Do social support and self- efficacy play a significant role in substance use relapse?

Introduction

Substance use such as alcohol, cannabis, opium, hallucinogens, hashish, and other is a psychological disorder that is characterized by cognitive, behavioural, and physiological symptoms that provoke substance users to continue using the substances despite their dangerous related problems (DSM-5). Substance use has long been recognized as a chronic relapsing condition.^1,2 This may due to the obvious behavioural effects of brain circuits’ changes that appear in those with repeated relapses and intense substance cravings when individuals are exposed to substance-related stimuli (DSM-5).

Relapse is a major and common challenge in substance use and it can be defined as the inability to remain abstinent, especially for long periods of time.³ It can be recognized through the recurrence of substance use symptoms after a period of reduced substance use.⁴

Relapse does not limited to failure of treatment but rather it may occur after successful detoxication and rehabilitation and it is estimated that about forty to sixty percent of persons relapsed after completing detoxication and rehabilitation treatments.
Other studies indicated that the relapse rates following treatments are high and reach 40–75 % in over three weeks to six months period following treatment.⁵ Also, Andersson, et al.,⁴ found that relapse occurred in 37% of the sample at three months following up. It’s worth noting that relapse occur at higher rate in middle- income countries than in high income countries.⁵

In Jordan, substance use is increasing significantly; the most recent statistics of the Anti-Narcotic Department of the General Security Directorate indicated that in 2021 the number of registered substance users has almost tripled compared to 2012, from 5,008 to 13,847 people persons. In contrast, the number of substance users who applied for help and received treatment was 431 in 2012 and this number increased to an estimated 500 in 2021. Thus, the number of treatment recipients is still very small, as currently, only 3% of the registered substance users receive treatment. There are not sufficient professional treatment centres to treat the number of substance users. In addition, most centres are located in the capital Amman which means those who live far from the capital cannot access treatment services which play an important role in relapse. For those who receive it, treatment is successful. In 2021 only 107 of the treated cases, about 20%, relapsed.⁶ Moreover, there are no professional preventive programs for people before starting substance use.

There are many risk factors that play important roles in the occurrence of relapse; one of the most prominent factors is social support; the positive interaction that aims to help the receiver of support to solve the problem he/she encounters.⁷ Also, it is defined as “the perception or experience that one is loved and cared for by others, esteemed and valued, and part of the social network of mutual assistance and obligations”.^8(p192)

Social support depends on personal, cultural, and environmental factors. For example; personal and close relationships provide supportive and meaningful ties more than relationships that are characterized by restricted role definitions. This may be due to the foundation of mutuality and security between the parties. Those who have a strong psychological sense of social support can tolerate better and have courage in the face of challenges such as substance use cravings.⁹ Following this line, one study found that perceived social support from family predicted 12% of substance use relapse.¹⁰

Jordanian society has special consideration in this area; it is a collective society in that family, general norms and religion play important roles in regulating and judging individual behaviour. At the same time, this society provides little support for substance users, especially females. This may be due to the social context that insists on religion as the basic foundation for acceptable and unacceptable behaviours. Both Christian and Islamic religions consider substance use as sin and wrongdoing. Moreover, Jordanian society is characterized as conservative (not open) so they focus more on religion, old customs and tradition to judge behaviour. This leads to this society generally rejecting substance use regardless of the amount used.

The literature review revealed that social support has been shown to be effective mainly for reducing substance use relapse.¹¹ However, this is affected by the person’s relationships and differs depending on whether the relationships provide positive encouragement for abstinence (specific support for abstinence) or negative encouragement for substance use, such as peers who are addicted to alcohol or other substances encouraging the individual to resume their previous behaviours.¹² In addition, Kabisa, et al.⁵ found that substance users who live only with their mothers had a greater risk of relapse compared to those living with two parents, and that substance users were more likely to relapse if they lived with their peers or in a family with conflicts.

