The Role of Family Atmosphere in the Relapse Behavior of Iranian Opiate Users : a Qualitative Study

1Department of Critical Care Nursing, Center for Nursing Care Research, Nursing and Midwifery Faculty, Iran University of Medical Sciences, Tehran, Iran 2Department of Psychiatric Nursing, Center for Nursing Care Research, Nursing and Midwifery Faculty, Iran University of Medical Sciences, Tehran, Iran 3Department of Psychiatric Nursing, Nursing and Midwifery Faculty, Substance Abuse Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran.


Introduction
Opiate use as a worldwide common phenomenon threatens economy, lives, families, and societies.According to the Iranian welfare organization report, the prevalence of opium or heroin-abuse persons in Iran has been estimated to be about 2 million users in 2010. 1 Unfortunately, in recent years, the number of opiate users in general and the number of users with less age, and slipcases and recurrence during or after treatment has dramatically increased. 2here is too much emphasis on prevention and treatment of relapse in the drug-abuse treatment process. 3The recurrence during the first six months has been reported up to 75 percent in various studies. 2,4,5In Iran and other countries, the relapse rates reported varies between 63 and 81 percent. 4any factors effect on relapse process in the clients as environment and social factors, physical, psychological, familial 6 and interactional factors. 7In many studies, relapse behavior has been introduced a multi factorials concepts. 8ulture and social interaction are the most important issues in relapse process.
In many studies, the role of social interactions in the treatment, rehabilitation Copyright © 2015 by Tabriz University of Medical Sciences and relapse prevention has been emphasized. 7,8Therefore, to under-stand the relapse process, experiences and interactions of clients in their social and cultural context should be examined. 9Family atmosphere is one of the important aspects in this field that needs to be studied carefully. 10Qualitative research is the best method for clarifying in social concepts that interpersonal interaction is the main factor in it. 11Thus, we used qualitative research method with grounded theory approach to study the relapse process among clients with a history of opiate user.This report is part of a research about relapsing behavior conducted using conventional content analysis approach.The aim of this paper is to discuss the impact of family atmosphere on relapse in opiate users.

Materials and methods
This report is a piece of an extensive qualitative study with the grounded theory approach performed as a doctoral thesis with the aim of explaining the process of relapse in opiate users.The present report discusses the impact of family atmosphere on relapse in opiate users, which was been done with conventional content analysis approach.
Drug abuse is an important issue in the province of Kermanshah.Trends in drug use and abuse are the cause of many social problems.Demographic, social and economic factors of Kermanshah and the structural failure are important factors that provides opportunity for drug-related offenses. 12The researcher referred to three private and three governmental drug-abuse clinics of Kermanshah, a city in West Iran.He selected these settings because of the high probability of finding potential informed participants.
Out of 19 opiate users with at least one episode of relapse, 12 participants gave consent to participate in the study.Inclusion criteria for opiate users were as follows: 1) having experienced at least one episode of relapse, 2) being at least 18 years old, 3) being able to speak in Persian fluently, and 4) not being affected by cognitive impairments.Furthermore, two out of fourteen family members of opiate users and three therapists (two physicians and one psychologist) shared their experiences about the phenomenon under study (relapsing process).The potential participants informed about the study; those who accepted to participate signed the written informed consent.
Maximum variation was been considered when selecting the participants, as this type of sampling helps in understanding the nature and dimensions of various causes and facilitates the investigation of various phenomena. 13The participants selected based on purposive sampling followed by theoretical sampling as the categories emerged.Sampling continued until no new information or category found in showing that saturation had occurred.
Data collection lasted from February 2010 to August 2011.Participants were been asked to agree upon an appropriate time and place for the interview.At the interview, openended questions were been asked with no fixed order but based on an interview guide.The interview guide 14 was based on a critical review of existing research surrounding this subject and the goals of the study (Table 1).During, and immediately after, each interview, some notes were made of significant points by the researcher.Interview duration ranged between 30 min and 70 min.The interviews were been audiotaped and transcribed.The third author performed all interviews and their transcriptions in the participants' mother tongue (Persian, the original country language), which was also his mother tongue.Quotations presented in this paper were been translated to English and validated to keep the correct nuances.
Ethics Committee of Tehran University of Medical Sciences approved the research (Code 409, NO.1504286).To provide autonomy, all potential participants were been informed that participation in the study was voluntary.All participants were been given oral and written information about the study and informed consent was obtained before the interview if they agreed to participate.The informed consent form stated that the participant agreed to be interview and that their words would be audiotaped and transcribed by the researcher for analysis, and that the participants had the autonomy to terminate their participation whenever they wanted.Only the researchers would be aware of the real identities with their respective tapes, report, or description and this guaranteed confidentiality.The third author served as a contact person ( by means of e-mail and telephone) for the participants, so that they could get in contact about new ideas or terminate their participation.
The content analysis method was used to analyze the data, meaning that throughout the analysis 11 , the researcher tried to make comparisons of similarities and differences in the data as well as questioning the data. 9In this method, data collection and analysis took place simultaneously.The researcher listened to the first interview and read the transcribed version several times and then started to open coding of the transcript.For this purpose, he extracted every word, phrase, sentence, or paragraph that seemed to be relate to the phenomenon under study during line-by-line reading of the text and then axial coding was been followed.The next transcribed interviews were been analyzed also in this manner.Selective coding was been used to relate the categories, validating the relationships, and filling in, refining and developing the categories.The above process was been repeated repeatedly by moving back to validate the emerging findings.The researcher wrote memos including ideas, reflections, and hypotheses about the data during the process to help with the data analysis.Finally, all of codes, subcategories and categories reviewed again by the research team.
To ensure the accuracy and reliability of the data, the researchers used four criteria suggested by Lincoln and Guba: credibility, transferability, dependability, and conformability. 11To achieve credibility, we presented our preliminary findings to our research colleagues to achieve collaborative analysis.In addition, the long-time involvement of the researcher with opiate users in the clinic can increase credibility.
Transferability refers to external validity.It rests with the readers of a research report to judge about the relevance of the findings to their situation based on the thick description of the findings.Dependability is been guaranteed when credibility is assured.In addition, we provided an audit trail and evidence that supported interpretations and dependability.The audit trail served as a document to assure conformability.In addition, we conducted all activities based on our initial research design.Other measures were to save all participants' information through audiotape recording and then transcribe the interviews.Participants checked transcriptions in terms of congruency in order for the researchers to correct if there had been some misunderstandings when changing audiotaped recordings to transcription.

