ARTICLES
https://doi:org/10.15270/59-2-1126

 

Perceptions of nyaope users regarding therapeutic services at private in-patient treatment centres in Gauteng

 

 

Noxolo Chairmaine Minenhle Zwane^I; Stephan Geyer^II

^IDepartment of Social Work and Criminology, University of Pretoria, South Africa https://orcid.org/0000-0002-2029-5956 mimizwane@yahoo.com
^IIDepartment of Social Work and Criminology, University of Pretoria, South Africa https://orcid.org/0000-0002-3765-3051 stephan.geyer@up.ac.za

 

 

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ABSTRACT

National data indicate that young adults are increasingly vulnerable to the harmful use of nyaope - an illicit drug. Consequently, there is a need for appropriate treatment services. This study aimed to explore and describe the experiences of nyaope users regarding therapeutic services at private in-patient treatment centres in Gauteng, South Africa. A qualitative study operationalised through a case study design, specifically an instrumental case study, involved 11 cases/participants who were recruited through a three-phase non-probability sampling process at treatment centres in two Gauteng metropoles. Following a method of reflexive thematic analysis, four themes with associated sub-themes, are reported. Recommendations focus on tailored service delivery at treatment centres and addressing limitations in policies.

Keywords: Nyaope; treatment centre; in-patient treatment; therapeutic services; case study design; substance use disorder; Gauteng province

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INTRODUCTION

Nyaope is a highly addictive illicit drug. Khine and Mokwena (2016) assert that nyaope is a novel psychoactive substance which comprises 10-70% third-grade heroin to which a variety of substances including antiretroviral drugs are added. Nyaope is particularly popular in South African townships because of its relatively low cost (Dada et al., 2015). Mokwena and Huma (2014) highlight that the drug is known by different names across the country. In KwaZulu-Natal, it is known as "sugars", "whoonga" in the Western Cape, "pinch" in Limpopo, Mpumalanga, and "kataza" in Johannesburg. Individuals who are dependent on nyaope encounter extreme difficulties when attempting to discontinue its use (Mokwena & Huma, 2014).

The National Drug Master Plan (NDMP) 2019-2024 (Department of Social Development [DSD], 2019), highlights that the use of nyaope among the youth, specifically children, adolescents, and young adults, is alarming. The use of the drug affects cognitive development negatively, and its use is associated with violent behaviours, accidents, injuries, sexual risk, and increased risk of victimisation.

Although nyaope has been increasingly and widely used in South Africa since 2000, it was only classified as an illegal drug in March 2014, according to the Drugs and Drug Trafficking Act 140 of 1992 (RSA, 2014). By smoking small doses of nyaope, users get a rush of euphoria and experience a sense of warmth and wellbeing. Larger doses cause drowsiness and feelings of being contented, safe and relaxed (Mokwena & Huma, 2014). People addicted to nyaope often lead disorganised lives that revolve around getting their next "fix". They often fail to think rationally and disregard their core values and beliefs. Male users are often involved in crime, mainly theft, so they can sell products to secure money to finance their habit. Conversely, female users often resort to sex work, which increases their risk of contracting HIV and other sexually transmitted infections (Mokwena & Huma, 2014).

The Prevention of and Treatment for Substance Abuse Act 70 of 2008 (RSA, 2008) makes provision for the treatment of substance use disorders (SUDs) at both in-patient and out-patient treatment centres, which could be either public or private institutions. Mokwena (2015) posits that in South Africa there are limited treatment facilities in the public sector and high rates of unemployment, which often make private treatment inaccessible. For many nyaope users, the situation has become so desperate that they create their own "rehabilitation services" by locking themselves into confined spaces to separate themselves from environments that are triggers for substance use (Mokwena, 2015). This situation is, of course, not only medically dangerous but also an injustice because there are in fact social service professionals available to guide users on their route to recovery.

During treatment at treatment centres, service users are typically removed from their social environment for a stipulated period (e.g. 21 days). This strategy is often ineffective for people addicted to nyaope. Upon re-entering their community of origin, persons who used nyaope, often relapse (Mahlangu & Geyer, 2018). Therefore, the establishment of treatment centres, in addition to any assistance that may be provided to a person with an addiction to nyaope, is needed to address this multifaceted challenge.

Heroin use in the form of nyaope is reported to be rapidly increasing and is affecting marginalised communities disproportionally. Likewise, data from the South African Community Epidemiology Network on Drug Use (SACENDU) (2021) demonstrated a rising trend in treatment admissions. Data collected from 34 treatment centres or programmes signal a total of 6 226 service users were admitted at Gauteng treatment centres during the period January to June 2021, of whom 29 per cent were found to be addicted to heroin which is a component of nyaope (SACENDU, 2021).