The literature review revealed that there are four types of social support that are directed to influence certain thoughts and health behaviours:

1. Informational support; such as providing information related to the health problem, advice and suggestion.

2. Instrumental support which means providing tangible help and services to meet the person’s needs directly.

3. Emotional support that is manifested in themes of love, empathy, and attention themes.

4. Appraisal support that indicates affirmation and constructive feedback to be used as self-evaluation.^7,8

Variant studies have been conducted regarding the role of social support in substance use in the western world but not in the Jordanian context. For example; Dobkin, et al.¹³ conducted a study to reveal the different outcomes between substance users with high and low social support at intake and 6 months later. Results indicated that, at intake, both high and low social support groups reduced their level of substance use over time. But patients with low social support at the intake phase reported higher use of alcohol and substances 6 months later. Furthermore; the study showed that social support was a modest predictor of reductions in the severity of alcohol abuse at follow-up stage. Also, Atadokht, et al.¹⁴ conducted a study to investigate the role of the participants’ perceived self-support in the relapse process. The result showed there is a negative relationship between perceived self-support and the frequency of a relapse. Moreover, Ellis, et al.¹⁵ found that female substance users whose families provided positive actions such as helping and being supportive were less likely to relapse in contrast to those who reported significant levels of conflict within their families.

It is documented that social support may increase commitment to treatment because it enhances feelings of self-efficacy.⁸ In this line, Stevens, et al.¹¹ highlighted that there is a significant positive relationship between social support and abstinence self-efficacy.

It is striking to note that, the link between self-efficacy and relapse after being abstinent is cognitively rooted.¹⁶ This is well documented in social cognitive theory (SCT) which explains the acquisition and maintenance of human behaviour,^17,18 and this has highlighted the concept of self-efficacy.¹⁹

Bandura proposed that human behaviour is a result of the reciprocal, bidirectional interrelationship of a person’s environment and cognitive processes.²⁰ And he defined self-efficacy beliefs as “cognitive-motivational forces that determine the individuals’ appropriate coping level when his/her skills and abilities are under pressure”.^10(p1)

Self-efficacy refers to a person’s belief that they can regulate their behaviour successfully or unsuccessfully¹⁷ and this affects every stage in the substance use recovery process; starting to change, proceeding, healing, and long-term maintenance of abstinence.^2,19 In fact, people who have low self-efficacy are more likely to continue their substance use.¹⁰ In contrast, those who maintain abstinence have stronger self-efficacy than those who relapse.^19,21

Self-efficacy determines individuals’ goals and how much effort they will invest to achieve them. It also increases their perseverance in the face of difficulties.^19,21 Unless people believe that they can produce desired effects by their actions, they have little stimulus to act or to persevere in the face of difficulties.¹⁹

Many studies have examined the role of self-efficacy in relapse and in this section, I am referencing those which are most relevant to my study. Nikmanesh, et al.¹⁰ studied the role of social support and self-efficacy on substance users. They found that there were significant differences between substance users who relapsed and those with non-relapse in relation to both self-efficacy and social support. Participants without relapse had higher self-efficacy compared to those with relapse. Torrecillas, et al.¹⁸ study results revealed that self-efficacy is inversely related to the quantity of substance use. In another study, it was found that there is a strong relationship between avoiding risky situations, low self-efficacy and dependence on alcohol. Warren, et al.²² suggested in their study that greater self-efficacy predicted less substance use. Liua, et al.²³ found that for those with low self-efficacy, giving more emotional support predicted less risky drinking at month 12, whereas giving more informational support predicted more risky drinking at month 12. Furthermore, Hashemi, Fotuhie-Bonab, et al.²⁴ concluded that there were significant differences between the relapse and non-relapse groups on irrational beliefs, self-efficacy, and social support.

The current study investigates the role of social support and self-efficacy alike in light of some variables amongst substance users (with and without relapse) in Jordan. This topic is rarely studied in the Jordanian context in contrast to higher income Western countries; and aims to identify the importance of these variables so they may be considered in substance use therapy in Jordan. The findings may also relevant to other Arab countries.

There are also other social factors that correlate with substance use relapse including environmental and family factors.¹⁶ According to the review by Brorson, et al.²⁵ the most consistent risk factor is younger age and none of the other demographic factors appeared to be such consistent risk factors. Another study also found that younger age is associated with an elevated relapse risk.⁴ Other reviews have also found that other contributing factors for relapse are: young ages at initiation, gender, unemployment, being single, peer group influence, family history of substance use, conflicts, poor family support, and environmental factors like availability and accessibility of drugs are contributing factors of relapse.⁵

Many of the previous studies referenced here examined the relationship between social support and self-efficacy among substance users²² but they did not take some other variables into account such as: gender, the duration of substance use, and substance use status (with or without relapse). All the previous studies used samples from Western countries. This study includes these variables (gender, duration of substance use and substance use status) and used participants from Jordan, a developing country such as Jordan. Therefore, this study builds on previous work by widening the scope of the research and comparing the results between Western Countries and Jordan.

