|Year : 2022 | Volume
| Issue : 2 | Page : 299-305
Self-stigma, hope for future, and recovery: An exploratory study of men with early-onset substance use disorder
Tanya Anand1, Arun Kandasamy2, LN Suman1
1 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Submission||04-Mar-2021|
|Date of Acceptance||30-Jul-2021|
|Date of Web Publication||02-Aug-2022|
Ms. Tanya Anand
3rd Floor, Department of Clinical Psychology, M V Govindaswamy Building, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: The internalizing of experience of stigma among patients with substance use disorders (SUDs) can be debilitating to recovery. Individual factors such as self-regulation and abstinence self-efficacy can impact confidence in recovery and hope for future. Aims: The aim of the study was to explore relationship among self-stigma, self-regulation, self-efficacy, optimism, and confidence in recovery of patients with early-onset SUDs. Settings and Design: The study was carried out on a sample of 40 male patients with SUDs. The study had a single group exploratory design. Materials and Methods: The Self-Regulation Questionnaire, Drug Taking Confidence Questionnaire, Substance Abuse Self Stigma Scale, Revised Generalized Expectancy of Success (GES), and visual analog scale for craving were the measures used in the study. Statistical Analysis: Pearson and spearman's correlation coefficient were used to test associations between the variables. Multiple regression models were drawn to examine predictors of generalized expectancy of success and confidence in recovery. Results: Self-regulation, generalized expectancy of success (optimism), and confidence in recovery were found to be significantly correlated with self-stigma dimensions. The multiple regression model revealed self-regulation and self-devaluation as significant predictors of optimism (GES), whereas abstinence self-efficacy and values disengagement dimension of self-stigma predicted patients' confidence in recovery. Conclusions: Poor regulatory capacities along with internalized feelings of shame, guilt, and devaluation may lead to lower levels of optimism and poorer expectancies of success from future. Patient's self-efficacy in terms of abstaining from use behaviors and disengagement from pursuing life goals can lead to lower levels of confidence in recovery from SUDs and have implications for treatment seeking.
Keywords: Abstinence self-efficacy, early-onset, optimism, recovery, self-regulation, self-stigma, substance use disorders
|How to cite this article:|
Anand T, Kandasamy A, Suman L N. Self-stigma, hope for future, and recovery: An exploratory study of men with early-onset substance use disorder. Ind Psychiatry J 2022;31:299-305
There are various neurobiological, individual, social, and systemic factors that put young people at risk for early initiation of substance abuse and development of SUDs further impacting treatment outcomes. Some of the internal factors that influence success in recovery from substance abuse include self-concept, self-regulation, and self-efficacy which have been extensively studied. Self-regulation skills facilitate goal-directed behavior; they allow a person to delay gratification in the short-term to achieve desired outcomes., Self-regulation is used to facilitate as well as resist addictive behaviors, whereas self-efficacy is known to play a strong role in abstaining from numerous habitual behaviors, including smoking, using illicit substances, and excessive drinking. Abstinence self-efficacy is a predictor of change during treatment, helps in maintaining treatment gains, and is associated with resilience among high-risk youth. Self-regulation and self-efficacy in the context of substance use disorders (SUDs) are studied to be linked.
Self-stigma is another self-related construct that has gained recent interest in substance abuse literature. Stigma is commonly experienced and reported by individuals with mental health issues and SUDs. It refers to a social process in which a perceived attribute marks an individual to be socially sanctioned and devalued. Self-stigma refers to the internalizing of these beliefs by the members of the stigmatized group. Self-stigma in relation to substance abuse holds important implications with respect to treatment-seeking behaviors, as it is linked to self-esteem and self-efficacy, increased severity of psychiatric symptoms, and lowered quality of life.