In this article, the authors argue that given the high prevalence of nyaope addiction, there is a need to ascertain, on the basis of the perceptions of participants, whether the therapeutic services at private in-patient treatment services are meeting the needs of those who are admitted for treatment. Hence, the authors sought to understand the participants' experiences regarding the therapeutic services at private in-patient treatment centres and to determine whether they perceived the therapeutic services provided as tailored to attend to the challenges associated with their use of nyaope. The authors undertook a context-specific investigation of the topic by focusing only on the Gauteng province - the province where they reside. Neither of the authors were directly involved with treatment at treatment centres.

The study endeavoured to answer the following research question: "What are the experiences of nyaope users regarding the therapeutic services at private in-patient treatment centres in the Gauteng province?" The study reported on in this article aimed to explore and describe the experiences of nyaope users regarding therapeutic services at private in-patient treatment centres. The article offers insight into the experience of service users regarding therapeutic services, often rendered by social workers, and how these services could be tailored at private in-patient centres in Gauteng, where addiction to nyaope is quite grave, to meet the specific needs of users.

The article provides a brief overview of the theoretical framework that underpinned the study, followed by an overview of the research methods, a discussion of the research findings, and ends by offering conclusions and making some recommendations.

 

SELF-DETERMINATION THEORY

The present study was underpinned by self-determination theory (SDT). SDT enabled the authors to make sense of the data and the ultimate findings that this study produced. Furthermore, the theory allowed for the identification of connections between cases that could otherwise have been missed (cf. Maxwell, 2013). SDT is embedded in a set of assumptions about human nature and motivation (Deci & Ryan, 2000). Humans are inherently motivated to grow and achieve and will fully pledge themselves to engage in even uninteresting tasks if their meaning and value are understood (Deci & Ryan, 2000). SDT suggests that individuals who thrive and grow achieve their goals and experience greater wellbeing under conditions that support the fulfilment of basic human needs. Through in-depth empirical research, investigators have identified three underlying human needs that are important to motivation and wellbeing: the need for autonomy, competence, and relatedness to others. The need for autonomy is rooted in the need to be causal agents and to act in harmony with one's integrated self. Deci and Ryan (2000) state that being autonomous does not mean being independent; it means requiring the freedom to act according to one's needs, interests, and core value system. The need for competence means the desire to control and master the environment and outcomes (Deci & Ryan, 2000). Lastly, the need for relatedness deals with the desire to "interact with, be connected to, and experience caring for other people" (Deci & Ryan, 2000:68). People's actions and daily activities involve other people and through this, they seek a sense of belonging (Deci & Ryan, 2000). SDT seemed to be the theory best suited to understanding the experiences of nyaope users regarding therapeutic services at in-patient treatment centres, as people are more likely to assimilate values and behaviours promoted by those to whom they feel connected with and trust. Essentially, for treatment to be successful, it is important for the participants to be motivated and to have the autonomy to turn their lives around. The study utilised SDT to determine what role recovering users' motivation played during their treatment, and what their sense of respect for their autonomy was during their journey (Deci & Ryan, 2000).

 

RESEARCH METHODS

A qualitative approach was considered appropriate for this research, taking into consideration the authors' adoption of an interpretivist paradigm, where the aim was to understand people within their unique contexts (Nieuwenhuis, 2020). Rubin and Babbie (2017) assert that qualitative research methods are more likely to tap into the deeper meanings of specific human experiences.

The case study research design was adopted as the authors aimed to understand and describe the experiences of nyaope users regarding the therapeutic services they received at private in-patient treatment centres in the Gauteng Province. More specifically, an instrumental case study was operationalised as it allowed the authors to collect data from several cases/participants (Creswell & Poth, 2018; Padgett, 2013) to understand their experiences of therapeutic services offered at private in-patient treatment centres. Ultimately the authors aimed to identify commonalities across cases to offer bottom-up recommendations for service delivery and policy, as they pertain to the people who are addicted to nyaope and receive therapeutic services.

