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Substance use disorder patients' attitude towards treatment with psychotherapy and self-help groups.

Introduction

Substance use disorders (SUD) is considered as Mental and behavioral disorders due to psychoactive substance use (1). SUD affects patient's physical health and it is directly associated with patient's mental disturbances. They are less able to protect themselves, less able to perform reasoning. They have affective self-deregulation, disturbed ability to control impulses. They have problems to maintain high self-confidence and have extremely poor ability to take care of them. They cannot tolerate and regulate interpersonal relationship. As it is known, risky and dangerous alcohol use habits substantially influence emotional and social functioning, cause behavioral problems, influence common health condition and social environment--relationships in the family and at work (2-4). Researches (5,6) show that people with legal or work problems seek help more often.

Taking into account the chronic and progressive character of the disease it cannot be self-limiting. Nevertheless data can be found some people with SUD never receive treatment (7,8).

Taking into account multi-etiological development of the disease and its influence on many areas of life, it is important for dependant patients to provide help that is oriented towards personal growth and enhancement of functioning. Such help cannot be offered using only medications, therefore psychotherapeutic involvement is necessary (9). Unfortunately psychotherapy (PT) in Latvia is available only for people with high income. Psychotherapy is not included is the list of services that are paid by government (10). Taking into account the chronic and progressive nature of the disease, it cannot be self-limiting, if dependant person does not improve his personal functioning, ability to understand himself, and ability to communicate and cooperate with others, risk of relapse exists. E. Cohen et al. (11) indicate that patients should be educated and informed, and stigma associated with treatment should be diminished.

Research methods

Participants. Participants were approached by researchers at two drug and alcohol services in Latvia. 587 patients with the ICD-10 diagnosis of substance use disorder (F10.2-F19.2) received the questionnaire. Inclusion criteria: diagnosis of SUD, at least 18 years of age and older; not in acute condition; agrees to give informed consent and fill out the questionnaire. Exclusion criteria: no substance use disorder diagnosis (is F10.1-19.1); less than 18 years of age; in acute condition; does not agree to participate of fills out the questionnaires deficiently.

Research Instrument. Quantitative research method was used in this study. The questionnaire was designed by the research authors and was pilot tested in order to be validated. The questionnaire consists of 24 questions and it consists from two parts--socio-demographic data collection and basic information collection. There are questions about addiction treatment methods, self-help groups, individual or group psychotherapy respondent has used in the basic part of the questionnaire. There are also questions in the basic part of the questionnaire about the duration of the treatment, duration of remission and improvements after using each therapy method. Patients' answers on questions regarding using psychotherapy or self-help groups are used in the article.

The research was approved by the Ethics Committee of Riga Stradins University.

Data were processed using Microsoft Excel program and SPSS 16.0 for Windows program, as well as using descriptive statistics and frequency analysis. As per Kolmogorov-Smirnov Z test, respondent groups are spread adequately. In order to calculate mean age of respondents t-test was used. Spearman Correlation test was used in order to detect connections among patient groups.

The aim--to find out the point of view of substance use disorder patients regarding number of visits, duration of treatment and efficacy of self-help groups, individual and group psychotherapy.

Results

587 filled out questionnaires were analyzed. Demographic data of respondents: 66.4% male, 33.6% female, mean age--39.6 (SD [+ or -] 11.3). 238 (40.5%) respondents are employed. 378 respondents have secondary or secondary-professional education (64.4%), higher education--89 (15.2%). 170 (29.0%) respondents have registered marriage, 155 (26.4%) respondents have non-registered relationships, the rest of respondents are divorced or single. 396 (67.5%) respondents have children. 97.4% (572) admit that have used alcohol, 33.7% (198)--drugs, but 29.3% (172)--gambling. 460 (78.4%) considers themselves as people with alcohol dependence. Dependence from drugs admit--130 (22.1%), from gambling--55(9.4%), but 48 (8.2%) respondents do not consider themselves dependent.

