Needs of Spouses of Patients with Substance Use Disorder: A Qualitative Study

Abstract
Background: The skill of adjusting and regulating the needs and adaptation are the most fundamental abilities of family members. Since substance use related disorders create serious health threats and cost burdens for family, it is important to investigate the needs of spouses of these patients. Regarding the wide spectrum of needs based on previous researches, the psychiatric needs were the focus in this study. By evaluating the needs, the executives of social services can better determine the basic needs of patients and their family members.
Methods: This is a qualitative study applying a content analysis approach. Based on the objectives of this research, purposeful sampling was done and continued until information saturation. In total, 16 spouses of patients using substance were interviewed. Initial interviews began with guiding questions and the probing questions were applied in the following interviews. Participants’ emotions were coded and codes with similar concepts were placed together in one category and subcategories were created.
Results: After conducting 16 in-depth interviews, 38 initial codes were obtained and categorized into 6 key concepts (Neglecting the reciprocal roles and rights, lack of responsibility, lack of motivation, psychiatric changes due to substance use, feelings of insecurity, and defective communication).
Conclusion: The present study paves the way in better understanding of the needs of the spouses of patients with substance use disorder, and enables the specialists in this area to adjust the treatment according to each individual patient and evaluate emerging patient related issues and challenges as well. Substance dependence, in addition to making problems for the individual and the society, leads to unsatisfied needs of close family members and acquaintances. In other words, treatment will be more effective if each patient is recognized individually, the family is educated, and family-level interventions are provided.
Keywords: Adaptation, Emotions, Psychological, Qualitative research,
Substance related disorder
Introduction
Many psychologists and sociologists believe that needs are the foundations of social institutions. The family, as a social institution, is not excluded from this rule (1). Perhaps, the skill of adjusting and regulating the new needs and adaptation to new conditions is the most fundamental ability of family (2). Some researchers defined “needs” as the measurable difference between the current position and the expected and ideal position (3). Some have defined need assessment as a systematic process to identify needs-based decision making, resource allocation, and implementation of activities to solve the problems that are the infrastructure of basic needs (4). The difference between needs and need assessment is prioritizing the needs after detecting them in need assessment process (5). In most countries, the services related to mental health should be assessed, evaluated, and modified to provide the best treatment and care which is fruitful in future appropriate planning (6). By evaluating the needs, the executives of social services can better determine what are the basic needs and how they can be responded (7). The aim of need assessment is generating information about the needs of people, organizations, and society (8,9). Several studies report the lack of support from family caregivers of patients with psychiatric diseases and lack of attention to their needs (10-12). Addiction as a physical and psychiatric illness with consequent problems in all aspects of life threatens the health of the individual, society, and particularly family (13). Several empirical studies have also indicated that using substances by an individual in the family has a deep effect on the behavior and other aspects of his/her life and the life of his/her family; for example, substance-seeking behavior, anger, feelings of rejection and disability makes his/her partner feel guilty and depressed (14). Literature indicates that providing health and social services in treatment of addiction, especially when coordinated and adapted with specific needs, leads to more favorable outcomes. In a study conducted by Marsh et al., they investigated racial/ethnical differences in matching needs and services in substance use treatment; they found that different racial groups have different needs and should receive distinct services; this effective strategy encourages the patients to follow the treatment and reduce substance use after treatment (15,16). Likewise, other researchers have investigated the needs, anxiety, depression, and caregiving consequences of psychiatric patients with comorbid substance use and patients who do not use substances, and found that psychiatric patients with comorbidity of substance use reported more unsatisfied needs (Need alcohol and drug, budget shortage, inadequate nutrition, inappropriate housing, and feeling of loneliness), anxiety, and caregiving consequences (17). Several studies have been conducted to build an instrument for measuring the needs of Iranian families. For example, in a research aimed at providing and designing a valid and reliable scale to assess the needs of families living in different areas of Shiraz, the results indicated seven major needs including economic needs, needs for affection, social security needs, primary welfare needs, educational needs, secondary welfare needs, and the need for psychological services. The scale manifested appropriate and consistent validity compared with other scales such as life satisfaction scales, family content, and strategies to encounter with stress (18). The findings of another study about psychometrics of the family needs scale for Iranian families (472 couples) indicated the reliability and validity of this scale and determined 5 major needs, including psycho-emotional needs, material-economic needs, physical health needs, recreational-entertainment needs, and educational-training needs (19). The results of the research investigating the nursing and care needs of the family of psychiatric patients after being discharged from the psychiatric hospital indicated that majority of psychiatric patients’ families reported some needs such as regular counseling by a specialist, care provision in the community, post discharge follow-up, educating the patient and family, and psychological and social rehabilitation (20). Regarding the wide spectrum of needs, and based on previous researches, the psychiatric needs of the spouses of patients with substance use disorder were investigated in this study. Most of the studies in assessing and evaluating the needs of the family are studies conducted outside Iran and influenced by the social and cultural factors governing those societies. Considering the limited number of Iranian studies, especially on the spouses of substance users, and serious health threatening and cost burden effect of substance-related disorders on substance users, family, friends and the community, this study investigated the psychiatric needs of spouses of patients with substance use disorder.
Materials and Methods
This is a qualitative study applying content analysis approach to evaluate the needs of the spouses of patients with substance use disorder. In this study, the subjects were the spouses of the patients using substance who were treated at Iran Psychiatric Hospital. Inclusion criteria were presence of a person with substance use disorder in the family diagnosed with DSM-V criteria and a psychiatrist’s opinion and medical record confirming the problem, at least one year of substance use history, and being married and living with the spouse. Exclusion criteria included having chronic physical disorders, such as cancer, kidney related diseases and primary psychotic disorder and bipolar disorder.
Purposeful sampling was done and continued until information saturation, i.e. not receiving new information, and the benchmark was repetition of the received information in the last three interviews. In order to collect data, a demographic data collection form was provided to be completed by participants and semi-structured interviews were used. The interviews were conducted by a senior clinical psychologist. The time and place of the interview based on the agreement with the participants were arranged in the consulting room of the addiction center of Iran Psychiatric Hospital. Initial interviews began with guiding questions which were obtained by investigating the previous literature. In following interviews, in addition to these questions, the information obtained from the previous interviews was also used and probing questions were applied to obtain deeper information. The interview duration was 40 to 60 minutes. The interviews were recorded and written on the paper word by word and then were checked again with the recorded information. While reading each interview transcript, the emotions of participants were coded and written on the margin of each interview transcript. Each of the above primary codes was evaluated using constant comparative method in a repeatable process with other codes of the same interview; also, they were compared with the codes of the previous interview and were temporarily placed in one of the experimental categories based on conceptual similarities which were suggested by researchers over time. In fact, codes with the similar concept were placed together in one category and subcategories were formed. During the axial coding, the relation between categories and subcategories was evaluated. Continuing this process led to the creation of new categories, integration of previous categories, or substitution of a code from one category for another. Using the Lincoln and Guba’s quadratic criteria (Credibility, dependability, confirmability, and transferability) (21), the accuracy and consistency of data were checked. The long-term participation of researchers and allocation of sufficient time for data collection (3 months) and the active participation of other members of the research team at all stages of data collection, data analysis and interpretation, besides the main researcher, helped to the credibility of data. Likewise, the full transcript of some encoded interviews was provided to the participants to evaluate the consistency of the concepts with their intention (22). For this purpose, some participants were asked to compare the codes allocated to the content of the interview with the original transcript and compare their understanding with that of the researcher. In order to evaluate the dependability (Reliability) of the data, another researcher read some of the interviews within several days and coded them again, and the results were compared with the first coding. In this way, by obtaining common codes, data dependability was confirmed. Likewise, in addition to the members of the research team, two experts in qualitative research were asked to code interview transcript. Then, congruence between the given codes was investigated. Moreover, several initial interviews after coding were given to the qualitative researchers to comment on how to ask questions and the process of coding. Therefore, the provided suggestions were considered in the subsequent interviews. In order to ensure the confirmability of the findings, all phases of the research were documented and presented to the qualitative researcher. Therefore, the consistency of the meanings and obtained codes was evaluated. In order to increase the transferability, all of the research processes and the performed actions in the study procedure were documented precisely to provide the possibility of following the research procedure based on the characteristics of the studied population.