The study population was comprised of nyaope users at private in-patient treatment centres in the Gauteng province. Aligned with the qualitative research approach, non-probability sampling was identified as most suitable for the study, as it allowed the authors to identify the participants who had certain characteristics that were most relevant for the study and to obtain rich data (Strydom, 2021). The sampling was conducted in three phases. During Phase 1 of the sampling process, the authors made use of a purposive sample, which means that participants are chosen for the research study based on the specific characteristics of the population and in accordance with the research question, goal, and objectives of the study in mind (York, 2019). The authors purposively focused on private in-patient treatment centres situated in two metropolitan areas of the Gauteng province. One private in-patient treatment centre in the City of Johannesburg and one in the City of Tshwane were purposively selected. Phase 2 of the sampling process also entailed purposive sampling. Participants were selected because they had certain attributes which made them ideal for sharing their perceptions (Nieuwenhuis, 2020). At each in-patient treatment centre, inclusion criteria were provided to a social worker who identified potential participants in the centre - thus an indirect form of recruitment. The following inclusion criteria were utilised:

• Participants had to be between the ages of 19 and 35 at the time of data collection;

• Participants could identify with any gender;

• Participants must have completed the detoxification phase of treatment;

• Participants had to be admitted to an in-patient treatment centre in the Gauteng province for the misuse of nyaope;

• Participants had to be able to converse in English;

• Participants had to give informed consent for their participation.

After potential participants had been identified by the social workers, the third phase of the sampling process was initiated. The social workers sent the first author a list of names of the individuals who were willing to participate in the study. The first author then conducted interviews with the participants at the respective private in-patient treatment centres.

In total, 11 participants formed part of the study, six participants were selected from the City of Johannesburg and five from the City of Tshwane, at which point data saturation was confirmed. Data saturation is a principle in qualitative research to determine sample size based on the notion that further recruitment of participants to continue with data collection is not facilitating the identification of new themes or changes in existing ones (Nieuwenhuis, 2020).

Data were collected through semi-structured one-on-one interviews. Semi-structured interviews are guided by an interview guide and allow the authors to gather detailed data and an understanding of the participants' experiences and perceptions (Geyer, 2021).

The reflexive thematic analysis method and process, as proposed by Braun and Clarke (2021a), was implemented. Braun and Clarke (2021b) posit that reflexive thematic analysis is a flexible method for data analysis and could be operationalised in studies with different theoretical positions, such as the present study underpinned by SDT, as well as different paradigmatic positions, e.g. the interpretivist position operationalised through an instrumental case study in this study. The following non-linear steps were specifically operationalised as follows: in step 1 the audio recordings of the interviews were transcribed by the first author, and the transcriptions were read and reread to identify items of interest. During step 2 the process of coding was undertaken for both semantic and latent content. It should be noted that although the study was underpinned by the SDT, the authors implemented an inductive analytical process to give an authentic voice to the participants. Step 3 entailed a review of codes and 'upgrading' them to potential themes and sub-themes. In Step 4 the themes and sub-themes were identified and reviewed, in partnership with the second author, in the light of the research question and the study's aim. In Step 5 the themes and sub-themes were finalised before reporting the findings. In the reporting of the findings (Step 6) the authors opted for an integrated approach, thus offering the themes, direct quotes and an interpretation of them with reference to the literature and the theoretical framework. Verbatim quotes are used illustratively.

Trustworthiness of the qualitative study was ensured by focusing on its credibility, transferability, and auditability (Amankwaa, 2016). Firstly, the credibility of the study was ensured through member checking and reviewing all the themes and sub-themes among the authors (i.e. peer debriefing) (Nieuwenhuis, 2020). Secondly, the authors aimed to improve the transferability of the research findings by reporting on the research methods that were used, allowing the possible reapplication of the study in similar research settings. The researcher also interacted with the participants until data saturation was reached, which helped to ensure that thick and accurate descriptions were obtained (Brink, van der Walt & van Rensburg, 2012). Thirdly, in terms of auditability, the authors kept an audit trail of all decisions that were made and steps that were taken during the study (Amankwaa, 2016).

Ethical considerations, such as avoidance of harm, debriefing of participants, voluntary participation, written informed consent, no violation of privacy, and confidentiality informed the study (Rubin & Babbie, 2017). Before obtaining ethical clearance, the authors received written permission from the treatment centres to recruit participants. The study received ethical clearance from the Research Ethics Committee of the Faculty of Humanities at the University of Pretoria (Ref no.: GW20180724HS).

 

RESEARCH FINDINGS AND DISCUSSION

In the reporting of the findings derived from case studies, authors often start with an overview of each case before discussing the themes and sub-themes generated across cases (cf. Creswell & Poth, 2018). However, in this article the authors start with a brief overview of the biographical profile of the participants, making use of participant codes to ensure that identities are protected, followed by an exposition and discussion of the themes and sub-themes generated from the data across the cases (Creswell & Poth, 2018).