26.2% (154) respondents have attended self-help groups (SHG). 96.1% have attended AA (Alcoholics Anonymous) meetings, 22.1%--NA (Narcotics Anonymous) meetings and 9.7% attended GA (Gamblers Anonymous) meetings. Respondents could check several answers. 96 respondents (62.3%) who attended self-help groups had secondary education and 37 (23.3%) had higher education. Socio-demographic data of respondents can be seen in Table 1.

There is no statistically significant connections regarding age and sex between the group that attended SHG and the group that did not attended SHG (p > 0.05). Statistically significant connections was found between these groups regarding having work, education, family status and having children (p < 0.05).

Individual psychotherapy received 18.5% (109) from all respondents. Respondents who attended and who did not attend individual psychotherapy did not statistically significantly connections regarding age (p = 0,168), sex (p = 0,150) and having children (p = 0,216), but did statistically significantly connections (p < 0.05) regarding having work, education, family status (see Table 2). From them 65 (59.6%) had secondary education and 30 (27.5%) had higher education.

7.0% (41) respondents admitted they have attended group psychotherapy. Respondents who attended and who did not attend group PT did not statistically significantly connections (p > 0.05) regarding age, sex, family status and having children, but did connections regarding having work (p < 0.001) and education (p = 0.002). From them 48.8% (20) had secondary education and 34.1% (14) had higher education. Socio-demographic data of respondents can be seen in Table 3.

84 (54.5%) respondents who attended self-help groups (see Table 4) stayed in the treatment for up to one year, 14.3%--more than 5 years ([r.sub.s] = -0.959; p < 0.001). Duration of remission of SHG participants was following--one year or more--(52, 33.8%), including remission up to 3 years--18.8%, up to 5 years--3.9%, but more than 5 years--11.0%.

62.4% (69) attended individual psychotherapy up to 6 months, but 24 (22.0%) attended individual PT for more than one year. This treatment has provided remission one year or more in 27 (24.8%) respondents, 21.1% considers they have had no remission, but 27 (24.8%) admits remission for up to 6 months (Table 4).

34.2 % (14) respondents attended group PT for more than one year, including more than 3 years--22.0% (9), but 41.5% (17) respondents attended group psychotherapy for up to half a year (Table 4).

No remission was recorded in 19.5% respondents who attended group PT, but 15 (36.6%) respondents, who attended group, had remission for one year or more, including more than 5 years--17.1%.

Self-help groups have improved emotional functioning in 76.6% respondents (see Table 5). 64.9% of respondents record substantial improvement in health and relationship areas, but 61.7%--in moral area. 9.7% from SHG attendants recorded no improvement in their lives.

79 (72.5%) from respondents who attended individual psychotherapy (Table 5) admits improvement in emotional functioning, 75 (68.8%)--improvement in relationships, but 10.1% recorded no improvement.

28 respondents (68.3%) recorded improvements (Table 5) in emotional functioning as the most important changes during group PT. Respondents (63.4%) record substantial improvements also in moral areas. 2.4% (1) respondents record no improvements in their lives.

Discussion

This article could interest people who work with SUD patients--doctors, nurses, social workers. It gives insight into patients' attitudes towards psychosocial treatment, that is very important in maintaining stable and lasting remission. Up until now studies about epidemiology of SUD have been performed in Latvia. There have been no studies about remission and improvements using one of the treatment methods in Latvia.

Mean age of respondents is 39.6 years. Other researches show that people seek help more often when they are 35-54 years old (6,12-14) Two thirds of respondents are male. Male seek help more often than women (8,15). Women seek help more often for their mental problems, but they are not willing to associate those problems with SUD (15). Nevertheless research shows that women reach remission for longer time than male (16). Biggest part of respondents is with secondary and secondary-professional education. Better prognosis of the treatment is for those who have higher level of education and higher income (17). However there are also research data that says that better prognosis is for man who has lower education level and who are not married (11). Our research results show that biggest part of respondents (55.4%) has registered and non-registered relationships. Only 40% of respondents are employed, that can cause financial difficulties to attend psychotherapy and self-help groups, especially if they are located farther from home. As other researches indicate (5,6) people with legal and work problems seek help more often. That leads us to think that perhaps loosing work has lead people to look for help. However it is important to remember that people with SUD use pathological or immature defense mechanisms that can hinder ability to see the problem and understand its seriousness (18,19). Stable employment can enhance long term improvement (20).