Drug users are generally found to have a pessimistic view of the future., The construct of optimism and hope is important in the area of recovery as expectancies play a significant role in goal-directed health behaviors. Positive and negative expectancies of the future may affect behaviors such as goal setting, help seeking and have an impact on the affect of the individual. It has also been found that late adolescents or emerging adults' plans do not extend very far into the future which contributes to their inability to delay gratification and foresee long-term consequences of their actions. Thus, given these self-related constructs that have a bearing on health-related and substance use behaviors, an inquiry into relationship between these variables among patients with early-onset SUDs can help understand the role; these factors play in patients' attitudes and expectancies of the future and recovery.
The aim of the present study was to explore the relationships among self-regulation, abstinence self-efficacy, self-stigma, and generalized expectancy of success for future among men with early-onset SUDs. The present paper is based on the quantitative data obtained in a larger study titled “Perceptions about self, recovery, and future among men with early-onset SUDs.”
| Materials and Methods|| |
Selection and description of Participants
Forty males seeking treatment for SUDs were recruited for the study using purposive sampling method. The patients were recruited from the Centre of Addiction Medicine, National Institute of Mental Health and Neurosciences (NIMHANS). The criteria for inclusion in the study were male patients diagnosed with early-onset (onset of use before 22 years of age) SUD, who were fluent in English or Hindi languages. The sample was recruited from the outpatient department (OPD) and inpatient (IP) setting of the deaddiction clinic of a tertiary care hospital in India. Patients with organic conditions, serious psychotic illnesses, and serious medical illnesses such as HIV/AIDs were excluded from the study. The study had a single group exploratory design.
Measures used in the study
- Sociodemographic Datasheet: Sociodemographic datasheet was prepared by the researcher and used to obtain information about the patient's name, age, marital status, address, occupation, income, details of family members
- Clinical Datasheet: Clinical datasheet was prepared and used by the researcher to obtain information about the diagnosis of the patient, onset of substance use, duration of substance use, consequences of substance use, and treatment details. The datasheet also obtained information about family history of psychiatric disorders and family history of substance use, along with conditions under which use was initiated, aborted, or maintained by the patients
- Self-Regulation Questionnaire Short Form (SRQ-SF): The scale is a measure of general self-regulation skills and is highly correlated with self-regulation in context of substance use behaviors. The SRQ-SF is a 21-item questionnaire with responses measured on a 5-point Likert scale (ranging from 1 – strongly disagree to 5 – strongly agree)
- Drug Taking Confidence Questionnaire (DTCQ-8): The 8-item scale aims to assess anticipatory coping self-efficacy against different relapse crisis situations clients rate their confidence levels in being able to cope in high-risk situations. The items of the tool are rated from 0 (not at all confident) to 100 (very confident), higher score indicating higher confidence
- Substance Abuse Self-Stigma Scale (SASSS): The scale was developed to measure self-stigma experienced by people who misuse substances. It is based on a functional contextual model which categories self-stigma in four components: self-devaluation, fear of enacted stigma, stigma avoidance, and values disengagement (VD). It is a 40-item measure with 4 subscales based on these components. Its items are marked on a 1-5 Likert scale, 1 being “few people” to 5 being “everyone”
- The Revised Generalized Expectancy for Success Scale (GESS-R): The scale is a 25-item measure designed to assess dispositional optimism. The current version is modification of the original 30-item scale. Higher scores on the scale are reflective of higher level of optimism.
- The visual analog scale (VAS): VAS was used to measure the subjective level of confidence in recovery of the patients at the time of assessment. It was represented as a 100 mm line anchored by the words – “not at all” on the left and “extremely” on the right end. This was used in the current study to measure how confident the patients felt about their recovery from substance abuse, on a continuum ranging from “not at all confident” to “extremely confident.”
Ethical approval from the Institute's ethics committee was obtained before recruitment of the patients for the present study. Informed consent forms were developed by the researcher. The tools in the present study were translated into Hindi and Kannada and back-translated after seeking appropriate permissions from the authors. Patients appearing to the OPD and IP department were screened based on the inclusion and exclusion criteria of the study. Verbal and written informed consent was obtained from the patients who were willing to participate in the study and were assured anonymity and confidentiality of information provided by them. Assessments were carried out individually with patients coming to the IP and OP settings of the CAM, NIMHANS. Patients were made comfortable and briefed about the purpose of the research and their right to refuse participation. The assessments were conducted as paper-pencil tests that took approximately 40 min to complete. They were carried out in a private, well-ventilated room in OP as well as IP departments designated for testing.
