Assessment of the Challenges in Care of Patients with Substance Use Disorder among Caregivers at Parirenyatwa Hospital Psychiatric Unit, Zimbabwe 

Assessment of the Challenges in Care of Patients with Substance Use Disorder among Caregivers at Parirenyatwa Hospital Psychiatric Unit, Zimbabwe 

Mahara, Princess¹; MalvirnT, Phiri²; Kusowa Kanganisai³; Bhake, Cynthia⁴; Mazwi, Nicola⁵; Nyikadzino, Rosemary⁶ 

^1,4,5,6Department of Psychology, Great Zimbabwe University

²Department of Psychology, Midlands State University

³Department of Psychology, University of Zimbabwe

DOI: https://dx.doi.org/10.47772/IJRISS.2023.7012129

Received: 28 November 2023; Revised: 13 December 2023; Accepted: 16 December 2023; Published: 14 January 2024

ABSTRACT

This paper assesses the challenges in care of patient with substance use among care givers at Parirenyatwa Group of Hospitals psychiatric Unit, Zimbabwe. This paper seeks to further explore the experiences of care givers supporting family members with substance use disorder and their engagement in self-care. Exploratory Qualitative research design was employed to facilitate the exploration of family experiences affected by Substance Use Disorder and to identify the necessary assistance they may require. A Sampling size of 21 participants was used to avoid biased information and participants were recruited using purposive sampling technique, by selecting individuals with members affected, by Substance Use Disorder. The findings from the study strongly indicated that family members were significantly affected by the responsibility of caring for individuals with substance use disorder. This article extensively explores the intricate and multifaceted challenges faced by the caregivers supporting individuals grappling with substance use disorder. Researchers recommended that it is crucial for health care system, to acknowledge the indispensable role played by caregivers and extend the necessary support system.

INTRODUCTION

This article examines the challenges faced by caregivers providing support to individuals with substance use disorders. It argues that caregiver distress often remains unnoticed and unaddressed a silent struggle. Addressing caregiver distress and identifying potential avenues for support and improvement within Zimbabwe’s healthcare systems, akin to global counterparts, is crucial. The study focuses on caregivers of patients with substance use disorders at Parirenyatwa Group of Hospitals Psychiatric Unit in Harare, Zimbabwe.

In Zimbabwe, similar to many parts of the world, substance abuse not only affects the substance users but also directly and indirectly impacts caregivers. Family members provide multidirectional care, including personal, financial, symptom management, and treatment continuation (Nordgan et al, 2020). Caring for a family member dealing with substance use disorder is a complex journey, involving emotional turmoil and uncertainty. Caregivers’ responsibilities go beyond physical care, encompassing emotional, psychological, and social aspects of their relative’s struggle.

Mental health policy is a powerful tool for enhancing a country’s mental health (Cohen et al, 2020). However, there are gaps between policy development and implementation in most countries, burdening family caregivers due to limited support services (Mavingire, 2019). In Zimbabwe, substance use disorder is often attributed to demon possession, leading to initial treatment by prophets and traditional healers due to its spiritual attribution (Alyafei et al 2021). Understanding caregivers’ experiences of substance use disorder within Zimbabwean cultural and spiritual beliefs is critical.

This paper seeks to explore the experiences of caregivers supporting family members with substance use disorder and their engagement in self-care. The study was influenced by the surge of patients with substance use disorders at Parirenyatwa Group of Hospitals Psychiatric Unit, deeply impacting Zimbabwe’s community, including early exposure to children and youth similar to what Tanzania is going through (Degestein, D. 2022). The primary aim is to document the emotional challenges faced by caregivers, acknowledging the serious issues within the caregiving role due to substance abuse. The study also emphasizes equipping caregivers with skills and knowledge from their experiences to help their family members reach their potential.

The research will be valuable for future researchers, mental health institutions, and those caring for family members with substance use disorder, aiming to explore the social and psychological impact of caring for relatives with substance use disorder and promoting stress management. The document comprises five sections: the introduction, Literature Review, Methodology, Discussion of Results, and Conclusion.