Results
In this study, 16 spouses of patients were interviewed. All of the participants in this interview were female, and substance users were diagnosed according to the DSM-V criteria and according to the opinion of psychiatrist together with their medical records.
The age range of substance users in this study was 30 to 51 years. Half of them were unemployed and the rest were employed. Their educational level varied. Out of the total interviews, 38 initial codes were obtained that were categorized into 6 main concepts and 18 sub-concepts in the analysis process (Table 1). Concepts that represent the biopsychosocial-spiritual needs of the spouses of patients with substance use disorder are listed in table 1.

Table1. Coding psychological needs

Discussion
Generally, the results of this study indicated that the basic needs of the spouses and other family members of the addicted individual were neglected by the patient. However, according to the definition of family structure, responding to the basic needs of family members is crucial (1,23,24).
Respecting the rights of the family members, accepting responsibility, motivational needs, planning, targeting and striving for their family’s quality of life, stability and mental health, emotional and behavioral health, providing physical, financial, and social security for family members, communication and interaction with the family, friends and acquaintances, are among the typical unsatisfied needs of family members. These findings are in line with previous researches which indicated that the family structure of the addicted individual is mostly damaged by substance dependence, and this damage is primarily life-threatening for spouse and children (25-27).
Considering the previous researches on the family problems of addicted patients, particularly educational and emotional problems of children and their psychiatric and physical illnesses, it can be concluded that lack of needs satisfaction of family members and neglecting their rights and lack of accepting responsibility all aggravate the family condition (27-29).
Another important point is that in addition to the addicted individual, the family members of them also need treatment and counseling (30,31). In this regard, the present study indicated that families of these patients, due to their specific needs, require family and psychological intervention as they suffer from social isolation, anxiety, and depression due to effects of labelling and social stigma (32,33).
Conclusion
The present study paves the way in better understanding of the needs of the spouses of patients with substance use disorder, and enables the specialists in this area to adjust the treatment according to each individual patient and evaluate emerging patient related issues and challenges as well. In this regard, various studies have indicated that the treatment will be more effective if each patient is recognized individually, the family is educated, and family-level interventions are provided (34). This study indicates the inextricable association between the illness of individuals and their inhibitions in larger scales. In fact, if the patient is treated successfully but his/her surrounding conditions are not optimal for his/her living, the risk of recurrence of symptoms of illness will be increased (35).
The study had several limitations. First, the association between various needs and their potential influence were not investigated in this study. For example, it is not clear whether lack of responsibility of the individual has an impact on the financial security need of the family.
Future studies can be implemented to determine the potential effects between different needs and the factors that might influence the relationship between different needs.