ARTICLES

 

Determinants of return to active use amongst previously rehabilitated users of nyaope with a history of multiple rehabilitations

 

 

Azwihangwisi Tshiangwana^I; Kai J. Jonas^II; Rob A. C. Ruiter^III

^IMaastricht University, Faculty of Psychology and Neuroscience, Limburg, Netherlands https://orcid.org/0009-0006-1154-9199 amatevha@gmail.com
^IIMaastricht University, Faculty of Psychology and Neuroscience, Limburg, Netherlands https://orcid.org/0000-0001-6607-1993 kai.jonas@maastrichtuniversity.nl
^IIIMaastricht University, Faculty of Psychology and Neuroscience, Limburg, Netherlands https://orcid.org/0000-0001-5017-3258 r.ruiter@maastrichtuniversity.nl

 

 

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ABSTRACT

Returning to active use of nyaope is one of the most problematic issues amongst previously rehabilitated persons who use this substance in South Africa. To understand this aspect in-depth, the study sought to explore the determinants of return to active use from those who have been rehabilitated multiple times. An exploratory qualitative design was utilised for this study. A semi-structured interview guide was developed, and face-to-face interviews were conducted with 13 participants who were recruited from a rehabilitation centre in Tshwane, Gauteng, South Africa. Interpretive phenomenological analysis was the method utilised to analyse the data collected. During analysis, lack of mental determination/compelled rehabilitation, incomplete rehabilitation sessions, failure to cope with stressful life events, supernatural influence, boredom, and hanging out with the same peers who are active users of nyaope, were identified as determinants of relapse. The findings of this study show that successful detoxification and therapy do not guarantee sustainable abstinence from nyaope. The results of this study highlight the need to improve the current interventions by incorporating strategies that will prevent users from returning to active use after going through the rehabilitation process.

Keywords: harmful use; nyaope; rehabilitation; relapse

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INTRODUCTION AND BACKGROUND

The use of nyaope in South Africa continues to have a negative impact not only on its users but also on the immediate family members and the community at large. Nyaope, whose main ingredient is low-grade heroin, is used widely by many young people and people with lower income in South African townships dominated by the black population (Fernandes & Mokwena, 2020). According to Matuntuta (2014) and Mokwena (2015) nyaope is viewed as an extremely addictive substance, with potential physiological and psychological addictive properties. Furthermore, nyaope is a cheaper substance and as such it is easily accessible to most young people (Fernandes & Mokwena, 2020). The effects of nyaope have been described as detrimental for active users (Fernandes & Mokwena, 2020), their communities (Nzaumvila et al., 2023) and their families (Nene et al., 2024).

Nyaope first emerged in the country in early 2000 in certain townships of Tshwane (Gauteng province), namely Soshanguve and Mamelodi (Mokwena, 2015), and has led to a country-wide rehabilitation response. In a bid to address the scourge of nyaope, the Premier of Gauteng province made an announcement in October 2022 about a new initiative that would be launched to rehabilitate youths who are affected by the use of this harmful street substance (Mntambo, 2022). This initiative does not only indicate the magnitude of the problem, but also the government's willingness to invest resources to address the challenges associated with street substances, including nyaope. Despite collaborations between the government and non-profit organisations (NPOs) to provide resources and support aimed at rehabilitating users, scientific evidence notes a high rate of returning to active nyaope use among those who eventually access and complete rehabilitation services (Strauss, 2022).

Mokwena (2015) also reports capacity and financial access hurdles for governmental and private rehabilitation providers. Some of these organisations are entirely private and mostly unaffordable for persons who use nyaope. However, several non-governmental organisations (NGOs) and few public sector rehabilitation institutions make rehabilitation services available and free to users who are willing to be rehabilitated during a six-week treatment protocol.

Evidence from the literature shows that in addition to the scarcity of rehabilitation services, preventing the return to active use is a major challenge that needs to be addressed through a systematic analysis of the determinants of relapse to inform the development of relapse-prevention interventions (Eldredge et al., 2016). Information from the South African Community Epidemiology Network on Drug Use (2023) shows that 44% of individuals who were admitted to the treatment centres in Gauteng (between July-December 2021) were not first-time admissions to those institutions. Focusing on nyaope users, studies show that the prevention of return to active use is a major challenge to users who have been subject to prior rehabilitation activities. Mahlangu (2016) reported on a six-week rehabilitation programme with 100% return to active use among its participants. Motsepe (2022) conducted a study on the psychosocial experiences of persons who use nyaope with histories of repeated rehabilitation. The participants in this study reported that they had been readmitted for rehabilitation between three to six times after rehabilitation. In fact, return to active use after rehabilitation seems to be a common phenomenon.

