need to call out and load the car very fast. It is noted that the energy required is too much and if one fails that means they are going home with a lesser amount yet everyone needs more leaving people at risk of relapsing as they have to continue using to meet the demands of their work. It is inevitable to maintain abstinence when working with the substances as shown by the results that one is earning a living from selling these substances. Substances are relieving work pressures whilst enhancing energy, again it becomes difficult to maintain sobriety even after treatment when one is returning to the same work place which has pressures they can’t handle alone but rather needs a substance to keep things in control

Theme 6: Cravings

Cravings were identified as a major theme influencing relapse. A craving is influenced by an expectation of re-experiencing the pleasurable or reinforcing effects of the substance, cravings may be triggered by different situations, for some it may be stressful yet they may be triggered by a positive situation as well leading to re-use of the substance. Three participants reported that cravings influenced them to re-take the substances. Participant 2 reported that:

“I had cravings for cannabis, cigarettes and crystal meth and began using again”

Participant 9 remarked:

“The craving is too much, I just couldn’t cope without I began taking a little just to do away with the craving until I returned to my previous high doses which then led to relapse. I would have cravings when someone comes to buy the substances from me”

Participant 5 also reported that:

 “I always had the craving but I had to re-take as I couldn’t resist it anymore at a party and started taking again”

Results of the study show that cravings are a factor leading to relapse. After discharge people still crave for the previous used substance. This prompts the user to then look for it and use again leading to relapse. Often people think they have it under control when they crave for the substance as noted that they begin by using a little until they wake up in hospital showing that it got out of hand. The results also show that there is an element of self-doubt when cravings take over where an individual’s feels they can’t maintain their abstinence and fall for the craving. Situations when one comes across the substance also trigger the craving and results show that people end up complying with the cravings which led to relapse.

Theme 7: Availability

Availability emerged as a major theme for factors leading to relapse. Statements below support the availability of substances as a trigger for relapse. Substances are reported to be available in the communities as well as houses for some are earning a living from it, sibling influence also emerged where one siblings may provide for another making it difficult to abstain. The results show that cravings can be triggered by the availability of the substance. It can be noted that when one is experiencing negative emotions they might end up craving for the previously used substance. Three participants commented on the availability of substances as a factor leading to relapse.

Participant 3 reported that:

 “The substances are use is all around in my community… I want to quit but just like previously when I got discharged I went in the same community and upon coming across them I felt the need to use again” he added that “ at some-point I told myself I had stopped but when the craving started I knew where my sister kept her meth and took it”

Participant 9 reported that:

 “If you have a history of SUD it’s hard to stop using especially when the drug is still available. I sell those drugs that means my house is always stocked up and because of that I relapsed because I couldn’t stop using”

Participant 4 reported that:

 “Drugs are everywhere, the suppliers sell at any time thus whenever I come across them I end up buying especially if I’m having a bad day I fail to resist, sometimes I search for them because of the bad day…it’s really hard to stop something you like when it’s readily available”

Availability is a factor leading to relapse. Substances are available in the communities as well as in houses where people come from as noted above especially when two family members are using the same substances because they can provide for each other at any moment. This also applies to those making a living out of selling these substances. Results show the availability of these substances is a strong leading factor to relapses they are easily accessible and also a trigger for cravings.

Risk Factors For Re-Admission

Theme 1: Unemployment

Unemployment emerged to be a risk factor for re-admission. Most participants reported that they were unemployed and substances help them relieve the burden of unemployment. However some have found employment in these substances as reported by another participant who actually sells for income. Four participants commented on unemployment.

Participant 8 reported that

 “I do not have a job and when I’m sober I will be stressed about it but after taking I forget about it I’ll be happy but it has landed me here twice now… probably if I had work to do I would not engage”

Participant 2 added that

 “I am unemployed sometimes I ended up engaging due to boredom from just sitting home all day like I noted earlier I started using drugs for fun until I developed this disorder and sometimes I feel like if I had been employed I wouldn’t have engaged and continued to use again after discharge but I just come back to the same environment where I don’t have anything to do and drugs are there to keep company they occupy most of my time”

Participant 9 reported that

 “I am not formally employed and now selling drugs has become my job, I got involved so I could earn a living and take care of my children but I do admit that it’s lack of employment that’s causing me to be admitted here… out of selling I end up using”

Participant 6 added that

 “We are going into the same environment where there are no jobs despite all treatment from hospital we end up using again and getting re-admitted because of a lack of employment”

The results of the study show that unemployment contributes to re-admission of SUD patients. Drug use begins as an escape plan from reality when one is suffering from the negative emotions coming from lack of employment such as boredom. Because of unemployment substances are being used for recreational purposes. While others are using out of boredom it has also become a source of income for those selling however this kind of exposure has led to a substance use disorder necessitating more than one relapse. Most participants wish they could get formal employment to keep them busy and avoid being idle which then contributes to re-admission.

Theme2: Lack of Social support

Lack of social support emerged as a risk factor for re-admission. Participants of the study pointed out that their support system is to blame for their relapses as they do not seem to understand them. Conflicts that arise and feelings of being unwanted, judged and lonely emerged as triggers caused by support system. In trying to cope with such negativity people may end up re-using the substances again. Four participants commented on this.