Material and methods

Data and sampling

Participants were all substance users who were resident in in five different settings; an addiction treatment centre run by the Public Security Directorate, a prison-based treatment centre administered by the prison administration, two male prisons and one female prison where treatment was not available. The treatment centre in one of the prisons allowed participants to use substances if they wished, but there was no access to substances in the other settings. The research and fieldwork took place in September/2022.

The sample comprised 197 Jordanian substance users (a convenience sample). Most of the 197 questionnaires were completed online by inmates who were convicted of substance use. Other questionnaires were collected from the treatment centres for substance use. Respondents from the treatment centres were in the initial phase of their treatment (one week at least) and the rest of the male sample was selected randomly from two prisons where they` did not receive any kind of treatment. The entire female sample was selected randomly from female prisons where they also do not receive any kind of treatment. The administration approved the study design and all participants provided informed consent to participate voluntarily and completed the scale anonymously.

As can be seen in Table 1, most respondents were male (84.3%). Their ages ranged from (18-70) years. Regarding marital status, most were single (57.4%) followed by married (31.5%), 10.7% were divorced, and .5% were widowed. 73.1% of the respondents were in prison. The employment status of the remaining respondents was as follows: most (13.7%) indicated that they were self-employed, (7.6%) were unemployed, (4.1%) worked full-time and (1%) worked part-time (See Table 1).

Measure

Multidimensional Scale of Perceived Social Support

Social support was measured using a Multidimensional Scale of Perceived Social Support. This tool is widely used and has an adequate psychometric characteristic. In its original version, it consists of 12 items divided into three dimensions: significant other (1,2,5,10), family (3,4,8, 11), and friends (6,7,9,12) on seven-point Likert scale with scores ranging from very strongly disagree (1) to very strongly agree (7) with Cronbach’s alpha coefficient (\(\propto\)=91).²⁶

For the purpose of this study; the Multidimensional Scale of Perceived Social Support was translated into Arabic and back-translated into its original language to ensure its compatibility. Then, the scale was adjusted to suit the Jordanian environment. Psychometric characteristics of the Jordanian version were investigated as follows: Item discrimination validity for the Jordanian version of this scale was calculated; items’ values ranged between (.512-.715). This indicates adequate items discrimination validity. In addition, Cronbach’s alpha coefficient was (\(\propto\)=68). These values are statistically significant indicating that the Multidimensional Scale of Perceived Social Support has adequate psychometric characteristics. This version consisted of 12 items assessing social support. Items were rated using a 5-point Likert scale ranging from ‘always’ “5” to ‘never’ to “1”.

Sherer’s General Self- Efficacy Scale

Self-efficacy was measured using Sherer’s General Self-Efficacy Scale. It is widely used and has an adequate psychometric characteristic. In its original version, it consists of 17 items on a five-point Likert scale with scores ranging from strongly disagree (1) to strongly agree (5) with Cronbach’s alpha coefficient (\(\propto\)=86)²¹

For the purpose of this study; Sherer’s General Self-Efficacy Scale was translated into Arabic and back-translated into its original language to ensure its compatibility. Then, the scale was adjusted to suit the Jordanian environment. Psychometric characteristics of the Jordanian version were investigated as follows: items discrimination validity for the Jordanian version of this scale was calculated; three items (when I set important goals for myself, I rarely achieve them, if something looks too complicated, I will not even bother to try it, and I don’t seem capable of dealing with most problems that come up in life) were deleted due to their low values then after deleting them, the items’ values ranged between (.271-.701). This indicates adequate item discrimination validity. In addition, Cronbach’s alpha coefficient was (\(\propto\)=68). These values are statistically significant indicating that Sherer’s General Self-Efficacy Scale has adequate psychometric characteristics. The amended version consisted of 14 items assessing self-efficacy. Items were rated using a 5-point Likert scale ranging from ‘always’ “5” to ‘never’ to “1”.