IBM SPSS (Version 16.0. Chicago, SPSS Inc.) was used to carry out statistical tests for the data obtained from the study sample. Descriptive statistical analysis was carried out to analyze data obtained on the sociodemographic and clinical variables. Assumption of normality was tested for the total sample using the Q-Q plots and Shapiro–Wilk test. The observations on the SRQ-SF and SASSS for the sample were found to be normally distributed, and Pearson's correlation coefficient was used to test association between them. However, observations on the DTCQ-8, VAS for confidence in recovery and GESS-R did not fit the test of normality, and Spearman's rho was used to compute association between the variables. Predictors of GESS-R and confidence in recovery were derived using multiple regression models for each variable. The Durbin–Watson value was computed for both models (2.101 for GESS-R; 1.77 for VAS confidence in recovery) to test assumption of multicollinearity, and assumptions of homoscedasticity were met as assessed by visual inspection of a plot of studentized residuals versus unstandardized predicted values.
| Results|| |
The mean age of the patients was 29.3 years (standard deviation [SD] = 7.6). Majority of the patients in the sample were educated up to higher secondary level of education (n = 14, 35%), followed by graduates (n = 12, 30%), and almost equal percentage were educated up till primary and secondary level (n = 7, 17.5% each). Twenty-six men in the sample were married (65%), 13 were single (32.5%), and 1 was separated from spouse (2.5%). Three fourth of the patients belonged to middle socioeconomic status (n = 31, 77.5%), and rest were from lower socioeconomic status (n = 9, 22.5%). Of the total sample, 35 patients were living in a nuclear family setup (87.5%), three in joint family (7.5%), and two were living alone (5%). Employment status was comparable with almost equal percentages of employed (n = 22, 55%) and unemployed (n = 18, 45%) patients present in the sample. The clinical and substance use profile of patients is shown in [Table 1] and [Table 2].
|Table 2: Frequency and percentage distribution of psychiatric comorbid conditions|
Click here to view
Correlates of self-stigma
The scores on SRQ-SF for self-regulation were found to be significantly correlated with the SASS subscales of SD (r = −0.496, P < .05) and SA (r = −0.478; P < 0.01) at 99% confidence interval and self-stigma total score (r = −0.323, P < 0.05) at 95% confidence interval. The two constructs were found to have an inverse relationship and were moderately well correlated. There was no significant correlation between SRQ-SF scores and FES and VD subscales of SASSS. The correlation coefficient is shown in [Table 3].
|Table 3: Pearson's coefficient for correlation between Self-Regulation Questionnaire and Substance Abuse Self Stigma Scale|
Click here to view
Thus, it was found that higher self-devaluation and stigma avoidance, among patients with DUD, were associated with lower self-regulation among the patients in the study sample.
The Spearman's rho (rs) for generalized expectancy of success and confidence in recovery with self-stigma total and its subscales was calculated and is shown in [Table 4]. GESS-R scores displayed a weak inverse relationship with the SASSS total score but were not significantly correlated (rs = −0.271, P > .05). However, GESS-R scores were significantly correlated with the self-devaluation (SD) subscale scores (rs = −0.421, P < 0.01), FES subscale scores (r = −0.339, P < 0.05), and VD subscale scores (rs = −0.378, P < 0.05). The results of the correlation analysis revealed that higher self-devaluation, fear of enacted stigma, and VD were associated with lower generalized expectancy of success and optimism about the future among the patients.
|Table 4: Spearman's rho for correlation between Revised Generalized Expectancy for Success Scale, Visual Analog Scale, and Substance Abuse Self-Stigma Scale|
Click here to view
The correlation between patient's confidence in recovery measured using the VAS with self-stigma measure and its subscales was carried out. Result indicated that VAS scores had inverse relationship with SASSS total score and its subscale scores. However, VAS did not have significant correlation (P > 0.05) with the SASS total, SA, SD, FES. However, VAS for confidence in recovery was found to have a significant negative correlation with the VD subscale scores (rs = −0.328, P < 0.05) at 95% confidence interval. Thus, it was found that higher VD among patients was associated with poorer confidence in recovery.