Participant 4 reported that:

“People are always talking about me at home… how bad I am and useless since I’m not contributing anything but jobs are rare to find nowadays… my mother actually bad mouths me with neighbours  and every time I come across that I always leave and come back drunk, recently this has necessitated my re-admission”

Participant 8 reported that:

 “I told my brother that I was not insane but just intoxicated but rather he said he wanted to get me admitted at a long stay house I felt unwanted and ran away from home to my friend’s house and began using from there I got admitted here at Annex so I’d say feeling unwanted by relatives can cause re-admission because it was because of that conflict that I ended up relapsing”

Participant 5 reported that:

 “my relatives always think that I do not want to quit taking drugs as result they want to know everything I’m doing yet I’m a grown-up we usually fight whenever they get suspicious unfortunately it triggers me to use again, I’m not free at our house if anything goes missing everyone suspects me”

Lack of support from those who use substances can increase the risk of relapse. Isolation, loneliness and stress are triggered by lack of social support. Pressure from family to recover can actually lead to re- admission as patients feel that they deserve to be free and supported through this hard time of trying to recover. Results show that prior relapse or re- admission there is a conflict that would have happened between the patient and their social support system.

Theme 3: peer influence

Peers were identified as a risk factor for re-admission. Associating with friends who are still into drug use triggered those who were trying to recover from the effects of SUD to re-use the substances leading to relapse. Results of the study also found out that these associations are more common when a conflict arises within the family where friends are viewed as an escape plan and in so doing may end up taking the substances again. Peer influence was also found to be within the family where siblings are both involved in drug use making it difficult for each of them to abstain as they continue to provide for each other. Four participants commented on this.

Participant 1 reported

“That we usually take with friends, when-ever we meet them they will be taking, and sometimes you even get sponsored and end up re-taking which then leads to re admission”.

Participant 3 reported that

“I defaulted, my medication as well because my friends told me that I cut down it wouldn’t   lead to any relapse so hanging out with friends who are still taking can lead to re-admission”

Participant 8 reported that

 “When I started using I was with friends… again when I had conflict with my family I went to my old friends and used again” some conflicts with family rose from the fact that my friends would visit and offer me the alcohol and other substances”.

Participant 7 reported that

“After fighting with my husband I went out with my friends because I was stressed I then took a lot of meth and burnt my mouth. If not for those friends probably I would have tried other ways of dealing with the stress but because I knew my friends were loaded I went to them”

From the above statements it is evident that peers actually sponsor the substances to be taken. When one is dealing with a tough situation drugs are offered as the solution to the problem, this is because they have not learnt to deal with situations by other means except drug use which is quick in producing reinforcing effects such euphoria and relaxation. It has also been noted that recovery is hard when siblings provide for each other. In trying to cope with negative emotions friends are the first point of call however friends who are into drug use seem to provide a solution by influencing those trying to recover to re-use again.

Participant’s number of relapses and the months they managed to stay sober from their previous admission.

The table shows the number of relapses one has had to date and the months or weeks it took them to relapse from their previous treatment. The greatest number of relapses was recorded to be 10 and the 10^th relapse occurred after 4months of successful treatment at Annex. The person with the greatest number of relapses had a dual diagnosis of bipolar affective disorder. The person with least relapse cases had relapsed one after 9months of abstinence. It can be noted that all relapses can occur during the same year multiple times after treatment as shown by the number of months taken before admission. This means that after treatment people maintain sobriety for a short time and engage into substance again. Relapse can occur from as early as 3months.Basing on table 5.2 it is evident that the person with the greatest number of relapses was using all substances noted to be the major ones which are crystal methamphetamine, cannabis, alcohol and cigarettes. Although other participants had less than 10 relapses it is also evident that almost everyone on the list used crystal methamphetamine.

Summary

The chapter presented the results of the study according to the objectives of the study and explained the themes under each objective. The objectives were to explore major substances used, to explore the factors that led to relapse and to explore the risk factors for re-admission.

Introduction

This chapter discusses the findings of this study on psycho social determinants of relapse among patients diagonised with substance use disorder at Annex psychiatric hospital. The findings will be discussed according to the objectives and research questions of the study. These discussions will be guided by the relapse prevention model and the literature deemed important for this study.

