Object Relations and Vulnerability to Substance Abuse Relapse among Addicts Visiting Narcotics Anonymous Centers in Qom City, 2018

Introduction

Substance abuse is a chronic and recurrent disorder that inflicts enormous costs on individuals, families, and societies (1). It is a multidimensional disorder that accompanies many other problems, mainly recurrent relapses that resist any treatment (2). Other studies have shown that risk factors for substance abuse are as follows: mental disorder, dysphoria, lack of household protection, social pressure, membership in social networks for substance abusers, interpersonal stress, social exclusion, lack of purposeful activities, and lack of hope to amend challenging relationships (3). Substance Use Disorder (SUD) occurs in roughly 40 to 60 percent of treated cases. Accordingly, it is of high significance to better understand the relapse phenomenon and tailor interventions to prevent it (4).

Long periods of detachment or mother loss may interrupt the attachment trend and lead to child’s lack of security about others in the future (5). Mother-child relations are of different features among people who become addicted. In such a mother-child interaction, the mother is either highly accountable for her child’s needs or due to lack of trust in relations or absence of mother, child’s needs are not met. Some scientists believe that in an attempt to suppress and defend against such inner feelings of insecurity, a substance can play as a shield that the person resorts to (6).

Hyman et al study showed that the severity of emotional abuse in childhood was associated with an increased risk of substance abuse relapse among addicted women. The severity of emotional abuse, sexual abuse, and childhood trauma correlated with the number of days women used cocaine during the follow-up. However, there was no significant relationship between childhood hurt and cocaine relapse consequences among men (7).

Considering the importance of object relations in substance abuse and its relapse, the number of studies on the issue is limited. Therefore, the present study aimed to investigate substance abuse relapse from the perspective of psychodynamic theories. By doing so, better ways to prevent such an adverse event can be detected.

Materials and Methods

In a cross-sectional study, the participants were 385 subjects who attended the Narcotics Anonymous Centers of Qom city in 2018; they were selected through a convenient sampling method. Narcotics Anonymous are an independent group, and non-members can’t attend its meetings. Still, in coordination with the group’s management, access to members was provided at the end of the meetings outside the meeting hall. However, due to cultural considerations and social constraints, it was not possible to access female clients.

In this study, a demographic questionnaire including age, gender, marital status, educational status, occupation, age at withdrawal, and duration of withdrawal was used.

Timeline Followback (TLFB) interview was the second instrument to evaluate the vulnerability to substance abuse relapse which contains 10 questions. Using a test-retest method, Zobel et al assessed this questionnaire’s validity among male and female subjects. The correlation between the two tests was r>0.87, indicating a high validity of the questionnaire (8). This questionnaire was used for the first time in Khademi and Monirpoor’s study in Iran, and its internal consistency was 0.93, using Cronbach’s alpha (9).

The third instrument was Bell Object Relations Inventory, which has 45 items grouped as four subscales for assessing the various dimensions of object relations: Alienation (ALN), Insecure Attachment (IA), Egocentricity (EGC), and Social Incompetence (SI). Using t Cronbach’s alpha and Spearman-Brown coefficient, the internal consistency of the inventory ranged from 0.78 to 0.90 for four subscales (10).

Data analysis

Data analysis was conducted using the Statistical Package for the Social Sciences (SPSS), version 21 (IBM Corp., Armonk, N.Y., USA). The data distribution was parametric, and the Pearson correlation coefficient was used to assess the correlation between variables.

Results

The sample of the study were male subjects. Their age ranged from 19 to 74 years (34.7±9.16). Moreover, 61.56% of the subjects were married, and 92.2% were employed. The mean withdrawal age and the duration of withdrawal were 31.42 years and 40.48 months, respectively. The demographic features of the participants are shown in table 1.

According to the findings, among subscales of object relations inventory, the highest mean score was related to the alienation subscale (29.83), and the lowest mean was associated with the social incompetency subscale (9.1) (Table 2). Alienation, insecure attachment, egocentricity, and social incompetence had a significant and positive relationship with vulnerability to relapse; however, there was no significant relationship between social incompetence and vulnerability to relapse (p>0.05) (Table 3).