Optimism and confidence in recovery
There was a moderate level of positive correlation found between scores of patients on the two measures (rs = 0.323; P < 0.05). The correlation was found to be statistically significant at 95% confidence level indicating that higher generalized expectancies of success in future were linked to higher confidence in recovery among patients.
Predictors of generalized expectancy of success
A multiple linear regression was calculated to predict generalized expectancy of success in the future based on self-regulation and self-devaluation. A significant regression equation was found (F (2, 36) =6.82, P < 0.000), with an R2 of 0.275 and adjusted R2 of 0.235. Patients' generalized expectancy of success for future increased by 112 score for each score of self-regulation and decreased by 1.02 scores for each self-devaluation score. Both self-regulation and self-devaluation were significant predictors of generalized expectancy of success in future. The regression model is shown in [Table 5].
|Table 5: Multiple regression model results for Generalized Expectancy of Success (Revised Generalized Expectancy for Success Scale)|
Click here to view
Predictors of confidence in recovery
A multiple regression model was run to predict patients' confidence in recovery based on VD subscale of SASSS and abstinence self-efficacy measured on DTCQ-8. The regression equation was found to be significant (F (2, 36) = 7.877, P < 0.000), with an R2 value of 0.304, and adjusted R2 value of 0.266. The regression model is shown in [Table 6].
|Table 6: Multiple regression model results for confidence in recovery (Visual Analog Scale)|
Click here to view
The results of the multiple regression model indicate that self-efficacy, on DTCQ-8 scale, and VD subscale of SASSS significantly predict patients' confidence in recovery measured by VAS.
| Discussion|| |
In the present study, self-regulation among the patients with early-onset SUDs was linked to lower self-stigma, lesser degree of self-devaluation. This could be due to the effects of positive regulatory experiences with respect to substance use behaviors where better self-regulatory skills may facilitate in challenge negative stereotypes and judgments held by others against their substance use. The finding also indicates that not all substance users experience high levels of self-stigma and internal factors may play an influential role in protecting against the processes of self-stigma.
Self-devaluation and generalized expectancy of success were found to have negative relationship, indicating that holding negative beliefs about oneself and one's substance abuse was linked to less positive expectancies and views about the future. A study evaluating the predictors of age of initiation of substance use among marijuana users found that high pessimism was related to marijuana use among adolescents. A progressive model of self-stigma was studied in terms of how progression of self-stigma among severely mentally ill patients influences their self-esteem and hope. It was found that being aware about negative stereotypes itself did not have a significant influence, however, patients who were found to apply these stereotypes to themselves demonstrated greater hopelessness and lower levels of self-esteem.
The association between optimism and pessimism with respect to alcohol and drug use has been found to report mixed evidence among younger age groups. In another study that was conducted with adolescents and their alcohol use, it was found that optimism and pessimism were related to alcohol use behaviors. They found that optimism was negatively and pessimism was positively correlated at age 14 years for boys' binge drinking patterns. This adds to the literature that optimism and pessimism with respect to views about their future are associated with harmful substance use behaviors at early ages. In the present study, drug users also reported lower levels of positive expectancies from future, however, age of the patient was not found to be significantly linked with it in the current study.
The present study found a negative inverse relation between fear of enacted stigma and generalized expectancy of success indicating higher fear of enacted stigma being moderately associated with poorer expectancies of success in future and higher optimism among patients. The studies conducted based on the Functional Contextual Model of Stigma report that stigma avoidance is negatively correlated with optimism. It has been found that individuals tend to cope with fear of enacted stigma by withdrawing from or discounting the importance of life domains associated with stereotypes, for example, interpersonal relationships, work-related goals such as seeking employment or continuing further studies. Thus, the relation of FES with GESS-R can be explained by avoidance behaviors with respect to attaining life goals and hence lower levels of success in life domains that are integral in evaluating positive or negative expectancies from future.