Biographical profile of participants

The biographical information, collected during the interviews, contains the ages, level of education, marital status, and other relevant biographical facts about the participants.

As indicated in Table 1, only three of the participants completed high school, while one had a tertiary degree, and four completed Grade 11. With one exception, the participants identified as male. In South Africa, most service users in treatment are male (Adewuyi & Akinsola, 2013). It is unclear whether these statistics accurately reflect the number of persons using illicit substances in terms of gender. Based on the limited data collected on females in this study, it has been deduced that substance-dependent women are faced with several barriers that impede them from entering treatment programmes. These barriers include the lack of childcare, fear of stigma, lack of family or financial support, denial, and co-morbid disorders (Taylor, 2010). The participants had different home languages, yet all conversed in English during data collection.

Table 2 reflects the age of the participants, the age when they started misusing substances, the frequency of use, the amount that they used and the number of the times they had been admitted to a treatment centre.

Table 2 indicates that most participants started using nyaope either in early adulthood or adulthood (Scales et al., 2015). The average age of the users of nyaope in this study was 26.8 years. Scales et al. (2015) state that adulthood signals that time in an individual's life typically characterised by more choice and control over one's life. All the participants but one smoked nyaope every day, whether they had the financial means or not. Five participants started using nyaope before the age of 15 and indicated that they were using 10 bags of nyaope per day. Thus, in contrast to other participants, evidence of tolerance was noticed.

The number of admissions for treatment was split in half, as some of the participants had been admitted to the treatment centre for the first time and the others had been admitted for a second round. Fisher and Harrison (2013) state that recovery is not limited to admission to a programme or to the number of times that individuals are admitted to a treatment centre but is rather a life-long process.

Themes and sub-themes

The research findings are outlined next and interpreted with reference to the literature and the theoretical framework.

 

Table 3

 

Theme 1: Motivation for in-patient treatment

The first theme gives an overview of the factors that contributed to the participants deciding to be admitted to an in-patient treatment centre. It takes an in-depth look at intrinsic and extrinsic motivations and the role that this played in their decision to be admitted. Motivation to seek treatment and continued recovery is essential for success; if the person is not willing, able, and ready to accept treatment, such lack of motivation can be an obstacle to successful treatment and recovery (Groshkova, 2010). The theme further describes the stigma associated with nyaope use and its contribution as a motivation for seeking in-patient treatment.

Sub-theme 1.1: Intrinsic motivation for in-patient treatment

It would appear that the experiences to which the participants had been exposed contributed to their decision to seek treatment and that the participants also sought self-actualisation to reach their potential. The participants expressed their intrinsic motivation to undergo in-patient treatment as follows:

Uhum me sister, I have got a bright future, my father wants me to go and get my matric, but I do not want to go back to school; me I want to do boiler making and those types of things. Anything that is not schooling actually. (PAR05)

Me first, I am my motivation and my two children and setting a good example for my kids. It is good if you know what you want: if you don't then it's a problem, you need to have the motivation. (PAR06)

Now I am older and I need to do something different. I am the oldest at home and I need to take responsibility and do things differently. (PAR11)

The literature highlights the point that an individual's perception of his/her behaviour as freely chosen affects the way he/she perceives motivation, which plays a role in the decisions that participants may make (Higgins, Marguc & Scholer, 2012). Deci and Ryan (2000) state that intrinsic motivation is characterised by engaging in an activity for its inherent satisfaction rather than to achieve some result. The more individuals are motivated to act and to engage in behaviours that will improve their lives, the more they are willing to make sacrifices to achieve set goals (American Addiction Centers, 2020).

Sub-theme 1.2: Extrinsic motivation for in-patient treatment

It has been established that nyaope use harms relationships with families and (marital) partners (Mokwena & Huma, 2014). Families were identified as important extrinsic motivators that drove the participants to want to be admitted to the treatment centre and to maintain abstinence. Some of the participant's views included the following:

It's a lot of things that are happening, you see I am fighting with my parents every day; actually my dad is a businessman, trucks and I am not allowed to touch his taxis and trucks, and in the past I stole from him so he does not trust me because of the smoking. (PAR03)

What will motivate me will be going back to my job, thinking of my daughter and the type of life she deserves to live and taking it one day at a time. (PAR04)

I want to spend more time with my kids because when I am smoking I will not be taking care of my children, I was thinking about myself. (PAR06)

Families and parental factors contribute toward building the capacity of substance-dependent persons to overcome any challenges facing them (Maluleke, 2013). Furthermore, self-determination theory (SDT) underscores how important it is for participants to change because of the way that their behaviour is affecting their families (Deci & Ryan, 2000). One of the major factors motivating people towards recovery could be considered extrinsic motivation (Groshkova, 2010). For example, family support is an important element that contributes positively to an individual's ability to maintain abstinence after treatment (Maluleke, 2013).