Zimbabwean Context

Limited financial resources deprive some individuals with substance use disorder of occupational participation benefits (Chikwanha, 2019), leading to misunderstandings between patients and caregivers. Zimbabwe’s focus on caregiver burden and substance use is limited, with most studies concentrating on substance abuse and challenges faced by caregivers of mental disorder patients. Hence, this paper uncovers specific challenges faced by those caring for relatives with substance use disorders at Parirenyatwa hospital psychiatric unit, Zimbabwe.

Two-thirds of Zimbabwean children have experienced violent discipline, increasing their vulnerability to mental health challenges (UNICEF, 2022), raising the likelihood of depression among caregivers. This paper aims to unveil the challenges faced by caregivers rather than delve into the causes of mental disorders. The escalating mental disorders at Parirenyatwa have compelled researchers to passionately undertake this study, emphasizing the significance of good mental health. Exploring stress management for caregivers dealing with substance use disorder is paramount.

Family life experiences negative impacts in interpersonal relations, leisure activities, and financial resources due to the presence of a substance abuser. Intrafamily conflicts often rise, negatively affecting other family members’ well-being (Sharma et al, 2019). Substance abuse not only affects the individual but also extends to caregivers, forcing them to navigate through unpredictable behaviours and emotional challenges, creating a multifaceted burden.

The stigma surrounding substance use disorders adds complexity to caregivers’ experiences (Pires, et, al 2020), leading to profound feelings of shame and isolation. Guardians, biological parents, and foster parents of children with substance use disorders face formidable emotional and physical challenges, often leading to depression, hopelessness, guilt, deteriorating health, and economic strain (Pires et al, 2020).

Intra-family conflicts, cognitive, emotional, and behavioural changes from substance abuse often evoke emotions like denial, anger, shame, guilt, and sorrow among family members, hindering effective coping mechanisms (Low, 2019). The ripple effects of substance abuse extend to community members, necessitating a comprehensive and empathetic approach to addressing this complex issue.

LITERATURE REVIEW

Substance use has surged in Zimbabwe and globally, emerging as a major health issue (Sahar et al, 2020). Existing research has acknowledged that having a family member with a substance use disorder adversely affects caregivers’ mental and physical health. However, there is a notable lack of specific studies in Zimbabwe focusing on this topic. This gap is significant as it extends beyond causing stress to caregivers, potentially leading to mental illness and substance abuse among caregivers—a phenomenon known as “burnout,” sometimes resulting in the abandonment of the individual in need.

The increase in drug and substance misuse in Zimbabwe can be linked to factors like high unemployment rates, challenging socio-economic conditions, and COVID-19-induced lockdown measures. For instance, a study in Canada (Maina et al., 2021) highlighted approximately 660,000 minors living with parents affected by alcoholism. Despite formidable challenges, caregivers often demonstrate remarkable resilience, finding support in groups that offer emotional expression, insights exchange, and effective coping strategies.

Children in families with substance abusers typically don’t experience neglect but are exposed to a higher risk of maltreatment, abuse, and psychological trauma, making them more susceptible to substance use. While several studies have explored aspects of substance abuse, there remains a gap in understanding caregiver stress within the context of substance use disorder (Shahraki et al, 2019).

This article aims to fill these knowledge gaps by shedding light on caregiver stress experiences in Zimbabwe and proposing strategies to mitigate its impact. The study focuses on the unique context of Annex Psychiatric Unit at Parirenyatwa Hospital. The findings highlight that caring for individuals with substance use disorders imposes significant objective and subjective burdens on caregivers, profoundly affecting their mental health.

Children exposed to illicit substances are at risk of developing psychiatric issues such as anxiety or depression, behavioural and cognitive difficulties affecting learning (Shahraki et al, 2019). Substance use triggers violence, legal issues, marital conflicts, and child neglect, leading to unmet needs, strained relationships, financial stress, emotional distress, and higher violence rates within families (Nordgan et al, 2020).

Caring for a partner or dependent with substance use disorder causes sustained stress for family members, resulting in emotional challenges such as anger, anxiety, depression, guilt, and behavioural disruptions. Relatives of individuals with substance use disorders often experience mental health issues like depression and anxiety (Ólafsdóttir, J, 2020). This cumulative stress severely affects family functioning. Understanding the impact on families becomes increasingly vital as the substance use crisis continues to grow, highlighting the lack of support for these families in community engagement events.