Major Substances Used

In exploring the major substances used the research found out that crystal meth, cannabis, cigarettes and alcohol were the most used substances. Worldwide the three common used substances are crystal meth, cannabis and opioids (UNODC, 2013). There is an element of advancing where an individual starts with the least addictive substance such as alcohol as they get used more substances come into the picture out of experimentation. This explains tolerance to the substance, when the body adapts to the effects of a substance over time requiring larger or frequent doses to experience the same effect. Because of this people may turn to more addictive substances with more effect so as to achieve the desired effect.  Alcohol usage causes both a direct stimulation of dopamine and an indirect increase in dopamine levels, which have been linked to the reinforcing effects of alcohol (Chen, 2007). According to Marlatt and Gordon, (1985) expected outcomes leads to continued use and this probably explains why people are taking at least two or more substances in search of the desired effect explained as the expected outcome. There is an expectation of increased energy, euphoria, from using crystal methamphetamine just to mention as few as discussed in the literature under the effects of the mentioned substances. Cannabis was found to be reinforcing because of its relaxation effects. Cannabis users are at risk of experiencing brief psychosis as well as chronic mental health conditions including schizophrenia (Volkow et al., 2016). According to Bloomfield et al. (2013), cannabis dependence is linked to the acceleration of psychosis in susceptible individuals.  It appears that more concentration is on the positive effects rather than the consequences of the substances and may anticipate only the immediate positive effects while ignoring or discounting the potential negative consequences of excessive drinking (Carey 1995).  These factors can lead to initial alcohol use (i.e., a lapse), which can induce an abstinence violation effect that, in turn, influences the risk of progressing to a full relapse (Marlatt& Gordon, 1985).Research also suggests that crystal methamphetamine, cannabis are highly addictive substances. This explains why these substances were found to be the major substances by patients with a history of relapse.

Psychosocial Factors Leading To Relapse

The study found out that stigma, stress, dual diagnosis, family, work pressure, cravings and availability led to relapse of patient’s diagonised with substance use disorder.

Stigma

Results of the study showed that stigma was a contributing factor to relapse of patient’s diagonised with substance use disorder. Stigma can be a judgmental attitude towards people with substance use disorders; this may come from society or individuals close to the person in recovery such as their family. Fear of being judged or rejected by a loved might lead to one fearing to disclose that they have a substance use disorder. Stigma can lead to feeling of shame, guilt and self -doubt which can increase the risk of relapse by triggering negative emotions and reducing self-efficacy (Hatzenbuehler et al 2013). Feelings of being judged also led to relapse where a person was trying to ignore the judgments from family and society this is because stigma may arouse feelings of shame, guilt and self-doubt .These negative emotions and thoughts can trigger a person to relapse back into substance use as a way to cope with the pain they feel as a result of stigma. It is thus important to address stigma and work towards creating environments where individuals in substance use recovery can be treated with respect  and empathy so as to empower them in an environment that support their efforts towards maintaining and improving their health and well -being. Stigma can be a lifestyle factor leading to relapse as noted in the results, in trying to escape one may end up spending more time with friends who may be a bad influence to the individual leading them to re-using the substances out of seeking comfort. This is caused by the fact that one fails to blend in the family after discharged as they are labeled. When one gets stigmatized they actually resort back to the substances as they cannot cope with the negativity it brings and in most cases the friends are not judgmental as they a see by supporting through providing drugs to the person. According to the relapse prevention by Marlatt this is both an interpersonal and intrapersonal high risk factor causing relapse (Marlatt and Gordon, 1985). Intrapersonal conflict can lead to self -doubt where an individual starts doubting themselves on the road to relapse. Bandura (1977) noted that low self-efficacy predicts a greater chance of relapse whereas higher self-efficacy will help in preventing relapse. Self -doubt which is brought about by stigma makes it difficult to stay sober as alcohol is perceived as the only way to happiness (Marlatt& Gordon, 1985).Stigma contributes to relapse, it is therefore important to address stigma to ensure that individuals in recovery are supported and empowered to maintain their sobriety.

Stress

Stress is a state of worry caused by a difficult situation.  As Marlatt & Gordon, (1985) noted when a lifestyle if full of demands one may develop negative emotions necessitating substance use as a coping mechanism while providing justification for use as a need to escape from the emotions. An individual may relapse in escaping from negative emotions. According to Baker, (2004) avoiding unpleasant impact is the main cause of drug relapse. These emotional states may be caused by primarily intrapersonal perceptions of certain situations or by reactions to environmental events (e.g., feeling angry about an impending layoff at work).Interpersonal relationships particularly interpersonal conflict for example with a member of the family can result in negative emotions and can precipitate relapse (Marlatt, 1996). Stressful events are often a result of intrapersonal or  interpersonal conflicts which in turn bring outs negative emotions such a when one has been stigamtised negative feelings about the self may arise necessitating substance use so as to forget about the situation and relieve the negative emotion. According to Conrad (2016), the majority of alcoholics in recovery think that drinking reduces stress, which increases the risk of relapse in such stressful situations, the drinker focuses primarily on the anticipation of immediate gratification, such as stress reduction, neglecting possible delayed negative consequences (Marlatt & Gordon 1985). It is evident that in difficult times people do not have the confidence and strength to face and deal with their intrapersonal or interpersonal while sober but rather they seek comfort in substances. The relapse prevention model proposed that people should adopt other ways of dealing with stressful moments instead of finding comfort in substances as it worsens the problem by continuously relapsing.