Seventeen interviews with opiate users (Table 2), their family members, and
Copyright © 2015 by Tabriz University of Medical Sciences therapists were completed.The therapist participants (two male physicians and one female psychologist) had 4-13 years' experience in working with opiate users.One family member participant was the wife of one of the opiate user participants and another was the mother of the other one.Out of the eight categories that emerged during the data analysis process of the original study; the family atmosphere was thought to have a basic role in the relapse process.Thus, we continued the study by theoretical sampling during which an additional three interviews were been conducted with three opiate users of the same participants about the role of the family atmosphere in the relapse process.Based on cumulative findings of the study, three subcategories explained the impact of family atmosphere on the relapse process: family and tribes' interaction, family challenges, and family structure.
The quality of the family atmosphere could be in harmony with or against the willingness of the opiate user towards the relapse.

Family and tribes' interaction
The relapse process was been considerably affected by interactions within the family and the ethnic group.During their interactions, if the opiate users faced sarcasm, negative attitudes, distrust, and inappropriate feelings from friends and relatives, the tendency for relapse increased.One participant said, "… bad and inaccurate attitudes of friends and family members, and that they do not trust in me.This provokes you so that you say it is better to turn to the drug, because they do not trust in you.For instance, when I smoked at home, they told me, you have again used the drug!I was been frequently asked.If I was sleepy, they asked me if I have again used the drug.These made me tired; rapidly get out of the home." Another participant stated, "In my opinion, the attitudes of the family members and relatives have a great influence.When they say how you have gotten well, how you are happy, when they provide you whatever you want, and when their behavior is not bad as before, you get energy, you would like to avoid the drug.You understand that your family loves you, wanting to help.But, when they frequently get me under control, asking about the case, I think I don't have self-esteem, no longer able to continue recovery and back to opium." On the contrary, interactions that produced the feelings of "being supported" were efficient in helping the clients for craving control and preventing the relapse: "Whenever I feel sick and not good and experience craving, I get the help of my friends and uncle's son, making me not back to opium."

Family challenges
The subcategory, "family challenges," describes the challenges and problems that clients experience within the family atmosphere.Exposures to the questions, frequent debates in the family about the client, and grudges and quarrels with family members and relatives produce psychological challenges, thereby putting the clients in trouble for maintaining a healthy condition.One participant stated, "There were always quarrels within the family; the problem was headstrongness.I had a deep problem with my father, we were two opposite poles… we did not stand well with each other; I did regularly what I wanted in spite of his advice and vice versa.We were trying to prove ourselves to one another, and I was coming back to the opium for the sake of head strongness… I did so to resist against and bother him, making him upset and his suffering calmed me down." In these situations, opiate users find the reuse of opiate as the basic key to all problems."Looking for any excuse to reuse opiate" as another finding of the original study, facilitates the justification of the client in these conditions.One participant said, "Those who become addicted to opium think that it is the remedy for all their sufferings, they think if they use the opium, all their problems resolve, but they are unaware of the fact that it gets worse… they don't know that the public treats them as ungodly, humble people and the situation gets worse."

Family structure
The subcategory, "family structure" refers to any phenomena within the family that can play either a positive or a negative role in the relapse process, directly or indirectly (through family interactions).The existence of such phenomena as addicted parents or family members, ethical problems, family dissoluteness, divorce in the family, single parent family, and power imbalance in the family can trigger the client to reuse the opiate.One of the participants said, "Everything was available for me, my addicted friends, a place for opium use, and everything was available for me.In our ethnic group, in parties and funerals the elders use opium, because this is a custom.This may tempt you to use opium … I can't control myself for a long time, because using opium in ceremonies is not considered as a bad behavior, but an honour." Family structure can be effective in mitigating the cause of or preventing relapse.A family structure in which the roles and position of the members are clear, members' rights to state opinions are respected and psychological and emotional support is been provided; the clients are encouraged to overcome their craving for opium reuse.Another participant said, "Addicted persons not only have financial needs but also the need for help from their family to meet financial needs and psychological support; also, they are in need of being warned for their wrongs and instable behaviors along the healthy periods …." Of course, the attempts to support are not always successful.One participant's mother said, "… We try to do whatever he wants, we have bought a receiver, video player and so forth for him … I able to achieve the treatment.After devoted my life for him, but he was not treatment, he was healthy only for 5-6 weeks, then he returned to the previous condition and now uses the opiates … we all respect him especially when he is at home, we respect him more."