Livingston and Boyd explain VD to be a method of coping from fear of enacted stigma where patients may abstain from treatment seeking or searching for employment to avoid experiencing self-devaluation and negative feelings associated with it. Research studying consequences of self-stigma among those with mental illness indicate that experience of self-stigma leads to decrements in self-concept, hope, self-esteem, social interactions, treatment engagement, academic and vocational achievement, life opportunities, and quality of life.
Optimism in future was positively associated with patients' subjective levels of confidence in recovery. A review done with co-occurring mental conditions and substance use problems explored the importance of hope among those using health-care services as well as nurses providing care. The broad findings were that hope was most important to people with mental disorders and substance abuse and highlighted the significance of service providers facilitating hope among the users by using a person cantered approach in intervention.
Some studies have linked higher hope to lower probability of entering substance abuse treatment as a result of overestimation of resources to deal with substance abuse problems which may in turn also be arising out of treatment seeking-related stigma., Studies in this area have shown contradictory findings suggesting higher hope being associated with treatment completion. In this study, self-regulation and self-stigma are found to be predictors of general expectancy of success for the future while abstinence self-efficacy and self-stigma have been found as predictors of confidence in recovery. Both these findings indicate that lower levels of self-stigma are related to more positive expectancies about the future as well as higher subjective levels of confidence in substance abuse recovery. However, further research in the area is needed.
Strengths and limitations
The study is among a few studies that have explored self-stigma in relation to self-regulation, self-efficacy, and optimism with a clinical sample of patients with early-onset SUDs. Very few studies have studied the role of optimism in treatment and recovery among patients with SUDs. However, the study presents itself with certain limitations due to its small sample size and nonrandomized sampling method. The sample of the study was heterogeneous in terms of substances abused by patients. Further, the sample was restricted to patients who spoke English or Hindi. Hence, the findings need to be interpreted with caution and warrant replication on a larger sample size to improve generalizability of findings.
Interpretation and implications
The study's findings have implications for future research and treatment. Self-stigma and multiple factors related to it such as self-regulation, age of onset, and type of SUD impact patients' substance use-related self-efficacy, hope for future, and recovery. Self-devaluation, fear of enacted stigma, and VD may play a role in patient's treatment seeking, attitudes toward treatment and adherence, and outcome expectancies. Self-stigma is very much prevalent among treatment seekers with mental illnesses. The “why try?” effect that commonly impacts treatment compliance and retention and following life goals in substance users has been linked with self-stigma. Treatment for substance abuse may benefit from addressing self-stigma to reduce the chances of further relapse, treatment avoidance, and dropout. A few studies carried out in the area of optimism and hope also indicate that there may be a complex association between optimism, and its differing presentation with treatment processes and outcomes, especially among young individuals. There is merit in exploring its role further and incorporating these themes in treatment to improve planning, goal seeking, and confidence of the patients in recovery.
Financial support and sponsorship
This study was financially supported by UGC-JRF.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baumeister RF, Gailliot M, DeWall CN, Oaten M. Self-regulation and personality: How interventions increase regulatory success, and how depletion moderates the effects of traits on behavior. J Pers 2006;74:1773-801.
Rasmussen HN, Wrosch C, Scheier MF, Carver CS. Self-regulation processes and health: The importance of optimism and goal adjustment. J Pers 2006;74:1721-47.
Baumeister RF, Vonasch AJ. Uses of self-regulation to facilitate and restrain addictive behavior. Addict Behav 2015;44:3-8.
Lee NK, Oei TP. The importance of alcohol expectancies and drinking refusal self-efficacy in the quantity and frequency of alcohol consumption. J Subst Abuse 1993;5:379-90.
Vielva I, Iraurgi I. Cognitive and behavioural factors as predictors of abstinence following treatment for alcohol dependence. Addiction 2001;96:297-303.