Aims and questions

The current study aims to examine the role of social support and self-efficacy in substance use relapse in Jordan to assess the position in relation to other comparable studies that have been conducted in western Europe and the USA). The study attempts to answer the following questions:

1. What is the level of social support among substance users?

2. What is the level of self-efficacy among substance users?

3. Does the level of social support differ according to gender, the status of substance use (with relapse and without relapse) and the duration of substance use?

4. Does the level of self-efficacy differ according to gender, the status of substance use (with relapse and without relapse) and the duration of substance use?

5. Do social support, self-efficacy, and duration of substance use predict relapse in substance users?

Results

To investigate the first question “What is the level of social support among substance users?” means and standard deviation were used. The results show a moderate level of social support among the study sample (M= 3.166, SD= .876).

The same assessment was used to examine the second question “What is the level of self-efficacy among substance users?” Means and standard deviation were used. The results show a moderate level of self-efficacy among the study sample (M= 3.4790, SD= .61549).

And, to investigate the third question "Does the level of social support differ according to gender, the status of substance use (with relapse and without relapse) and the duration of substance use? The means and standard deviation of study variables were calculated. The results show that there are apparent differences between the means due to the different levels of the variables (see Table 2). To verify the significance of the differences, 3 Ways ANOVA was used (see Table 3).

Table 3 shows that there are gender differences in social support in favor of males and differences due to the duration of substance use but there are no differences in substance use status. An LSD test was used to find out favor of whom the duration of substance differences (see Table 4).

Table 4 shows that there are differences in substance use duration between less than one year and one year- less than two years level in favor of one year- less than two years. Also, there are differences between less than one year and ten years and over in favor of one year- less than two years.

For question four “Does the level of self-efficacy differ according to gender, the status of substance use (with relapse and without relapse) and the duration of substance use?” The means and standard deviation of study variables were calculated. The results show that there are apparent differences between the means due to the substance use status in favor of without relapse but there are no differences regarding gender and substance use duration (see Table 5). And, to verify the significance of the differences, 3 Ways ANOVA was used (see Table 6)

Finally logic regression was used to investigate the fifth question "Do social support, self-efficacy, and the duration of substance use predict relapse in substance users?. The results indicated that self-efficacy and duration of substance use have the ability to predict relapse. There is less chance of relapse if the substance user has self-efficacy however the likelihood of relapse increases according to the length of time that the individual has been a substance user. (see Table7).

Discussion

The purpose of the current study was to investigate if social support and self-efficacy play a significant role in substance use relapse. The results revealed that there were moderate levels of social support and self-efficacy among participants. This result may be explained by considering the study sample; as is shown in Tabel1 which shows that most of them are with relapse (67.5%) and maybe this indicates they lack suitable social support and self-efficacy affected their ability to quit and maintain stopping the substance use. Furthermore, most of the participants are gathered from prisons and just a few from the treatment centres.

Also, another study found substance users were feeling lonely already and substance use may exacerbate this negative feeling.²³

Furthermore, the results indicated gender differences in social support levels in favour of males. This result is in line with Soman, et al.,²⁷ who found in their study that males received higher social support than females.

This may be explained by the nature of life in Jordan where the culture adds pressures and constraints on females’ behaviours particularly substance use in terms of taboo, stigma and punishment. This manifests in different ways; for example, the family and community tend to neglect female substance users, and most females hide their substance use and do not request help from treatment centres. In other words, most female’s substance users in Jordan do not receive social support at least from their family indeed they may be punished for their transgressive behaviour. This contrasts with the situation for males who tend to receive social support from both their family and wider communities who often accept them regardless of their wrongdoings and try to help them by encouraging them to correct their behaviour. Most inpatients in treatment centres are males without any females receiving treatment. This shown in the study sample where all females were prisoners, and none were in treatment centres

More males use substances than females and this may make their behaviour more socially acceptable, thereby enabling their family and communities to accepting their situation and encourage them to seek and receive treatment whilst also not neglecting nor punishing them.²⁸

Moreover, as indicated in the literature review, there is societal denial of substance use by women and this combined with the higher rate of substance use by men has led to much more research being conducted on males rather than females^29,30 This means there is missing information concerning women’s substance use.

Generally speaking, gender difference issues are very complicated due to many factors that play vital roles such as biological, historical and environmental factors.³⁰ Moreover, most research that was conducted in American and European contexts found that women substance users receive social support from their friends meanwhile men substance users receive more social support from their families.²⁹ To conclude we are in need of more research into gender differences in social support with substance users, especially in the Jordanian context.