Dual diagnosis

The research study found out that dual diagnosis of mental health diagnosis led to relapse. Mental health conditions such as bipolar affective disorder, depression and schizophrenia were identified. It was noted that these disorders predispose patients to greater relapses. The nature of mental health disorder such as bipolar leaves patients vulnerable to engaging more in pleasurable activities if not managed well when the person is in a manic phase on the other  hand depressive symptoms may also trigger one into substance use as they try to alleviate their mood. Results of the study revealed that for schizophrenia substances were used as self- medicating in trying to silence hallucinations. Thomsen et al, 2018 commented that the likelihood of readmission is increased by co-occurring SUD and schizophrenia. Depression can increase the risk of relapse for individuals with substance use disorders. When a person is experiencing depression, they may experience feelings of sadness, hopelessness and despair which can make it difficult to maintain sobriety. The use of substances can temporarily alleviate these feelings resulting in a sense of relief from the emotions that they are going through. However, substance use only provides temporary relief and can ultimately exacerbate the symptoms of depression, leading to a vicious cycle of substance use and worsening depression. There is evidence of a persistent link between alcohol use disorders and depression, according to Kendler et al. (1993) and Hill (1990). It is therefore important to address depression as part of treatment plan for individuals with substance use disorders in order to reduce the risk of relapse.  Marlatt (1996) noted that negative emotional states contributed to more substance relapse and the temporary relief from the emotions provided by the substance will leads to continued use contributing to relapse.

Family conflicts

Conflict with the family can cause relapse. When a conflict arises in the family, People who have been into drugs lack confidence and strength to face and solve problems in their lives and resort to substance use because of the reinforcing effects of the substances which they believe will make them forget about the stressful event. The entry of a new person into the family such as a spouse can cause a relapse for a person who would have tried to remain sober for a long time especially if stigma is perceived or imagined. When family members become too involved in a patient’s life showing doubt, discriminating, limiting autonomy they feel unwanted and in trying to cope and live up with that they are prone to relapse as they seek comfort from substances again. Family can also contribute to relapse if another family member is involved in substance use disorder, this results in members influencing each other to continue taking making it difficult to remain abstinent. A family history of drug addiction is connected with a high likelihood of relapse, according to Mattoo, Chakrabarti, and Anjaiah’s (2009).  Results also showed that family conflict contributing to relapse is also resulting from issues of domestic violence. One tries to deal with domestic violence by taking substances so as to forget about it although the scars still remain. Interpersonal relationships particularly interpersonal conflict for example with a member of the family can result in negative emotions and can precipitate relapse (Marlatt, 1996).  Women are mostly affected by this as shown by the results of the study. Families are the variables that most influence people toward drug addiction relapse, claims Noor Zalifah (2007) in his case study on cases under the supervision of the National Anti-Drug Agency (NADA), which studies the reasons of addiction relapse.

Work pressure

The study found that the need to cope with work conditions contributed to relapse. The more demanding a job is will lead to the need to boost energy. Results showed that working long hours can precipitate the need to use stimulants such as amphetamine which allows one to be energetic and awake. Depressants such as alcohol can cause a decrease in feelings of fatigue and drowsiness as well. In a study by Boys et al. (2000) on the common uses of drugs, it was discovered that cannabis was used for sleep, relaxation, and activity enhancement. Cannabis users are at risk of experiencing brief psychosis as well as chronic mental health conditions including schizophrenia (Volkow et al., 2016).  Boys et al, (2000) commented that crystal meth was used for euphoria and staying awake. Alcohol usage causes both a direct stimulation of dopamine linked to the reinforcing effects (Chen, 2007). According to Marlatt& Gordon,(1985) outcome expectancies  may  anticipate only the immediate positive effects while ignoring or discounting the potential negative consequences of excessive drinking (Carey 1995). The results of the study show that people only focused on the reinforcing effects of the substances they took while ignoring the consequences which then led to a substance use disorder and currently have relapsed while seeking treatment or trying to abstain from the substance. Apart from outcome expectancies the relapse model also posits that lifestyle balance is an important that if not taken care of can lead to relapse. This encompasses high demanding jobs which may leave people prone to continued substance as they rationalize the problem and continue. If stressors are not balanced by sufficient stress management strategies, the client is more likely to use alcohol in an attempt to gain some relief or escape from stress. This reaction typically leads to a desire for indulgence that often develops into cravings and urges. Two cognitive mechanisms that contribute to the covert planning of a relapse episode are rationalization and denial (Marlatt, 1977).

Cravings

Results of the study show that cravings are a factor leading to relapse. After discharge people still crave for the previous used substance. This prompts the user to then look for it and use again leading to relapse. Often people think they have it under control when they crave for the substance; however tolerance develops leading to dependence and re-admission. As individuals progress through recovery, they often experience intense cravings for the substance they have been using, which can be triggered by a variety of internal and external factors (Budney & Hughes, 2006). These cravings can be so hard to resist leading many individuals to relapse even after prolonged periods of abstinence.  According to Ibrahim (2009), most addicts lack the confidence to deal with the challenges that lie ahead; it is simple to give up and fail to deal with a situation in a constructive and intelligent way. The results also show that there is an element of self-doubt when cravings take over where an individual’s feels they can’t maintain their abstinence and fall for the craving. As a result, individuals are susceptible to drug impact, which can cause relapse. The Relapse Prevention model proposes that both urges and cravings are precipitated by psychological or environmental stimuli. Ongoing cravings, in turn, may erode the client’s commitment to maintaining abstinence as his or her desire for immediate gratification increases (Marlatt & Gordon, 1985). Mastering life style factors, emotional and physiological factors that leads to craving was identified as a way to conquer these craving by the relapse prevention model. According to (Smith, Williams & Jones, 2021) cravings can be a challenge that hinders recovery from substance misuse.it is really important to target other aspects which may be unique to the individual when dealing with cravings as a factor leading to relapse. As shown by the results availability and negative situations or emotions may  trigger a relapse, this means that psychotherapies should focus of the triggers for cravings when identifying high risk factors for relapse as in Marlatt’s relapse prevention model.