Yang C, Zhou Y, Cao Q, Xia M, An J. The relationship between self-control and self-efficacy among patients with substance use disorders: Resilience and self-esteem as mediators. Front Psychiatry 2019;10:388.
Luoma JB, Nobles RH, Drake CE, Hayes SC, O'Hair A, Fletcher L, et al.
Self-stigma in substance abuse: Development of a new measure. J Psychopathol Behav Assess 2013;35:223-34.
Crapanzano KA, Hammarlund R, Ahmad B, Hunsinger N, Kullar R. The association between perceived stigma and substance use disorder treatment outcomes: A review. Subst Abuse Rehabil 2019;10:1-12.
Trommsdorff G. Future time perspective and control orientation: Social conditions and consequences. In: Zaleski Z, editor. Psychology of Future Orientation. Lublin, Poland: Towarzystwo Naukowe KUL; 1994. p. 39-62.
Sulinto L. Adolescent's Health Behaviour and Future Orientation [Master's Thesis]. Jyväskylä, Finland: University of Jyväskylä; 2005.
Nurmi JE. How do adolescents see their future? A review of the development of future orientation and planning. Dev Rev 1991;11:1-59.
Neal DJ, Carey KB. A follow-up psychometric analysis of the self-regulation questionnaire. Psychol Addict Behav 2005;19:414-22.
Sklar SM, Turner NE. A brief measure for the assessment of coping self-efficacy among alcohol and other drug users. Addiction 1999;94:723-9.
Hale WD, Fiedler LR, Cochran CD. The revised Generalized Expectancy for Success Scale: A validity and reliability study. J Clin Psychol 1992;48:517-21.
Wray TB, Dvorak RD, Hsia JF, Arens AM, Schweinle WE. Optimism and pessimism as predictors of alcohol use trajectories in adolescence. J Child Adolesc Subst Abuse 2012;22:58-68.
Lee JW, Brown ES, Perantie DC, Bobadilla L. A comparison of single-item visual analog scales with a multiitem likert-type scale for assessment of cocaine craving in persons with bipolar disorder. Addict Disord Their Treat 2002;1:140-2.
Brown RL. Perceived stigma among people with chronic health conditions: The influence of age, stressor exposure, and psychosocial resources. Res Aging 2015;37:335-60.
Smith GM, Fogg CP. Psychological predictors of early use, late use, and nonuse of marijuana among teenage students. In: Kandel DB, editor. Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Washington, DC: Hemisphere-Wiley; 1978. p. 101-13.
Corrigan PW, Rafacz J, Rüsch N. Examining a progressive model of self-stigma and its impact on people with serious mental illness. Psychiatry Res 2011;189:339-43.
Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Soc Sci Med 2010;71:2150-61.
Jones N, Corrigan PW. Understanding stigma. In: Corrigan PW, editor. The Stigma of Disease and Disability: Understanding Causes and Overcoming Injustices. Washington, DC: American Psychological Association; 2014. p. 9-34.
Sælør KT, Ness O, Borg M, Biong S. You never know what's around the next corner: Exploring practitioners' hope inspiring practices. Adv Dual Diagn 2015;8:141-52.
Ellingstad TP, Sobell LC, Sobell MB, Eickleberry L, Golden CJ. Self-change: A pathway to cannabis abuse resolution. Addict Behav 2006;31:519-30.
Setia S, Krägeloh C, Bandyopadhyay G, Subramaniam K. Inculcating dispositional optimism for prevention of mental and substance use disorders throughout and after the coronavirus disease-19 pandemic. Alternat Complement Ther 2021;27:68-78.
Sobell LC, Klingemann HK, Toneatto T, Sobell MB, Agrawal S, Leo GI. Alcohol and drug abusers' perceived reasons for self-change in Canada and Switzerland: Computer-assisted content analysis. Subst Use Misuse 2001;36:1467-500.
Corrigan PW, Larson JE, Rüsch N. Self-stigma and the “why try” effect: Impact on life goals and evidence-based practices. World Psychiatry 2009;8:75-81.
Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav 1997;38:177-90.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]