Caregivers face stressors like financial pressure, burnout, and heavy workloads, resulting in distress. Families dealing with addiction exhibit stress-related behaviours such as insomnia, anxiety, depression, isolation, suicidal thoughts, and resentment (Kallander et al, 2021). Few studies have explored these dynamics, emphasizing the need for research on factors contributing to caregiver distress, including quality of life, the well-being of other children, marital status, marriage length, and education levels.

THEORETICAL FRAMEWORK

The impact of substance use and its effects on caregivers is better explained using the Family Systems Theory. The Family Systems Theory, developed in the mid-20th century primarily by Murray Bowen and other key figures, offers a comprehensive framework for understanding the complexities of family dynamics. At its core, the theory views the family as an emotional unit, emphasizing the interdependence among its members. It posits that individual behaviours and interactions within the family are interconnected, leading to a system where changes in one part can reverberate throughout. Central to the theory is the concept of differentiation, which refers to the balance between maintaining individuality and emotional connection. Family roles, boundaries, and the multigenerational transmission process are key components, illustrating how patterns of behaviour and emotional responses are passed down through generations. The theory also explores phenomena such as triangulation, where conflicts involve a third party, and emotional fusion, characterized by overly enmeshed relationships (Gavazzi, S.M. & Lim, J.Y. 2023).

The Family Systems Theory proves especially valuable in understanding addiction recovery as substance use disorder impacts not only the individual struggling with addiction but also significantly affects caregivers. Caregivers often grapple with emotions such as anger, helplessness, and anxiety, while family dynamics can contribute to the persistence of addiction. This theory aims to enhance communication within the family structure and stands as a pivotal aspect of effective family theory. When a caregiver experiences anxiety while tending to a patient with a substance use disorder, this anxiety can permeate throughout the family, affecting all members.

This theory is particularly advantageous for several reasons, chiefly because it enhances communication among caregivers and other family members. It assists in delineating boundaries between the caregiver and the patient, aiding both the individual in recovery and their family members in comprehending and respecting each other’s boundaries. Furthermore, it introduces a novel perspective on family problems.

However, it is not without its limitations. The Family Systems Theory can be ineffective when dealing with unwilling participants. Bowen’s theory highlights that “progress in elevating one’s differentiation of self beyond the level of the previous generation of parents is both slow and insubstantial” (Castronova, M & ChengFeng, J. 2020).

METHODOLOGY

This study adopted a qualitative research approach, enabling the researchers to engage deeply in understanding distinct methodological traditions that explore social issues. Employing an exploratory qualitative design facilitated the exploration of families’ experiences affected by Substance Use Disorder (SUD) and identified the necessary assistance they may require. The qualitative approach was instrumental in gathering information on the experiences of caregiver stress while caring for a relative with SUD. A sample size of 21 participants was selected to ensure a diverse range of unbiased information, and verbal and written consent were obtained from all participants.

The research employed semi-structured interviews conducted among caregivers of individuals with SUD at Parirenyatwa Groups of Hospitals Annexe Psychiatric Unit, Crisis Support Centre. This non-profit organization was established to address the psychosocial needs of Parirenyatwa Group of Hospitals (PGH) clients and the broader community, emphasizing patient and family-centred mental health care. The use of semi-structured interviews allowed flexibility in the administration process, minimized observer subjectivity, and facilitated the presentation of standardized stimuli to all participants, ensuring higher reliability.

Hancock et al, (2021) noted that an explorative case study is utilized in situations where the intervention being evaluated lacks clear, singular outcomes. This exploratory design aimed at enhancing the researcher’s understanding of the existing problem without providing conclusive results, assisting in determining the best course of action or effective methodologies for the study. The qualitative explorative design facilitated familiarity with crucial details, settings, and concerns.

Participants were recruited through purposive sampling, selecting individuals with family members affected by SUD, including siblings, parents, partners, children, or grandparents. Interviews focused on participants’ life experiences, their encounters with substance use, perceptions of its impact on themselves and their families, and the coping strategies employed. Professional counselling was offered to participants for debriefing after the interviews.

Thematic analysis, a qualitative method for identifying and reporting patterns in data, was employed for data analysis. This approach provided rich and descriptive data organization, utilizing pseudonyms to protect participant identities. Thematic analysis aimed to identify significant themes within texts across various levels.

Additionally, documentary analysis was used to supplement the data obtained through interviews, further enriching the research insights.