Availability

Availability is a factor leading to relapse. Substances are available in the communities as well as in houses where people come from especially when two family members are using the same substances because they can provide for each other at any moment. This also applies to those making a living out of selling these substances. Results show the availability of these substances is a strong leading factor to relapse. Availability serves as a trigger for use even after a long time of non-use. Research has shown that the easier it is to access to their drug of choice, the more likely they are to relapse (Wagner & Anthony, 2002). Availability is identified as a high risk factor leading to relapse in Marlatt’s relapse model which requires one to execute effective coping strategies such as leaving the place, situation. People who have copied well with the situation are assumed to experience a heightened sense of self-efficacy (Bandura 1977; Marlatt et al. 1999), conversely people with low self-efficacy perceive themselves as lacking motivation or ability to resist drinking in high-risk situations. Easy access to drugs and a live environment that promotes substance use contributes to relapse among individuals recovering from substance use disorders. It is critical to reduce the availability of substances and establish supportive living environments that promote abstinence to reduce the risk of relapse.

Risk Factors For Re-Admission

Unemployment

The results of the study show that unemployment is a risk factor to re-admission of SUD patients. Drug use begins as an escape plan from reality when one is suffering from the negative emotions coming from lack of employment such as boredom. Substances are being used for recreational purposes as participants indicated that they do not have anything else that could occupy their time. Substance use has also become a source of income for others however it has led to substance use disorder out of experimentation and now a number of relapses triggered by availability of the substances. It was noted that jobs are rare to find, in as much as this job is not good there is nothing else to do so as to provide for the family. Research has revealed that individuals who are unemployed are at a higher risk of relapse and re-admission due to financial stress, lack of social support and exposure to high risk environments (Bezerra et al, 2018).The study revealed that most participants wish they could get formal employment to keep them busy and avoid being idle which then contributes to re-admission. Yaqub,  (2013) suggested that global poverty is rapidly spreading and joblessness is rising, which causes many people to experience mental stress and worry as well as a lack of social networks, which prompts them to look for shelter in narcotic drugs and substances. According to the relapse model life style factors may lead one into viewing alcohol or substances as the only means of obtaining pleasure or escaping pain (Marlatt& Gordon, 1985. As a result people engage more into substance use leading to relapse cases in trying to cope with boredom, frustration and self-doubt. In as much as lack of employment is a problem in our country it has added to more problems as people are engaging in substance use out of misery. Young adults were found to relapse in high risk situations such as unemployment, rejoining drug-using social groups after receiving treatment, access to and availability of drugs, particularly in high-density areas, and a lack of infrastructure, particularly in terms of positive entertainment in communities (Bain, 2004).unemployment can be considered a risk factor for re-admission for people with SUD  therefore it is important to provide access to healthcare and support for unemployed individuals to reduce the likelihood of re- admissions.

Lack of social support

Lack of support from those who use substances can increase the risk of relapse. Isolation, loneliness and stress are triggered by lack of social support. Pressure from family to recover can actually lead to re- admission as patients feel that they deserve to be free and supported through this hard time of trying to recover. Results show that prior relapse or re- admission there is a conflict that would have happened between the patient and their social support system. Patients who have limited social support are more likely to relapse and require re-admission. These individuals may not have a supportive network of family or friends to lean on during recovery making it more challenging to maintain abstinence (NIDA, 2016). According to Marlatt & Gordon, (1985) lack of social support may trigger negative emotions such as anger, anxiety, depression, frustration, and boredom, which are also referred to as intrapersonal high-risk situations, are associated with the highest rate of relapse (Marlatt &Gordon 1985) Lack of social support can make it difficult for patients to manage triggers well such as places, people and situations that were previously associated with substance abuse as these will become a rescue point when conflict arises and when they do not have any support system. Lack of support may also lead to a lack of accountability where a person loses motivation to remain sober. Without a support system financial stress may arise, without a support system one may return to drugs as a way to cope with their financial difficulties. Substance use disorders often lead to social isolation, estrangement from family, loss of employment. Recovering from addiction is a challenging process and it is much more difficult without a strong support system. A lack of social support can lead to re-admission to treatment therefore it is important for treatment to prioritize building and strengthening social support networks for patients which can involve engaging family, friends, support groups and other resources in the community to help sustain their recovery.

