<Figure 1 about here>
The present study is the first to explore factors that facilitated drug use, motivated ceasing one’s drug use, and managing one’s ongoing recovery among clients who utilized community services at < blinded for review > in Singapore. Of note was that the trajectory around managing one’s recovery tended to transverse several subthemes, from uncovering personal identities, losing motivation and drive toward recovery, overcoming struggles, to preparing for aftercare. As noted in previous literature, clients may regress to earlier stages of recovery when they experience a relapse (Berger, 2013; Prochaska et al., 1992). Consistent with our case study, the client struggled to work through his personal identity, relationship strains, and other external stressors. Therefore, clients tend to be more vulnerable to potential relapse as they navigate through the first three stages of recovery.
As illustrated in Table 2, one of the prominent motivations that drove continued drug use was to manage one’s feelings and emotions. A reason why clients could be more prone to relapse was that they relied on drugs as a maladaptive coping strategy, including avoidance coping strategies aimed at reducing or avoiding immediate distressing experiences (Coriale et al., 2012). Consistent with alcohol use literature, evidence suggests that individuals who rely on avoidance coping strategies are more likely to engage in problematic drinking behaviors (Wang et al., 2021). Generally, reasons for clients to engage in drug use vary from being bored to managing anger, guilt, and shame. Further, we note that the clients were sexual minorities, where minority stress processes could kick in and lead to higher levels of psychological distress compared to the general population (Meyer, 2003; Meyer, 1995). Hence, rendering these individuals at greater risk of substance use and dependence (Tan et al., 2021; Tan et al., 2018).
Drawing from the case study, feelings of loneliness and hopelessness appeared as prominent themes that were identified when the client lost motivation and drive for recovery. Loneliness as a subjective experience is associated with poor physical and psychological health outcomes (Shankar et al., 2011). Further, the general excerpts and case study identified feeling lonely as a risk factor for drug use relapse. This aligns with the extant literature investigating the relationship between loneliness and drug use and found that loneliness is a significant risk factor for drug use (Hosseinbor et al., 2014; Kayaoglu et al., 2021). Nevertheless, this relationship could be moderated by the type of coping styles employed by individuals (Mannes et al., 2015). Conversely, hopelessness increases when clients face a series of adverse events and believe that recovery is impossible. When revisiting the qualitative data, the theme of hopelessness is identified in the earlier stages of recovery. Further, feelings of hopelessness were identified in our case study, where the client navigated through a breakup, worsened familial tensions, and managed feelings of inefficacy.
Notably, this study identified the significance of social belonging, pertinent to the recovery process, specifically in the aftercare phase. A sense of belonging refers to an individual’s perception of relatedness to a social group (Mahar et al., 2012). While true belonging demands authenticity and courage from individuals to show up as themselves, it could be extremely challenging for individuals in recovery from drug use in drug-free societies to achieve (Brown, 2021). A potential explanation would be that belonging is enmeshed within the broader socio-political landscape that highly stigmatizes drug use (Batchelder et al., 2020). For clients at < blinded for review>, commonly stigmatized labels that were internalized, enacted, or anticipated include being a person who used drugs, sexual minority, or being HIV-positive. Interestingly, stigma was identified as a motivator for clients to seek recovery and a threat to a client’s recovery process. For clients who expressed their desires to reconnect with others who do not engage in drug use, being able to show up as an individual in recovery could be a vulnerable and uncomfortable experience. To make matters worse (since drug use is highly stigmatized in Singapore), clients often face social rejection from loved ones who do not engage in drug use. Therefore, the social pressure to fit into the drug-free narrative and the desire to reconnect with others could have motivated clients to seek out drug recovery services (Birtel et al., 2017). With that in mind, a client’s desire for social belonging can further hinder his/her recovery process especially in the Singaporean context, where harsh criminal penalties create barriers for individuals access healthcare resources provided by community services (Chua et al., 2013). This fear of once again having to experience rejection from their loved ones and social network could be bolstered and demoralize clients from working toward recovery. Conversely, re-engaging in substance use behaviors could reinforce a client’s sense of belonging. For example, intimacy could be achieved with sexualized drug use, or as a way of socially engaging with peers (Tan et al., 2021; Tan et al., 2018). Overall, clients who are caught in between social connections who both engage or do not engage in drug use will have to eventually choose between going through recovery or not, which potentially risks losing valuable relationships.