8.2% respondents do not admit addiction even if they have diagnosis and receive SUD treatment. This brings us to assumptions that patients use primitive non-mature ego defense mechanisms (denial). That does not allow them to test and fully perceive reality and endangers the length and quality of their remission. Because of that SUD patients do not receive adequate care and professional help aside from detoxification provided by emergency care and are at risk of starting PAS use again. When comparing treatment time of self-help group and psychotherapy, it can be seen that most respondents attended SHG up to one year, but PT--up to 6 months. 22.1 % attended SHG more than 3 years. Individual PT for more than 3 years attended 11.0% respondents, but group PT--22.0%. That allows us to think that SUD patients prefer treatment in the group. However only 7% of all respondents attended group psychotherapy.

Good results are seen in cases where SHG have been used. Self-help groups are used more often than any other treatment method, Grant et al (21) indicate that three thirds of all those who attended any treatment, attended also Alcoholics Anonymous meetings. 26.2% respondents in our research attended Alcoholics Anonymous meetings. SHG provide good results because patients admit it helps to decrease feelings of shame about their addiction. They also become more able to communicate and talk about themselves with others who have similar problems. These groups help to reduce projections--"everybody judge me", "everybody think I am bad", "everybody reproach me", "nobody understands me". Similar data are found in other published research (22).

From all kinds of psychotherapy it is seen that group PT provides remission for more than one year. 36.6% recorded that, but individual PT attended only 24.8%. Perhaps that is due to low self esteem of SUD patients, that makes therapeutic alliance hard, but does not cause that much problems in group where are several people with similar problems. Besides patients admit that it is easier to take criticism from other group member than from psychotherapist. No improvement was recorded in 10 % of those who attended SHG and individual PT, but in only 2.4 % in those who attended group PT. All respondents who recorded improvement in important areas of life indicated emotional functioning as the most frequent improvement. That could be due to feeling of shame and guilt, as well as lessening of fear and increase of self-esteem.

The area that was influenced the least was respondents' problems associated with law. That leads us to think that perhaps respondents did not do any violation, therefore they could not record any improvement. However since part of the respondents were drug addicts, buying drugs and using them is a crime per se. Drug addicts often do not admit that.

Limitation of this study would be self designed questionnaire where answers are not designed in Likert scale, but rather is given one answer--yes or no. Another limitation is the fact that data are based only on patients' self-report. However all questioning was performed individually maintaining confidentiality. That could lessen the urge to hide the information about oneself and the treatment.

Conclusions

SUD patients need self-help group treatment and psychotherapy. Many of them continue further psychosocial treatment. Nevertheless, it is not sufficient, therefore patients' remission along with life and work quality are endangered. This research affirms data from scientific literature about efficiency of SHG and PT in the treatment of SUD patients. Important part of this research is also data about patients' reported improvement of their emotional life, that is an ethiological factor in the development of addiction and relapses. This is an important finding because majority of health care institutions of Latvia provide relieve of pshysical symptoms for SUD patients using detoxification without providing psychosocial improvement and treatment.

It would be important to introduce these research findings to professionals who work in addiction field and to stimulate cooperation among addiction treatment specialists and psychotherapists. It is neccessary to improve patients' awareness about their addiction and the benefits and improvements of SHG and PT. Nationally it would be neccessary to find possibility to include psychotherapy in the list of government paid services.