Participants were thoroughly briefed about the study objectives before arranging interview sessions. In the consent process, caregivers had the option to sign consent forms or use a thumbprint as agreement symbolism if illiterate. Consent was also sought for the use of tape recorders during interviews to ensure accurate documentation. Participants were assured of the rigorous maintenance of privacy, confidentiality, and anonymity throughout the study.

RESULTS

In this study 21 individuals participated which included 4 males and 17 females who were aged 27 to 72 years. The table below elaborates the details of relatives who had a member with SUD OF 21 participants. 13 indicated that they grew up in families where members relatives used substance at an early age. Four themes, whose overwhelming focus is on the psychological impact of caring for a relative with SUD are discussed and these are grieving the loss, living in dread and despair, living in perpetual crisis, and mitigating the impact of substance use in the family.

Theme 1: Grieving the Loss

Several participants repeatedly mentioned the loss of their relationship with the family member abusing substances. The caregiver often struggled to maintain the necessary relationship dynamics required to support them and maintain healthy coexistence with all family members. This loss of relationship pushed caregivers to go the extra mile, investing their time, money, and energy to ensure the individual’s safety and survival, with the hope that the severed relationship would be restored to normal. Despite their positive efforts, when things failed to return to normal, some participants lost hope for recovery and subsequently grieved the loss of the relationship and the person.

One participant expressed, “I know it sounds cold, but I washed my hands of him because I tried my best to help him and he does not seem to appreciate it. If he decides to help himself, that’s when I will then step in as a caregiver,” (33-year-old sister). Another shared, “I was deeply affected and grieved a lot. I felt like I had lost my son, especially since I lost my firstborn son due to the same problem,” (58-year-old mother).

Additionally, two participants grieved over the negative impact of living with a substance abuser in the family. The substance abuser sold properties that the parents loved, damaged assets while under the influence, and the caregivers felt unsafe due to the social circle that the relative was involved in. This situation made them feel like they had lost control.

“I and my wife discovered that we were losing so many things in our house. We then decided that we would no longer buy properties, which was incredibly frustrating. It put both of us under immense stress, and we began to view going to work as a means of escape. We’re always trying to get away from our house because they have almost taken control of it and everything inside,” (66-year-old man).

Furthermore, four participants who witnessed substance abuse by their parents also grieved the loss of their innocence during childhood. Their children encountered neglect and insecurity while growing up, leading to their placement in foster homes where they witnessed and, in some cases, were exposed to violence.

Theme 2: Living in Dread and Despair

The ongoing substance abuse has left caregivers in constant worry, living in fear that they might lose their loved ones to their addiction.

“I’m now at a point where I fear getting out of bed each morning, dreading that I might find my son dead. Some nights, I can’t sleep; thoughts of my son occupy my mind, and I regularly check on him. Every half-hour, I rush to his room to ensure he still has a pulse,” shared a 46-year-old man, describing the heartbreaking fear of losing his son to substance abuse.

The anguish of spending sleepless nights, anxiously checking on his son’s well-being, brought overwhelming feelings of helplessness to the caregiver. The constant fear that substances could claim his son’s life made intervention attempts feel futile.

Another participant, a 44-year-old sister, lamented,

“My brother is 38 years old, with his own family, yet he continues to abuse substances. He has so much to live for, but it seems addiction has blinded him. Now that both our parents are gone, everyone looks up to me, and then, here comes a substance abuser in the family. It’s deeply hurtful and burdensome being a sibling to a drug addict.”

Reflecting on the situation, a 52-year-old shared,

“At some point, I convinced myself that I couldn’t keep living like this. I felt she didn’t want my help, and simultaneously, I realized I couldn’t help her. I worry about her whereabouts and where she sleeps at night. After years of this experience, I told myself I can’t continue like this; it’s affecting my health. It became clear that I needed help myself.”

The constant worry and uncertainty surrounding their loved one’s addiction can take a toll on their mental health.

Theme 3: Living in Perpetual Crisis

The ongoing crisis, stemming from chronic abuse, the overwhelming demand for care, neglect, and the absence of life’s basic necessities, created an environment where substance abuse became intergenerational among families. Several participants expressed the serious challenge of intergenerational addiction, deeming it nearly impossible to control despite exhausting all available treatment options.