Discussion
The family in the Iranian context is a fundamental social unit and could been expected to have important influences on the development of social behaviors such as Copyright © 2015 by Tabriz University of Medical Sciences substance use and the relapse process. 10We found that the family atmosphere is an influential factor in accelerating or decelerating the relapse process.Been suggested that family interventions may be useful to advance treatment response or decelerate the relapse process. 15ccording to the findings, interaction with addicted friends may affect the relapse process.This finding supports the findings of other studies suggesting that peer group is an important leading factor to relapse behaviour. 10,15Besides the effect of peer groups, numerous studies show that drug availability is also one of the risk factors contributing to relapse in opiate users. 10It is evident from the interviews that interaction with addicted friends serves as a reminder of the previous pleasant experiences of opium use, as well as, means increased drug availability for clients.
The family may have a dual role in relapse.Family structure (low family support and high family challenges) and defined roles promote response to treatment and prevent the relapse behaviour.Families with a stable structure, and cooperative relationships, and families in which the members realize their roles, could be a therapeutic environment for clients experiencing rehabilitation.These findings are congruent with the findings of some previous studies. 10,15In addition, and other studies reported relationship problems and break up within the family as one of the causes of the relapse. 16n the other side, families in which opium use is common are not an appropriate environment for client recovery.The participants frequently reported the use of opium by family members, especially a parent, as a main cause of the relapse.Few studies reported that using opium by family members and inappropriate family structure are the main causes of relapse. 8In addition, we found that frequent lies of the client lead to family distrust to the client followed by negative attitude of the family toward the client.
The results suggest that parental drug addiction predisposes the family to such problems as divorce, parental separation, economic constraints, lack of control over the behavior of children, violent behavior in the family, and anxiety problems in children.The relationship between these variables is complex and interactive; therefore, it can be the aim of another study to address exactly which one affects the other.Some researchers in their studies concluded that drug abusers tend to report a meaningfully poorer relationship with their parents compared to non-drug abusers. 15ther researchers have considered this idea. 5,8,17Parental substance use, lack of parental support, lack of communication with parents, divorce in the family, and problems in the parent relationship may affect the participants during the treatment period, leading to a return to the drug. 5ccording to the findings, the clients are in need of more attention from their family members and friends during the rehabilitation period.They like to be understood and supported by their family.During the period of rehabilitation, the clients' expectation of family for support increases, because they think that they have done their best.Further interviews raised the impression that this may be just for justification and if this increased expectation remains unmet, it may be an excuse for returning to the opium.The reason is that clients' increased desire to use opium during the rehabilitation period leads to frequent psychological challenges followed by searching for any rationale, including family shortcomings, to come back to the opium.
We found that such phenomena as addicted parents or family members, ethical problems, family dissoluteness, divorce in the family, single parent family, and power imbalance in the family are those components of family structure accelerating the relapse process.This calls for special attention and focus of recovery programs on the comprehensive assessment of the structure of family in the beginning.It seems that a fragile structure of the family is a big hindrance against success of the recovery program.One study reported that one third of the opiate users come from single parent families. 18oor communications in the family, poor family support and management, and lack of parental affection and friendship found to place family members at a risk for relapse. 19,20During treatment and recovery, clients need to have family comprehensive support, because the family is the only place for the majority of Iranian opiate users to return after recovery. 10,17

Conclusion
A better understanding of the impact of the family atmosphere on the relapse process suggests treatment and rehabilitation programs to be family-focused more than before it.This is true that some components of the family atmosphere such as family structure cannot be corrected or manipulated, but there is enough room to man oeuvre on other components as family interaction and challenges.In Iranian families, specific cultural context and deep.
The family in the Iranian context is a fundamental social unit and could been expected to have important influences on emotional relationship between the members create a collaborative and collective condition when a member of the family is involved in a problem.This makes the role of the family more prominent in the relapse process.
Appropriate education of the family members of the opiate user about how to deal with the problem may make their emotional and verbal behaviors facilitative rather than obstructive during the treatment period.Conducting similar studies recommended providing more knowledge about the factors affecting relapse among opiate users.
Our findings illustrated the impact of family atmosphere on the relapse process among Iranian opiate users.The experiences and opinions of limited Iranian participants regarding relapse in opiate users would not have high generalization.In addition, because of socio-cultural sensitivity to addiction, participants might have not revealed all their experiences and opinions about the phenomenon under study.

Table 1 .
Interview guide

Table 2 .
Demographic characteristics of the opiate users