Sub-theme 1.3: Stigma associated with nyaope contributing to motivation for seeking in-patient treatment

Nyaope users are often rejected by their communities because of their criminal activities and the perceptions the communities have of them (Mokwena & Huma, 2014). The following quotations highlight some of the challenges the participants experienced in their communities that contributed to their motivation for being admitted for in-patient treatment:

People don't like people who smoke nyaope; they always criticise them, because people who are smoking nyaope are stealing and lying and they do not wash. They do not have time to look after themselves. They must go and look for something; they must go and steal something and going to ask for nyaope, so I needed to change. (PAR02)

... people hate nyaope, because of the negative behaviour that is associated with it and how people just change when they start smoking it. It had a huge impact on me, as I could not write my two exams because I was looking for my fix in the morning - so I don't have matric that is why I need to change my life. (PAR03)

People who smoke it obviously think it 's cool. But those who don't smoke it actually see the reality of nyaope that we don't see. Nyaope is a selfish drug and contributes to you isolating yourself and neglecting your life. But now, I always tell myself and motivate myself that it was not me, but now I feel that I have found [name of treatment centre] and the person that I have always been, the clean person that I know. I tell myself that I am going to make it no matter what. (PAR04)

The social repercussions of nyaope include being shunned by their communities because of the criminal element; however, lack of acceptance by the community is associated with labelling, which can alienate users (Mahlangu & Geyer, 2018). In response to the negative perceptions of the communities, the nyaope users seem more committed to changing their behaviour because of the stigma associated with them. From the SDT perspective, the need for relatedness deals with the desire to relate to people around you (Deci & Ryan, 2000). Nyaope users can only re-establish relations in their communities if they turn their lives around and present with pro-social behaviour.

Theme 2: Coping through the detoxification process

This theme gives an overview of how participants experienced the first part of treatment, i.e. detoxification. The theme consists of four sub-themes, namely the physical impact of the detoxification process, its psychological impact, the impact of medication during the detoxification process, and the role of intrinsic motivation during this process.

Sub-theme 2.1: Physical impact of the detoxification process

The data give an indication of the physical challenges the participants experienced during detoxification. It was found that because of the pain, some of the participants contemplated leaving the treatment centre. Some of the participants' sentiments included the following:

It 's not good if you didn't go to detox; you will never go because the pains were too much but I stayed because I wanted to change ... even on Monday it felt too much and I wanted to go. (PAR01)

I was feeling pain, sister; it was both psychological and emotional pain at the same time and spiritual. (PAR04)

I have been here for 27 days. The detox period was very difficult, I struggled with the methadone. After I stopped taking the methadone, I started having strong physical withdrawal symptoms and I was also not in a good emotional state. I was even contemplating leaving. (PAR07)

The above comments substantiate the finding that drug addiction is associated with damaging physical, mental and social health, and interferes with crucial developmental tasks. It is challenging for recovering users to cope with the detoxification process after a significant period of drug misuse (van der Westhuizen, Alpaslan & de Jager, 2013). It is further evident from the quotations that the withdrawal process is challenging. Recovering users have stated that they find it difficult to withstand the pain of withdrawing from nyaope. Several participants even contemplated leaving the treatment centre because of the challenges associated with the withdrawal period.

Sub-theme 2.2: Psychological impact of the detoxification process

The participants described struggling with cravings during detoxification and indicated that they did not know how to adapt to this transition. Some of the participants' views included the following:

It was emotional ... I struggled a lot as I had the cravings and I was thinking of what I would be doing outside and how I would be smoking with my friends. I struggled emotionally as well, as I felt like I wanted to go home. (PAR08)

It was hard cause it was like it was my first rehab and it was a shock for me to adapt to life. It was like I was going crazy alone in there. (PAR09)

I was starting to talk to myself; being isolated during detox is hard. (PAR11)

The above confirms the statement that substance-dependent individuals are negatively affected by using the drug, as their physical health and their psychological and social wellbeing are affected (Montesh, Sibanda, Basedo & Lekubu, 2015). It was found that the participants experienced some level of stressful psychological impact through the withdrawal period. It is evident that long-term drug abuse is most likely to lead to depression owing to the lack of serotonin in the brain; furthermore, other long-term effects include mood disorders such as anxiety and paranoia (Montesh et al., 2015).