Peer pressure

Hanging around with friends who are still into substance use or abuse can be a risk factor for re-admission. Friends using substances have been identified to be the risk factors because they sponsor drug use which then becomes easy accessibility, spread myths around the issue of relapse. In hard times people turn to their friends who are into substance use so that they can also use and forget about their sorrows. Such friend’s support relieves stress by providing substances. As part of preventing relapse there is need to demystify myths around substance use shared amongst friends, helping the client learn more effective coping skills. Relevant coping skills can be behavioural or cognitive in nature and can include both strategies to cope with specific high-risk situations (e.g., refusing drinks in social situations and assertive communication skills). Results show that people turn to their friends because they do not have other coping mechanism to adopt when faced with a stressful situation. It is also evident people do not only turn to their friends for support but rather for the substances as the friends provide easy access to the substance of choice.  Peer influence is a challenging subject, according to earlier research, 50% of former SUD patients’ old acquaintances persuaded them to start using drugs after they were released from treatment facilities (Broom, 2002; Hasin et al. 2013). The same author also found that 76% of old friends help recovering addicts obtain the substances they require. The social setting was shown to have the potential to help or hinder a patient’s ability to change their behavior after therapy. Negative peer impacts, for instance, have been linked to the emergence of substance use behaviours and the encouragement of relapse (Sapkota, 2019). .According to Marlatt and Gordon, (1985) identifying risk factors such as peers can help prevent relapse whereas failure to do so will result in more cases of relapse it is important to be aware of the influence of peers and be mindful of the potential for relapse when in the presence of others who are engaging in the same behaviour. It is essential that individuals learn how to resist peer pressure, make responsible choices and surround themselves with positive influences to avoid falling into substance abuse.

Conclusion

The study sought to explore the major substances used, the psychosocial factors that led to relapse and the risk factors for re-admission among patients diagonised with substance use disorder. The study found that crystal methamphetamine, cannabis, alcohol and cigarettes were the commonly used substances. Psychosocial factors that led to relapse were found to be stigma, stress, dual diagnosis, family conflicts, work pressure, cravings and availability of the substances used. The risk factors for re-admission were found to be unemployment, lack of social support and peer pressure. These factors were directly linked to the major substances used. Individuals with a dual diagnosis of mental health conditions may be at higher risk of using cannabis, crystal methamphetamine or alcohol to self – medicate their mental illness, leading to relapse and re-admission. Similarly individuals who experience work pressure or stress may use crystal methamphetamine as a way of coping with these challenges again leading to relapse and re-admission. Furthermore unemployment, lack of social support and peer pressure may influence one to use crystal methamphetamine, cannabis or alcohol which may impact their ability to function there by causing unemployment and increasing the risk of admission. Psychosocial factors leading to relapse are also linked to risk factors for admission. Individuals experiencing stress at work may be more likely to relapse causing unemployment again which is a risk factor for re-admission. Similarly, individuals with a dual diagnosis or family conflicts may experience social isolation and a lack of social support which in turn increases the risk of re-admission. Furthermore, the availability of substances and peer pressure can contribute to a relapse and increase the risk of re-admission. Therefore it can be concluded that the major substances used, psychosocial factors leading to relapse and the risk factors for re-admission are closely associated. Addressing these underlying factors in substance use disorder treatment programs can assist in mitigating the risk of relapse and re- admission such as employment support, social support, addressing co-occurring mental health conditions and stress.

CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS

This chapter discusses the conclusions derived from the findings of this study on psycho social determinants of relapse among patients diagonised with substance use disorder at Annex psychiatric hospital. The conclusions are based on the purpose, research questions and results of the study. The effects of these findings and the resulting recommendations will also be explained based on the conclusions and purpose of the study. Limitations of the study will be discussed as well.

Conclusion

The research study on psycho social determinants of relapse among SUD patients found that the major substances used were crystal meth, cannabis, alcohol and cigarettes. It appeared that these substances are available in the communities that people come from. This is similar to a study by (WHO, 2017) in west and central Africa where prevalence of substance use was high due to the availability of hallucinogens and cannabis. Cannabis, amphetamines, and opioids are the three illicit drugs that are most often used worldwide according to (UNODC, 2013); from the results obtained alcohol is also one of the most used substances.  These were used to enhance physical activity because of the nature of jobs participants. The more demanding the job is the greater risk of engaging in substance use as it serves the function of relaxation, alertness and energy throughout the day. Peer pressure was identified as a cause of taking substances. Because of the need to belong in a group people end up compelled to take as well, the study also found that even after a long period of abstinence when people meet their friends they are likely to take. When a conflict arises within a family, friends are there to offer support but this has triggered relapse as people began using the substances again. Family influence also appeared as a reason for initially taking. Results revealed that siblings can take the same substances and influence each other’s treatment plan, by providing substances as they stay in the same house.

The above mentioned substances leave patients vulnerable to relapse as noted in the results because of the powerful effects on the brain and body that makes quitting difficult. Withdrawal effects can be so intense and in avoidance of symptoms people may end up relapsing. The drugs used modify how the brain works, and these changes may persist long after a person becomes intoxicated or develops a tolerance to the drug leading to dependency (Kobo & Le Moal, 1997).This theory also explains why some of the participants alluded that they began using one substance which is alcohol but later advanced to more substances such as cannabis and crystal methamphetamine.