Table 1. Demographic features of participants

Table 2. The descriptive indices of variables (Object relations, its subscales and vulnerability to relapse)

Table 3. The relationship between object relations subscales and vulnerability to relapse

Discussion

According to the findings, there was a significant and positive relationship between alienation and vulnerability to relapse. This finding is in line with a study of Farley et al (11), and Simons et al (12). Alienation subscale indicates lack of trust in relationships, inability to achieve intimacy, and despair of maintaining a stable and satisfactory level of intimacy; those who get high scores may have feelings of suspicion, caution, and isolation and believe that there is no one for sharing their internal feelings and thoughts (10). Substance abusers have some disorders in their emotional functions and object relations. They have a kind of dual experience in their feelings towards others, but they resort to pretentiousness and trust to get support. When this pretentiousness is failed contrary to personal expectations, they begin to attack others. Considering that abusers usually suffer intensively at the beginning of the self-government phase, they tend to trust the substance and alcohol. Therefore, they experience substance use, symbolically, as an object related to the mother. Since these damages exist during abstinence, substance abuse relapses occur again, and the substance happens to be the symbolic object for mother.

The findings showed a positive and meaningful relationship between the subscale of insecure attachment and vulnerability to relapse, which is in line with the Mcmahon’s (13) and Doumas et al’s (14) findings. Those who got high scores in this subscale had painful interpersonal relationships. They are highly sensitive to rejection and have neurotic anxieties by the desire to be liked and accepted. Although the items show that the relationships are so significant, it can be said that anxiety, feelings of guilt, and jealousy lead the relationships to sadomasochistic – abusive tendencies (10). Those who suffer from insecure attachment tend to substance use to compensate for interpersonal relationships, which brings them temporary relief. However, if the substance abuse continues for a long time, it endangers neurological and psychological functioning and destroys the biological structure due to its poisonous nature. Therefore, the addict’s interpersonal skills will be affected by the slow deterioration process of substance abuse; relationship management, therefore, becomes more difficult and causes more trust in substance. These kinds of degradation patterns, finally, will increase the addiction-like response.

According to the findings, there was a positive and meaningful relationship between egocentricity and vulnerability to substance abuse relapse. These findings are in line with Ramos’ (6) findings but contradict the conclusions of Hyman et al (7). The items related to egocentricity indicate three main regularities in the relationships: some motivations are due to distrust, some individuals tend to egoism in relationships, and some try to manipulate others to achieve their purposes (10). Relationship with mother changes to an internalized object relationship (as having interaction with a person), and it shapes a unit which has three parts: the concept of subject in its environment, its concept in interaction with the subject, and the attached emotions to the concept of subject and its concept affected by present drivers at interpersonal interactions. To simply put, the unit, if internalized, is a self-concept, concept of the subject, and feelings attached to those two concepts. Considering the serious and constant damages received by the people in relation to the early objects, they have a negative representation of themselves and external objects, causing inferiority complex and feelings of inadequacy and distrust toward the people around them. Thus, they tend to use a substance to reduce anxiety and stay away from this paranoid atmosphere and find a response to their needs. As these conditions go on into the period of abstinence, there is a possibility of substance use relapse.

However, there was no significant relationship between the social incompetence subscale and vulnerability to substance abuse relapse. This finding is in line with the results of Walton et al (15) and Drake et al (3). This subscale indicator points to shyness, anxiety, and scruple in interaction with the opposite sex. These indicators describe the inability to make friends, not being comfortable in gatherings, avoiding close relationships, and non-satisfactory sexual compatibility (10). According to the results, which show that 61.5% of subjects were married and 92.2% were employed, it seems that in this sample, the substance abusers successfully returned to society and their family after substance withdrawal, and they were accepted to a large extent. These factors removed the feeling of incompetence; therefore, there was no relationship between social incompetence and vulnerability to substance abuse relapse.

Conclusion

The results showed that substance abuse relapse is influenced by the quality of object relations so that damage to individual relationships with primary objects can explain the substance abuse relapse. The lack of timely response and satisfaction of the infant’s needs by the primary objects relations causes psychological trauma in infants. In the process of growing up and relieving the anxiety caused by these traumatic relationships, one turns to substance abuse. The temporary relaxation that results from substance abuse encourages the person to continue. Over time and with repeated substance abuse, one’s nervous-psychological system also gets involved with the effects of substance abuse so that he/she can no longer survive without the substance. After abandoning the substance and avoidance due to the traumatic effects of early object relationships in the individual and the anxiety that results from it, the individual may not be able to resist environmental stressors and may choose substance as the only known strategy in coping with the stress.

Acknowledgments

This article was extracted from a thesis for a Master’s Degree in clinical psychology at Islamic Azad University of Tonekabon (Ref Code: 2262036). The authors would like to extend their gratitude to all university officials at Azad University in Tonekabon, and public relations staff at Narcotics Anonymous Centers in Qom city who wholeheartedly helped the authors.

Conflict of Interest

There is no conflict of interest to report by any of the authors.