Regarding the duration of substance use this study found that those who are in the one year- less than two years group have more social support compared to those who have used substances for less than one year or ten years and over. This result indicated that during the first stage of substance use the social support is high but when the period of substance use is very long then the user’s social support resources lose hope that the user’s behaviour will change or become accustomed to the reality that the subject is continuing their substance use. Within the Jordanian context, this may be true because those who are in the first stage are more likely to receive empathy and encouragement from may be their families to stop substance use. When substance use is long term this may cause many negative effects on the person’s life whilst also impacting negatively on the family and friends who are offering support making them less likely to offer the same level of social support as earlier.

Furthermore, the results revealed no differences in social support levels regarding substance use status. This result is not in line with Ellis, et al.,¹⁵ and the study of Nikmanesh, et al.,¹⁰ who found that social support does play a role in relapse. The finding in this study may be explained by the finding that both those with and without relapse who receive support. This result is somehow logical within the Jordanian context because the society considers male substance users to be victims of bad conditions or bad company so families and communities try not to blame the individual and support males in different ways such as encouraging their admission to treatment centres. This contrasts with the attitudes towards women who are personally held personally responsible and blamed.

Moreover, the results revealed differences in self-efficacy levels in substance use status in favour of substance users without relapse. There were no differences in self-efficacy levels due to gender or the duration of substance use. This result is in line with Nikmanesh, et al.¹⁰ who found that there are significant differences between substance users with relapse and those with non-relapse in self-efficacy. Also, substance users without relapse had higher self-efficacy compared to those with relapse.

To explain more, those people without relapse may still be in their first stage of substance use and never tried to quit it. This area needs more investigation and further research.

Bandura argued that individuals who believe in their capacity and have the core skills to do tasks or change their behaviour, can more easily mobilize their effort to resist the high risky situations for substance use.³¹ To sum up, self-efficacy is important for initiating and continuing to abstain from substance use^32,33 and this relates to the persons’ beliefs in their capacity to regulate their behaviours.³³

Despite these findings, little research has been conducted on self-efficacy among substance users so this area needs more attentions.^31,33

The current study found no gender differences regarding self-efficacy level. It should be noted here that there is no trend in gender differences; Tsekane & Amone-P’Olak³³ revealed that females have more self-efficacy than men in substance use. Other studies revealed no differences in self-efficacy according to gender and the duration of substance use. Also Kadden & litt³¹ found in their review a link between the duration of substance use and self-efficacy.

The results indicated that self-efficacy and duration of substance use have a predictable effect on substance use relapse. This result is in line with previous studies^10,23,24; Warren, et al.,²² and the study of Torrecillas, et al.,¹⁸ that also found that the duration of substance use play role in substance use relapse. However, this result is not in line with Ellis, et al.,¹⁵ and the study of Nikmanesh, et al.,¹⁰ who found that social support does play role in relapse.

Low self-regulatory efficacy and outcome expectations of the pleasurable effects of an addictive substance are strong predictors of urges to use the substance¹⁹

Generally speaking, the relationship between substance abuse and social support may vary depending on the sources of social support.¹² Relapse is a combination of demographic and physiological characteristics, situational and socio-cultural features, and treatment characteristics such as self-efficacy.¹⁶ Further, low self-regulatory efficacy and outcome expectations of the pleasurable effects of an addictive substance are strong predictors of urges to use the substance¹⁹

Strengths and limitations of the present study

This study has identifiable strengths; It is the first study within Jordanian context to study the roles of social support and self-efficacy in substance use relapse. Furthermore, this study modified social support and self-efficacy scales to suit the Jordanian context which can now be used by other researchers to use them in their studies. Moreover, the current study included substance users who were in prison and in treatment centres. In all settings, the role of social support and self-efficacy was statistically significant in determining their likelihood of relapse.

The findings demonstrate that there is a need for further research in order to gain a deeper understanding of the issues regarding substance use in Jordan and how to best support and treat both male and female substance users.

Limitation of the study: there were some limitations like applying this study in some treatment centers and in prisons. Also, most of the study sample was male and smaller number was female. It should be noted that the author visited all the treatment centres and prisons to explain the purpose of the study to the participants and, where appropriate, helped respondents to complete the online questionnaire if they had low literacy levels.