Sub-theme 2.3: Impact of medication during the detoxification process

Participants believed that the medication played an important role in the detoxification phase, as they perceived that it helped them to deal with the physical pain and decreased the cravings. The participants expressed themselves as follows:

It's fine ... just [that] now I no longer get the medication maybe it has been for six days now. But I sleep only maybe after two [at night]. So ... it's hard sleeping after you are off the medication. (PAR01)

It was fine, it was just sweating and you won't sleep during that time but they give you sleeping tablets and medicine called it the syrup, methadone. (PAR02)

Physically I was okay, because of the medication and the amount of medication they had given me. The medication helped and assisted with sleeping. It was emotional where I struggled as I had the cravings and I was thinking of what I would be doing and how I would be smoking with my friends. I struggled emotionally. I felt like I would go home. So I struggled to adapt. (PAR03)

The above comments are substantiated in the literature, as it seems that the medication assisted the participants with the physical withdrawal symptoms that they were experiencing. It was also deduced that the first few days of detoxification may be intense for many recovering users, requiring the medical staff to be constantly required to provide effective support to deal with withdrawal symptoms such as sweating, agitation, a runny nose and insomnia (Hayashida, 1998).

Sub-theme 2.4: The role of intrinsic motivation during the detoxification process

The participants had to rely on intrinsic motivation in analysing why they chose to change their lives and embark on the journey of treatment and ultimate abstinence. The participants expressed themselves as follows:

I had to motivate myself in there as I want to leave this drug life. I thought if I go back I will still smoke so I told myself to think straight. So I went to the sisters and they were advising me accordingly and giving me tips on how to cope with the withdrawals and that helped. (PAR02)

What motivated me a lot is the support that I received. Also that I want to change my life as I do not want to live the life of being an addict anymore. (PAR04)

The medication helps if you are positive, it helps. Ai, if you are not positive you are wasting your time and you feel like it is not working. (PAR05)

Psychological models suggest that recovering users can motivate themselves to give up the drug by resisting cravings (Higgins et al., 2012). A recovering user going through detoxification often experiences heightened levels of anxiety and restlessness as the body and mind attempt to adapt without the drugs. Depending on the severity of the dependency, recovering users suffer from intense cravings for the substance to numb the emotional trauma of detoxing. The recovering users must focus on their reasons for seeking admission during this time. Deci and Ryan (2000) state that an individual's perception of their behaviour as freely chosen also affects the way they perceive external contingencies, which plays a role in the decisions that participants may make.

Theme 3: Therapeutic services at in-patient treatment centres

This theme illuminates how the participants experienced the therapeutic services at the in-patient treatment centres with regard to the value of exposure to a therapist, the experience of a professional relationship with the service provider, and the impact that the group sessions had on them.

Sub-theme 3.1: Exposure to a therapist during treatment

The participants believed that the therapists (e.g. social worker or psychologist) had a positive impact on them, as they had someone on whom they could rely, who supported them and guided them in making the appropriate decisions. The treatment programmes are part of a rehabilitation regimen in which a service user receives intensive therapy and counselling sessions with the purpose of identifying the root cause of addiction in order to ensure the person can be most effectively treated (United Nations Office on Drugs and Crime [UNODC], 2021). The participants expressed themselves as follows:

"The therapist was good, talking helped and it did help me a lot it gave me confidence again. That find that you messed up, but you still can try again" (PAR02).

"I have learnt from her that you have to forgive yourself and that it is important to ask for forgiveness from the people you have wronged" (PAR06).

"I am a black person ... so therapists or psychologists are something I was not used to, but I was open to it. It went well. I feel that I have learnt a lot about myself and how to cope and also about my drug of choice and what to look out for when I am discharged. I feel like this time is different for me because I am mature and I feel that I am ready for the change" (PAR09).

The above comments are substantiated in the literature provided by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2015), which states that the individual treatment plan and goals should be person-centred and include strength-based approaches, or ones that draw upon an individual's strengths, resources, potential, and ability to recover, to keep the patient engaged in care, as this increases the likelihood of successful treatment engagement and retention. People undergoing treatment must focus on their future and not the past if counselling is to be effective. It was also clear that the participants' exposure to a therapist allowed them to express concerns relating to their dependency and they received support from their therapist (SAMHSA, 2015).