It would be neccessary to continue the resarch with wider population group including patients from all regions of Latvia. Experimental study would be suitable in order to test the changes in patients after attending SHG and PT using validated research instruments (depression scale, anxiety scale, emotional intelligence scale) and comparing the results with data from a control group. It would be neccessary to find out opinions of professionals who contact SUD patients on every day basis about efficiency of self-help group and psychotherapy treatment.

Conflict of interest: None to declare.

Abbreviations: PT--psychotherapy; SHG--self-help group; SUD--substance use disorders.

References

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Velga Sudraba [1] *, Inga Millere [2], Elmars Rancans [3]

[1] Postdoctoral Studies, Riga Stradins University; Riga Centre of Psychiatry and Addiction Disorders, Latvia

[2] Faculty of Nursing, Riga Stradins University, Latvia

[3] Department of Psychiatry and Addiction Disorders, Riga Stradins University, Latvia

* Corresponding Author: Velga Sudraba, MD, Riga Stradins University, Postdoctoral Studies; Riga Centre of Psychiatry and Addiction Disorders, Tvaika 2, Riga, LV-1005, Latvia

Tel/Fax: +37167080210 | Email: velgasudraba@gmail.com
Table 1: Socio-demographic data of respondents who have attended
or not attended self-help groups

                             Attended self-help   Did not attend self-
                               groups (N=154)      help groups (N=433)

                                  N       %             N       %

Mean age [+ or -] SD         40.4 [+ or -] 10.5    39.3 [+ or -] 11.6

Sex         male                 101    65.6           289     66.7
            female               53     34.4           144     33.3
Work        has                  78     50.6           160     37.0
            does not have        76     49.4           273     63.0
Education   basic                21     13.6           99      22.9
            secondary            45     29.2           137     31.6
            secondary-           51     33.1           145     33.5
            professional
            higher               37     24.0           52      12.0
Family      married              63     40.9           107     24.7
status      divorced             32     20.8           72      16.6
            widower               3      1.9           25       5.8
            single               24     15.6           106     24.5
            non-registered       32     20.8           123     28.4
            relationships
Children    has                  110    71.4           286     66.1
            does not have        44     28.6           147     33.9

                             [r.sub.s]       p

Mean age [+ or -] SD             --        0.284

Sex         male               -0.011      0.794
            female
Work        has                0.123       0.003
            does not have
Education   basic              0.144      <0.001
            secondary
            secondary-
            professional
            higher
Family      married            0.159      <0.001
status      divorced
            widower
            single
            non-registered
            relationships
Children    has                -0.096      0.020
            does not have

Table 2: Socio-demographic data of respondents who attended
or who did not attend individual psychotherapy

                            Attended individual     Did not attend
                                PT (N=109)          individual PT
                                                       (N=478)

                                N       %             N       %

Mean age [+ or -] SD        38.4 [+ or -] 9.8     39.9 [+ or -] 11.6

Sex         male               66     60.6           324    67.8
            female             43     39.4           154    32.2

Work        has                60     55.0           178    37.2
            does not have      49     45.0           300    62.8

Education   basic              14     12.8           106    22.2
            secondary          30     27.5           152    31.8
            secondary-         35     32.1           161    33.7
            professional
            higher             30     27.5            59    12.3

Family      married            43     39.4           127    26.6
status      divorced           13     11.9            91    19.0
            widower             5      4.6            23     4.8
            single             25     22.9           105    22.0
            non-registered     23     21.1           132    27.6
            relationships

Children    has                73     67.0           323    67.6
            does not have      36     33.0           155    32.4

                            [r.sub.s]     p

Mean age [+ or -] SD                    0,168

Sex         male             -0.060     0.150
            female

Work        has               0.141     0.001
            does not have

Education   basic            -0.147     <0.001
            secondary
            secondary-
            professional
            higher

Family      married           0.083     0.044
status      divorced
            widower
            single
            non-registered
            relationships

Children    has              -0.051     0.216
            does not have

Table 3: Socio-demographic data of respondents who attended
and who did not attend group psychotherapy

                             Attended group PT     Did not attend
                                    (N=41)         group PT (N=546)