More importantly, our qualitative data supported the notion that clients required various social groups to achieve their recovery needs. As illustrated in Table 3, when clients completed the intake assessment, they expressed assistance-related concerns, such as guidance, non-judgmental support services, and discussions on navigating social relations. For example, clients who received validation for their recovery process reported feeling valued and confident in achieving abstinence. They subsequently indicated an interest in wanting to give back to society by becoming peer supporters towards the end of counselling sessions, further suggesting that social support serves to bolster self-confidence and empowers clients in addiction recovery. This is consistent with Hall et al.’s (2019) and Ogilvie and Carson’s (2022) studies that demonstrated clients who were perceived as competent in addiction recovery were less likely to relapse in the future. Similarly, the subjective perception of recovering clients could have uplifted their self-confidence, motivating them to overcome their addiction issues (Booth et al., 1992).
Moreover, a significant part of overcoming recovery struggles requires clients
to internalize and work on their personal growth (i.e., self-awareness, self-esteem, and self-security) and reinforce coping skills (Birtel et al., 2017). These reframed thoughts are pertinent in helping clients increase their self-efficacy with the belief that they can sustain recovery beyond counselling (Kadden & Litt, 2011; Yang et al., 2019). As illustrated in Table 3, general excerpts revealed that achieving a level of personal growth positively influenced the client’s recovery journey. Notably, these clients possessed the ability to acknowledge their strengths, weaknesses, values, and the awareness of maladaptive behaviors in times of distress. Clients acquired a more objective view of themselves as a result, which may in turn, increase their self-efficacy. This is consistent with Kang et al.’s (2018) study which demonstrated that journey toward drug use recovery is a process of personal growth (and not just abstaining from drugs).
Lastly, psychoeducation appeared to be a significant element in counselling. As illustrated in Table 3, psychoeducation materials were tailored based on the clients’ needs ranging from designing and attempting exposure-based experiments, and distress tolerance coping skills, to integrating healthy and sustainable habits into clients’ everyday lives. Clients are taught about their drug use tendencies, trauma symptoms, practice various coping skills, and share their struggles in addiction recovery. Thus, psychoeducation allows clients to reflect on their experiences through a psychological lens and develop appropriate tools to aid them in their recovery journey. As mentioned above, sustaining abstinence from drug use is only one of the many struggles faced by clients in recovery. This demonstrates the importance for clients to take ownership of their recovery needs and develop/re-design a variety of healthy yet sustainable skills when needed.
Limitations of the present study should be noted. First, the qualitative data consisted of clinical case notes that were summarized by counsellors. This introduces inaccuracies in data interpretation and may not necessarily reflect the emotions and feelings of clients accurately. Second, our study did not uncover the influence of individual difference mechanisms on recovery (i.e., social support and stigma). This could potentially overlook unique nuances that may impact a client’s journey in recovery. Third, clients who came forth to access clinical services at < blinded for review > could likely represent a specific population within sexual minorities in addiction recovery (i.e., gay men, and higher education attainment). As such, the results may not be generalizable to other sexual minorities (lesbian women, transgender individuals, etc.). Taken together, it is recommended that future qualitative studies explore the influence of individual difference mechanisms, including a wider sexual minority population, and possibly the perspectives of primary caregivers, and the barriers they face in supporting individuals in addiction recovery. Further, it would be of clinical interest to explore the psychotherapeutic processes at play in drug use cessation and the clinical management of recovery outcomes to improve addiction services in community organizations.
Implications and Future Directions
With the results and limitations in mind, the strength of the present study is bolstered by its novelty in attempting to uncover factors that influence addiction recovery in the context of sexual minorities in Singapore. The study uncovered that willpower by itself is insufficient to maintain sobriety since there is a complex relationship between the motivations for drug use and drug cessation. Further, the findings revealed individuals who engage in drug use contend with realities, such as prejudice against sexual minorities and drug use behaviors, both of which impede their ability to rehabilitate. Therefore, our study demonstrated the importance of delivering holistic programs for clients in addiction recovery, specifically a model that emphasizes personal growth, social support structures, and healthy coping mechanisms to empower them to take ownership of their recovery journey.
Notably, there are further implications arising from this study that could be of relevance to the community, mental health practitioners, and policymakers. First, in communities, it is crucial to provide additional opportunities that prioritize judgement-free care for individuals in drug use recovery. Moreover, communities must confront the stigma they often attach to individuals who engage with drugs and understand that these negative connotations can pose significant barriers to those seeking recovery services. Rather than isolating or stigmatizing these individuals, friends and family members could strive to empathize with those in their recovery journey and provide social support toward recovery (Grim & Grim, 2019; Kelly et al., 2010; Luoma, 2010). Second, mental health practitioners play a pivotal role in aiding individuals in drug use recovery to identify and address their struggles. Additionally, practitioners could highlight key personal growth milestones in their client’s recovery journey, which may, in turn, encourage these individuals to continue persevering through continued recovery. Third, from a policy perspective, recognizing the multifaceted nature of factors impacting the recovery process underscores the necessity of formulating comprehensive metrics for the identification of vulnerabilities associated with drug relapse.