“Intergenerational addiction is a severe problem that seems unstoppable. I’ve tried nearly every treatment method, but it’s like dealing with a moving train; you just can’t halt it, “explained” a 59-year-old mother.

The presence of addiction often led to violence and the need to escape toxic environments, resulting in family dysfunction and disintegration. One participant, a 32-year-old daughter, shared her experience:

“My biological father used substances when I was young, which escalated to physical abuse, leading to my parents’ divorce. My mother remarried a man who abused illicit substances, subjecting me to various forms of abuse as necessary”

Almost every participant noted that substance abuse perpetuated family crises, with many reporting instances of child and spousal abuse. Some participants observed that having a substance user in the family led to neglect of other family members.

“I neglected other family members because my focus was solely on one child. I constantly worried about whether my child ate, who they were with, what they were doing, and if they were using substances. These thoughts consumed my mind,” revealed a 53-year-old mother.

A 42-year-old sister emphasised that:

Some family members lack awareness of triggers. They don’t understand when the abuser experiences a psychotic episode. It’s crucial to educate other family members about what the individual is going through and what triggers substance use. Quitting is a process, not a one-day task.

Participants frequently mentioned their limited knowledge regarding substance use disorders and addiction due to a scarcity of available resources for psycho-education.

A mother emphasised that:

“We lack sufficient education on SUD and addiction. There’s a complete absence of information. When we seek help from local clinics, they refer us elsewhere. Community clinics should have mental health practitioners to aid in education.”

The commitment to not giving up on individuals with substance use disorders transformed caregivers into full-time providers, responsible for financial support, basic necessities, and healthcare expenses. However, this long-term role assumption took a toll on caregivers, affecting them physically, mentally, and emotionally, disrupting their work-life balance due to the perpetual need to care for the substance users.

Theme 4: Mitigating the Impact of Substance Use in the Family

Many participants displayed limited knowledge about how addiction impacts their families. This lack of awareness influenced their perception regarding the necessity of self-care and hindered their ability to identify effective ways to provide support. Some participants highlighted Alcoholics Anonymous (AA) groups as a valuable resource that helped them cope with caregiver fatigue. However, a few were unaware of these self-help groups. Within the AA meetings, they found a space where they felt free to share their struggles, life situations, and stress, allowing them to comprehend each other’s experiences and find solace. A Mother stated that “when I shared my son’s addiction issue at AA, everyone empathized with me. Other participants shared similar stories, making me feel less burdened and realizing that I’m not alone on this journey”.

In addition to AA groups, some participants sought formalized counselling from psychologists. These mental health professionals provided crucial support in managing stress and caregiver burnout. A Sister shared that;

“I’ve personally been seeing a private psychologist for stress management and caregiver fatigue. They equipped me with coping skills for stress, which was very helpful. Unfortunately, due to financial constraints, I had to discontinue my sessions.”

Formal counselling sessions proved enlightening, benefiting both substance users and caregivers by enhancing their understanding of the causes and short-term/long-term effects of substance abuse. These sessions also provided valuable insights into coping mechanisms. A Mother stated that:

“My husband and I have always believed in seeking professional help from psychologists. We attend therapy sessions at least twice a month. Since starting these sessions, we’ve found them tremendously helpful, reducing our caregiver burden”

Overall, counselling and support services can be beneficial for caregivers who live with a substance use disorder. They can provide caregivers with the necessary tools, knowledge, and emotional support to navigate the challenges they face and prioritize their own well-being.

According to the above caregivers living with substance use disorders faced numerous challenges that have a significant impact on their well-being and ability to provide care. These challenges can be both physical and psychological in nature.

DISCUSSION

The study findings strongly indicate that family members were significantly impacted by the responsibility of caring for individuals with substance use disorders. The loss of relationships with substance users had profound effects not only on families but also on the wider community, directly reflecting the impact of substance addiction. Similar observations were made by Mavingire et al. (2019) in their study in Zimbabwe, although their focus was primarily on the experiences of caregivers looking after bipolar patients. Some participants in our study expressed grief over the loss of their relationships with substance users, experiencing a form of “social death” that affected their social networks, identity, and integration within society. Addiction, in this context, was equated to a real loss, leaving family members grieving for the individual who was still alive but disconnected.