Sub-theme 3.2: Relationship with the therapist

The participants stated that they were able to have a good relationship with the therapist to whom they were allocated. Some of the participants' views included the following:

She was good, she understood me. We have a good relationship and that's why I feel more motivated. (PAR04)

She was very good, she allowed me to talk about the things that are hard for me, especially with my family and why I was using the drug and how to cope when I am outside. We discussed why I started smoking in prison because I couldn't cope with the amount of time that I was given but now I have an opportunity to start over. (PAR05)

Counselling needs to be done in a safe environment where mutual trust and support are experienced. Counselling is integral in assisting persons with a SUD to identify their challenges, gain knowledge about their addiction or disorder, and identify appropriate skills to maintain actions to sustain change (Fisher & Harrison, 2013). It was deduced that the counselling contributed to the motivation of participants to recover (Deci & Ryan, 2000).

Sub-theme 3.3: Value of group work sessions

The participants expressed a change in perception after the group sessions and were grateful for having a platform to express their nyaope-related challenges. Participants' opinions included the following:

It changed me, it showed me a lot of things ... like when things go like this you should do this and the things that I need to avoid to not smoke outside. (PAR01)

It feels good, you know, when you talk to someone, and tell myself that I have to let go: get back to work and get my life in order. She helped me a lot with insight into myself and how I view life. (PAR04)

It helped a lot because I was able to figure out that I am not alone in this battle. I was able to understand other people's problems, which sometimes are bigger than my problems. It has been an eye-opener. (PAR08)

Many therapeutic settings make use of group work to capitalise on the social reinforcement offered by peer discussions and to promote drug-free lifestyles. This environment further enabled the participants to identify with others who are struggling with the same issues, and this provided an opportunity for sharing (Higgins et al., 2012). Group work is important in recovery because it allows the group members to share common experiences in a safe and supportive environment. Each participant may gain a deeper understanding of their own addiction-related issues (Swanepoel, 2014).

Theme 4: Overall experience of treatment

Theme 4 covered participants' opinions on the strengths and limitations of the in-patient treatment experience.

Sub-theme 4.1: Opinions on the strengths of the in-patient treatment experience

From the quotations, it became evident that the multidisciplinary team in the treatment centre played an important role in the participants' experience of the treatment and their motivation to endure the challenges to which they were exposed during treatment. Some of the participants' views included the following:

The treatment here is very good and when you don't feel good, you can go to the nurses and they can assist you. (PAR04)

It is the help that I got ... they do not judge you and they try to help you at all times and they accept and advise. (PAR06)

... the medical staff, the social workers and the environment help you change your mind set, have a routine, change in sleeping patterns and also learn to live with rules again. (PAR07)

The treatment helps me, and the information and medication provided by Dr [XX] help me not to think too much about my past and get to know myself. (PAR09)

The goal of the in-patient treatment is to assist individuals living with an addiction or SUD to achieve and maintain maximum functioning (Higgins et al., 2012). It is apparent that the multidisciplinary team played an important role in the participants' experience of treatment and their motivation to endure the challenges to which they were exposed during treatment. This was important, as the participants mentioned during the interviews that the multidisciplinary team provided them with the motivation and support to persevere throughout the treatment process (Higgins et al., 2012).

Sub-theme 4.2: Opinions on the limitations of the in-patient treatment experience

The participants felt that the duration of the treatment was not sufficient. SAMHSA (2015) concurs that the period of formal treatment is often not adequate to address the multitude of challenges experienced by service users. Furthermore, most of the participants indicated that they would appreciate it if the treatment period could be extended. Some of the participants' views included the following:

The period should be 35 days or longer because when the people are leaving here they are not sure about themselves. (PAR01)

For me, 28 days is a bit little, but I feel the medication helps, especially with cravings. I feel that I was working towards physical health. (PAR06)

I think for nyaope users, 30 days or more [is necessary for treatment] because of the physical withdrawals and cravings. Those are the two things that are very difficult to overcome. The withdrawals are a huge one; then you look on working on finding yourself and what you want for the future. (PAR09)

Mokwena (2015) suggests that a tailor-made programme may hold the key to successful treatment for people who are dependent on nyaope. The development of treatment programmes, in addition to any assistance that may be provided to the person living with addiction, is needed to address this multifaceted challenge (Mokwena, 2015). Research has shown unequivocally that good outcomes are contingent on adequate treatment duration (National Institute of Drug Abuse 2012 in Swanepoel, 2014).