                                  N       %            N       %

Mean age [+ or -] SD         38.6 [+ or -] 10.1    39.7 [+ or -] 11.4

Sex         male                 25    61.0           365    66.8
            female               16    39.0           181    33.2
Work        has                  31    75.6           207    37.9
            does not have        10    24.4           339    62.1
Education   basic                7     17.1           113    20.7
            secondary            5     12.2           177    32.4
            secondary-           15    36.6           181    33.2
            professional
            higher               14    34.1            75    13.7
Family      married              16    39.0           154    28.2
status      divorced             7     17.1            97    17.8
            widower              1      2.4            27     4.9
            single               9     22.0           121    22.2
            non-registered       8     19.5           147    26.9
            relationships
Children    has                  26    63.4           370    67.8
            does not have        15    36.6           176    32.2

                             [r.sub.s]     p

Mean age [+ or -] SD                     0.505

Sex         male              -0.032     0.443
            female
Work        has                0.196     <0.001
            does not have
Education   basic             -0.125     0.002
            secondary
            secondary-
            professional
            higher
Family      married            0.059     0.153
status      divorced
            widower
            single
            non-registered
            relationships
Children    has               -0.017     0.680
            does not have

Table 4: Duration of attending self-help groups, individual
and group psychotherapy, and the duration of remission
as reported by respondents

                                  Self-help group

                             N      %     p([r.sub.s])

The            /1 month      7     4.5       <0.001
duration of    /1 year      84    54.5      (-0.959)
attendance     /3 years     29    18.8
               /5 years     12     7.8
               >5 years     22    14.3

Remission      0            28    18.2       <0.001
               /1 month     22    14.3      (-0.869)
               /6 months    31    20.1
               /1 year      21    13.6
               /3 years     29    18.8
               /5 years      6     3.9
               >5 years     17    11.0

                                  Individual PT

                             N      %     p([r.sub.s])

The            /1 month      3     2.8       <0.001
duration of    /6 months    69    62.4      (-0.973)
attendance     /1 years     14    12.8
               /3 years     12    11.0
               >3 years     12    11.0

Remission      0            23    21.1       <0.001
               -1 month     21    19.3      (-0.864)
               -6 months    27    24.8
               -1 year      11    10.1
               -3 years     11    10.1
               -5 years      7     6.4
               >5 years      9     8.3

                                  Group PT

                             N      %     p([r.sub.s])

The            /1 month      3     7.3       <0.001
duration of    /6 months    17    41.5      (-0.959)
attendance     /1 years      7    17.1
               /3 years      5    12.2
               >3 years      9    22.0

Remission      0             8    19.5       <0.001
               -1 month      3     7.3      (-0.890)
               -6 months    10    24.4
               -1 year       5    12.2
               -3 years      3     7.3
               -5 years      5    12.2
               >5 years      7    17.1

Table 5: Improvements in important areas of life as reported
by respondents after attending self-help groups, individual
and group psychotherapy

                           Self-help group   Individual PT
                               (N=154)           (N=109)

                              N       %         N       %

Improved   health            100    64.9       58    53.2
           work               83    53.9       52    47.7
           relationships     100    64.9       75    68.8
           emotional         118    76.6       79    72.5
           functioning
           sexual             63    40.9       35    32.1
           functioning
           moral              95    61.7       64    58.7
           associated         43    27.9       23    21.1
           with law
           financial          83    53.9       41    37.6
Nothing improved              15     9.7       11    10.1

                            Group PT
                             (N=41)

                           N       %

Improved   health          22    53.7
           work            20    48.8
           relationships   23    56.1
           emotional       28    68.3
           functioning
           sexual          13    31.7
           functioning
           moral           26    63.4
           associated      9     22.0
           with law
           financial       14    34.1
Nothing improved           1      2.4
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Author:Sudraba, Velga; Millere, Inga; Rancans, Elmars
Publication:International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH)
Article Type:Report
Geographic Code:4EXLA
Date:Jul 1, 2012
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