However, considering substance abusers as socially dead, while a coping mechanism for caregivers dealing with emotional distress (Gegiekaite, G. 2021), also posed dangers. This approach, while assisting in navigating the stages of grief, unfortunately, led some caregivers to remain stuck in the depression stage (Leake et al 2019).

The inability of caregivers to alleviate substance addiction fostered feelings of hopelessness and worthlessness. This failure often stemmed from a lack of knowledge about addiction, depleting caregivers’ resources to handle their own emotional distress and engage in self-care. These findings align with other studies focused on understanding caregivers’ difficulties, highlighting consequences such as burnout, stigmatization, lack of social support, and diminished quality of life (Areia et al., 2019; Alyafei, 2021).

Furthermore, the continuous relapses and reluctance of substance users to engage in treatment shattered the hopes of many caregivers. Notably, within families affected by addiction, vulnerability increased for relatives, leading to instability, maltreatment, domestic violence, and even divorce. The overwhelming emotional burden on caregivers resulted in a myriad of emotions including frustration, anger, confusion, depression, abandonment, fear, anxiety, guilt, and embarrassment (Bullinger, R.L & Wing, C. 2019). It also fuelled stigma against both caregivers and substance abusers within their community.

Despite the visible impact of addiction on families, some health professionals failed to recognize the stress caused by caring for substance users. This investigation highlights the need for specific resources catering to caregivers. Without these resources, unresolved health needs may persist within families. Supporting self-care for families affected by addiction requires acknowledgment of caregiver distress, which can significantly improve their ability to support their loved ones in recovery (Tamizi et al, 2020).

Despite facing barriers to addiction services, caregivers demonstrated resilience and a strong motivation to seek support systems, resources for self-care, and strategies to cope with caregiver stress. Alcoholics Anonymous groups emerged as pivotal for caregivers, providing them with essential strategies to address addiction and its psychological impacts (Pfund et al 2023).

Substance use and addiction are considered family diseases due to their impact on family members, resulting in various forms of caregiver stress. Some participants suggested interventions that could address these issues, emphasizing the need for patient-centered support and caregiver fatigue screening (Liu et al., 2020). Recognizing and addressing caregiver distress is crucial, and institutions like the Parirenyatwa Hospital Psychiatric Unit play a significant role in providing comprehensive support. Through offering counselling, educational resources, and stigma-reduction initiatives, these institutions can alleviate caregiver stress and promote holistic well-being.

CONCLUSION

In conclusion, this article extensively explores the intricate and multifaceted challenges faced by caregivers supporting individuals grappling with substance use disorders. It underscores a crucial but often overlooked phenomenon: caregiver distress. Recognizing and intervening in this distress is of paramount importance, not only within Zimbabwe but on a global scale. Comprehensive support and enhancements within healthcare systems worldwide are imperative.

Through the lens of caregivers at the Parirenyatwa Group of Hospitals Psychiatric Unit in Harare, Zimbabwe, this article sheds light on how substance abuse doesn’t solely impact those directly involved; its effects resonate through families, profoundly impacting caregivers both directly and indirectly. The caregiving role encompasses a vast array of responsibilities, including personal care, financial assistance, symptom management, and ensuring continuity of treatment for individuals with substance use disorders.

Caring for a family member or relative ensnared in the complexities of a substance use disorder presents an arduous journey fraught with emotional turmoil and an overwhelming cloud of uncertainty. Caregivers shoulder a substantial burden that extends far beyond physical care, involving the intricate dimensions of emotional, psychological, and social support for their afflicted loved ones. Given these immense challenges, it’s crucial for healthcare systems, not only in Zimbabwe but universally, to acknowledge the indispensable role played by caregivers and extend the necessary support networks. Addressing caregiver distress is not merely an act of compassion; it’s a fundamental step towards nurturing healthier, more resilient families and communities in the face of substance use disorders.

This recognition calls for action, advocating for enhanced caregiver well-being and the implementation of comprehensive care strategies that address the full spectrum of challenges encountered by families affected by substance abuse. This includes access to mental health resources, caregiver support programs, educational initiatives, and stigma-reduction efforts to foster a more understanding and supportive environment for those impacted by substance use disorders. Attending to the distress experienced by caregivers is pivotal, serving as the cornerstone for building stronger and more compassionate healthcare systems that can effectively confront the challenges posed by substance abuse within families and communities.

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