The results indicated that most participants used more than two substances. The number of relapse cases was ranging from one to 10, with most participants having about three relapse cases. These relapses occurred within a period of 1 year the earliest being 3weeks after successful treatment at Parirenyatwa Annex. Although research suggests that substance use became more prominent during the covid -19 era the results of the current study do not support the idea as the number of relapse cases dated from last year 2022 when covid -19 was no longer prominent meaning that apart from covid -19 there are other reasons which have led to drug use and an increase in the number of relapse cases. The factors contributing to relapse will be discussed below. It can be concluded that the use of more than two addictive substances is the one that increases the rate of relapse because mixing substances can increase the level of intoxication making it difficult to make rational decisions about drug use, increased dependency will also make it hard to quit as it increases the risks of withdrawal effects. As noted in Marlatt’s relapse prevention model, people often anticipate positive outcomes from the substance and will take the substance to control any negative situation or emotion around them. Using more substances may also cause polysubstance disorder where the person is addicted to multiple substances making it harder to achieve long term recovery.

The major determinants of relapse were found to be stigma, from individual where a person actually judged themselves and feared how the next person would react towards them if it was known that they had a substance use disorder. One can be stigmatized by their own family as well as the community they live in, in trying to escape the negative emotions aroused by this stigma people seek comfort in substances by expecting to alleviate their moods and also forget about what people say about them. Dual diagnosis was noted to be another factor contributing to relapse. The research study found that the patient with greater relapse cases had bipolar affective disorder; another dual diagnosis was noted to be schizophrenia comorbid substance use and depression. The nature of these mental health conditions can worsen drug use leading to more relapse cases. This finding is similar to Thomsen et al (2018) who found that relapse is increased by co-occurring conditions. It seemed that abstinence was very much difficult because of the nature of these mental health disorders where at time one began use just to silence hallucinations however continued use led to tolerance until a substance use disorder with multiple relapses same as bipolar where one engages a lot in pleasurable activities in this case it was found to be substance use which again has led to 10 relapses. Screening of other mental health conditions should be mandatory before treatment so as to make a correct diagnosis and informative treatment plan. Using multiple substances can increase the risk of developing another mental health condition. Cannabis users are at risk of experiencing brief psychosis as well as chronic mental health conditions including schizophrenia (Volkow et al., 2016).Crystal amphetamine has hallucinogenic effects, However when it wears off it can lead to feelings of depression, anxiety, distorted perceptions, fatigue and headaches (Bungay et al,2006 & Canadian Centre on Substance Abuse, 2005). Dual diagnosis can result from initially using substances as continued use leaves one prone to developing other conditions.

Family conflict was found to be a cause for relapse. As people try to avoid negative symptoms, they end up re-joining old friends who may still be taking substances. These conflicts may result in isolation, neglect or family members being over protective. Such feelings of isolation and neglect were identified as risk factors for re-admission because they often trigger cravings and re-joining of old groups to seek comfort and also use the substances as a coping mechanism. as one is pushed into the environment where substances are vast.  A person with a history of substance use when provoked will often seek comfort in re-taking the substance. Marlatt, (1985) noted that interpersonal conflict can lead to relapse and it was identified as one of the high risk factors which one had to be aware of and prepare so as to prevent a relapse. Apart from conflicts, family influence amongst siblings was noted to be a risk factor for relapse. The results showed that the two siblings in the study used similar substances and their number of relapses were the same. It was noted that recovery can be very difficult in such a situation where these members continue to provide the substances for each other there by triggering cravings and making substances available in the same house. The researcher came to this conclusion as each one of them reported that there is a time when they wish to quit but influence from the sibling made them continue.

Cravings were found a factor influencing relapse, the study found that the cravings are often felt in certain situations such as when one comes across someone using. The most common substances are available in communities hence have easy access to them which then influences re-take. Unemployment leaves many bored and idle leading to substance use as it becomes any activity to do as people hang out with their friends, because of lack of formal employment some have begun selling these drugs to earn a living and ended up using, still such people find it hard to maintain abstinence as they come across the substances every day. It was noted in the results that selling them also triggers use and cravings when one decides to stop thus leading to re-admission. Zimbabwe’s extremely high unemployment rates, coupled with destitution and hopelessness, have led to a rise in the number of young people who use drugs for recreational purposes (ZIMFACT, 2021); this has been made worse by the readily available and affordable nature of these substances to young people and adolescents as they interact within their social circles.

Given the underlying factors in relapse of patients with substance use disorder, it is important to note that the major substances used are directly linked to the psychosocial factors as well as the risk factors for re-admission, therefore addressing these underlying factors in treatment programs can help in mitigating the risk of relapse and re-admission.