 

CONCLUSION AND RECOMMENDATIONS

Some limitations of this qualitative study should be noted. The authors were able to collect data only at two treatment centres, because of challenges with the availability of willing nyaope users at the time as well as with getting permission from treatment centres to interview their service users. Most of the participants were males; hence, the data gathered from a female perspective were limited.

Nonetheless, several conclusions may be put forward. Nyaope users are often exposed to the drug at a very young age in their various township communities; its availability in most townships poses a challenge to curb the use of nyaope in South Africa. Nyaope users need to have intrinsic motivation to be admitted to treatment centres, complete the treatment, and maintain abstinence. Yet extrinsic motivation also plays an important role in the users being admitted for treatment; their families and significant others, as well as the stigma within their communities, motivate them to complete treatment with a view of maintaining abstinence. The substance has a significant impact on the wellbeing of nyaope users. The users could share the physical challenges they experienced because of nyaope, more especially how it had affected them during the detoxification process. It also became evident that the use of nyaope has a distinct impact on the psychological wellbeing of users. The participants were only aware of the physical and psychological impact (i.e., health, mental well-being, and relationship with significant others) of their nyaope use but failed to gain insight into the other domains affected. Participants often failed to acknowledge the impact of their nyaope use on their employability, finances, and the negative consequences for the community where they reside. The detoxification period seems more challenging without the medication provided to recovering users. The first weeks play a key role in the users' perspective on treatment, because of the detoxification challenges that they encounter. Therapists, such as social workers, play an important role in the overall positive experience of their treatment, while group work sessions were highlighted as especially beneficial to share challenges with peers (i.e. the relatedness component was significant) and to motivate themselves to complete the treatment and maintain their abstinence. This study also concludes that the treatment period in the treatment centres is considered inadequate; participants proposed, among other things, that it should be extended to deal with triggers, once they are released. This could decrease the number of times that nyaope users relapse and are readmitted to the treatment centres.

Although the study is of limited scope, a number of recommendations are offered below.

Recommendations for the effective treatment of nyaope users in private in-patient treatment centres

• The various treatment centres should consider increasing the duration of treatment from three weeks to six weeks, which would be a more suitable period; the focus of the first few weeks would be on the challenges that nyaope users face during the withdrawal-cum-detoxification period and then the next four weeks can be focused on crucial elements such as individual and group counselling.

• Therapists were found to be very helpful during treatment. However, the role of social workers or psychologists needs to be more prominent during the detoxification process. It has been deduced that the participants struggled physically and psychologically during that time. The role of therapists, not only medical staff, during the period, could increase the participants' motivation and improve the process of building rapport with service users.

• Treatment centres should focus on educating township communities about nyaope and the impact that it has on nyaope users. In so doing, the stigma associated with nyaope could be softened and appropriate empathy for nyaope users cultivated.

Recommendations for policy and legislation

• As none of the current domestic policies is tailored to address the unique challenges that nyaope users are experiencing, the DSD needs to reconsider the policies and services, specifically regarding how they can be changed or improved to ensure appropriate and successful services are rendered to nyaope users.

• Policy needs to create an environment where the DSD and its partners deploy more social workers in townships to meet the needs of nyaope users at their respective communities through satellite offices. This may assist with the early identification of people who are harmed by the use of nyaope. In so doing, users could be prevented from developing an addiction or SUD and this would at the same time decrease the ultimate pressure on treatment centres for rehabilitation.

• It is equally important for policy to emphasise that social workers should offer aftercare and reintegration services to prevent relapses and readmission of nyaope users to treatment centres.

Recommendations for future research

• The current study needs to be expanded to more treatment facilities in South Africa to undertake comparative studies in the country.

• More research needs to be conducted in which all ethnic groups participate to reflect the demography of the diverse population of South Africa. In the current study, the authors were only able to conduct the study with African males and one female, because these were the participants who were available at the treatment centres. The availability of more ethnic groups would provide more data from different perspectives, which could afford a more holistic view representative of the rainbow nation.

• More research is to be targeted at female users to obtain their perspectives.

Generally, the participants experienced the treatment as positive, and they were of the opinion that it appropriately attended to their multifaceted needs. The role of therapists, such as social workers through the implementation of social work methods, was particularly highlighted as crucial to ensure the support of service users during treatment at private in-patient treatment centres and assist in the successful completion of the treatment.

 

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Article submitted 8 October 2022
Article accepted: 16 June 2023