Recommendations

The study recommends that more studies should be done on psychosocial determinants of relapse in different psychiatric hospitals so as to generate more data that can help develop a relapse prevention model that caters for all or rather different areas of the country. In addition more time should be spent in identifying high risk behaviours and addressing them as a way of  reducing relapse cases. Since problems resulting from family were noted to cause re-admission it is essential to bring in family members or caregivers whilst one is still admitted so that they gain an insight of what substance use disorder and relapse is, how best they can offer support top their relative in order to reduce stigma within the family and strengthen social support. The study also recommends that apart from the 21 days of  detoxication and psychotherapies there should be rehabilitation centers where people can be admitted in after, whilst taking their medication, continuing with psychotherapies, learning new skills which they can later apply in their lives and earn a living from it such as chicken projects, carpentry just to mention a few. This might help reduce the unemployment gap as most of the participants were unemployed. A stay at rehab for some time might help reduce cravings as the environment will be drug free, support from others at the same center may help strengthen and boost confidence to conquer substance use disorder as other patients share their successful stories. Awareness campaigns should be conducted so that everyone understands substance use disorders and how they affect behaviour as well as the steps involved in recovery. This may help reduce stigma in the communities and families. Some people lack knowledge pertaining to treatment of SUD hence awareness may help reach out to them, it will also serve as prevention plan to those who have not yet engaged in substance use and for those battling with recovery the awareness may help boost help seeking behaviour. Support system plays a greater role in recovery hence there is need to spread the knowledge so that those recovering get support.

Limitations

The sample of the study was too small with only ten participants hence not representative of all. The study had participants from one hospital, results from other hospitals and rehabilitation homes can help aid more information on the psychosocial determinants of relapse among patients diagnosed with substance use disorder. More studies from different sectors, regions and culture or language groups might reveal additional information on the psycho- social determinants of relapse among patients diagonised with substance use disorder. The issue of relapse is a lived experience hence participants only related to their personal stories, this makes the study not generalisable.

ACKNOWLEDGEMENTS

I would like to begin by expressing my deepest gratitude to God for providing me with the strength, courage and wisdom to complete this research. Your guidance, grace and blessings have been the cornerstone of this accomplishment.

To my family thank you so much for the unwavering support, encouragement and love throughout this journey. Your patience, understanding, and sacrifice have provided me with the necessary motivation and inspiration to persevere through the challenges and obstacles encountered.

 I am indebted to my supervisor Lilian Chichevo, for their invaluable guidance, supervision and mentorship throughout this research. Your dedicated commitment, insightful feedback and constructive criticism have been critical in shaping the outcome of this dissertation

Finally, I would like to acknowledge all of the participants who gave their valuable time, energy and perspectives to this study. This research would have not been possible without your participation and willingness to share your experiences.

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APPENDIX 1

Interview Schedule

Interview Questions

1a) What is your age?

1. b) What is your Sex/gender?
2. c) Are you married?
3. d) What is occupation or previous occupation?
4. e) Where do you stay/suburb?

2a) When did you start taking drugs/ substance?

1. b) Which drugs/ substances do you take?

3a) Is this your first admission?

1. b) How long were you admitted?
2. c) Why were you admitted?
3. d) any behaviours you remember or were told that you were doing

4a) What are the factors that led to relapse?

1. b) When did the relapse occur?
2. c) How many relapses have you had?

d)What support system do you have?

APPENDIX 2

INFORMED CONSENT FORM (ENGLISH)

RUMBIDZAI NZWENGE

36 KLOOF SUNRIDGE HARARE

0774459786

My name is Rumbidzai Nzwenge, a clinical psychology student from university of Zimbabwe.

You are being requested to participate in the research study titled the psycho social determinants of relapse among patients diagonised with substance use disorder.

The aim of the research study is to examine the psycho-social determinants of relapse among patients diagonised with substance use disorder. The interview is expected to last about 30 minutes. Interview questions will include the use of substances and the causes of relapse.

Participation in the study is voluntary; choosing not to participate will not disadvantage you in any way. Before you decide to take part it is important to understand why the research is being done and what your participation will involve. You may ask any questions for clarity. The research study will help set up a program for relapse prevention in order to reduce the high prevalence of SUD relapse, to inform the caregivers and community about psycho social risk factors of relapse. Information obtained will be used for the purpose of this study and will remain confidential. You will be assigned a number before the interview and throughout the study to secure your identity. Participant’s identities will not be revealed and will remain anonymous in any publications resulting from this project. Once you agree you will be given a form to sign. Please note that you may decide to withdraw from the study at any point. If you feel that the question you have been asked is too sensitive or you do not wish to answer you may ask the researcher to omit the question. There will be no compensation for participating in the study.

STATEMENT OF CONSENT

• I have been informed about the study being conducted by Rumbidzai Nzwenge.
• I understand the purpose of the study.
• I have been given an opportunity to ask questions about the study and have had answers to my satisfaction.
• I declare that my participation in this study is entirely voluntary and that I may withdraw at any time without any consequences.
• I understand all information obtained will be stored safely and securely.
• If I have further questions or concerns related to the study I understand I may contact the researcher.

PERSONS TO CONTACT IF YOU HAVE QUESTIONS OR CONCERNS

If you have any questions or if study harmed you in any way, you are too free to contact 0774459786   (Rumbidzai Nzwenge).

Signature   of participant…………………………………………   Date………………………………

Signature of the researcher……………………… ………………..Date………………………………

Signature of witness………………………………. Date……………………………..

APPENDIX 3

APPROVAL LETTER (UZ)

APPROVAL LETTER (MRCZ)

APPENDIX 4

PLAGIARISM REPORT