There is a gap in studies investigating the determinants and correlation of return to active use after detoxification and rehabilitation. The study aimed to understand the occurrence of return to active use of nyaope among users with a history of multiple rehabilitations. The findings drawn from the personal experiences of users can pave the way towards developing more sustainable interventions to prevent return to active use and maximise the effectiveness of rehabilitation interventions and thus encourage permanent abstinence from nyaope for rehabilitated users. The results of this study lay a solid foundation for comparative studies in this area.

 

RESEARCH METHODOLOGY

Design of the study

As the return to active nyaope use has not been studied in detail to date, the qualitative approach adopted for the research entailed conducting individual interviews with nyaope users who returned to active use despite multiple rehabilitation sessions. An exploratory design was appropriate to shed light on the issue, so that the findings could influence an improvement of the interventions to minimise the return to active use after rehabilitation (Saka et al., 2023).

Study setting

The study was conducted in Tshwane (Gauteng province of South Africa), where the use of nyaope is highly prevalent (Madiga & Mokwena, 2022). The data were collected from the Fabian and Florence (FF) Ribeiro Treatment Centre, which is run by the Gauteng Departments of Health and Social Development. The treatment centre has a dedicated team of professionals which is comprised of social workers, psychologists and psychiatrists who support the rehabilitants throughout their rehabilitation journey. Since this is a wholly government-run institution whose services are free to people who use harmful substances, most of the previously rehabilitated users return to this institution after resorting to active use of the substance once again.

Population, sample, and recruitment procedure

The study population was comprised of previously rehabilitated persons who use nyaope and who were readmitted to the rehabilitation centre after returning to active use of the substance. The study included both males and females who were 18 years of age and older, were in good mental health and who consented to participate in the study. Regarding the exclusion criteria, first-time rehabilitants, users who were below 18 years of age, and those who were not in good mental health were excluded, since the researcher was not trained to give them the support and guidance that might be required during the process of interviewing them. With regard to determining the status of mental health, the researcher relied on input from the health care providers in the healthcare facility (social workers and psychologists) who work with the patients on a daily basis.

The recruitment process was supported by the rehabilitation centre staff, who provided a list of persons using nyaope who were undergoing the rehabilitation process. The researcher then identified those who have a history of rehabilitation and returning to active use through a brief interview. This was done to identify the relevant candidates who met the inclusion criteria. After that, an arrangement was made to conduct interviews at a time that was convenient to the participants to ensure that the interview session does not interfere with the treatment schedule of the participants. A total of 13 participants who met the selection criteria were included in this study.

Ethical considerations

Approval to conduct the study was obtained from the Maastricht University Ethics Research Committee Psychology and Neuroscience (ERCPN- 188_10_02_2018_S61). Permission to conduct the interviews with previously rehabilitated users of nyaope who were readmitted to the FF Ribeiro Treatment Centre after returning to active use was also obtained from the Office of the Premier in Gauteng. The Management of the FF Ribeiro Treatment Centre gave approval for the interviews to be conducted with the participants in the centre at an appropriate time. The participants were supplied with the information pertaining to the study several days before the actual recruitment phase for them to be able to make an informed decision about whether to participate in the study. Only the participants who provided written consent were interviewed. It is important to highlight that there was no debriefing conducted with the participants since none of them indicated a need for such service. However, the informed consent form contained information on how the participants could reach the researchers and obtain future support.

Data collection

A semi-structured interview guide was developed for data collection with the participants. Prior to the development of the interview guide, the researcher consulted the relevant scientific literature in the area of nyaope use as well as the broader domain of relapse prevention in the context of substance use. The findings of previous research guided the researcher to develop the questions that were considered relevant to answer the research question of study. The interview guide contained the participants' demographics, the number of rehabilitations that the participant underwent as well as questions that explored factors that were perceived to have contributed to return to active use by the participants. The individual interviews were recorded to ensure that the participants' narratives were well captured for proper data analysis. Permission to record the interviews was obtained from all the participants who took part in the study.

The interviews were conducted in the languages that the participants were most comfortable with, which included English, Isizulu and Setswana. On average the interviews took approximately 60 minutes, with a few cases where the interviews lasted for more than 60 minutes. Some of the interviews took longer as the researcher was taking notes on the observed behaviours of the participants during the interviews. To enhance trustworthiness, the researcher had to establish a trust relationship with the participants considering that the bar to participate was set relatively high, bearing in mind that there was a likelihood of disclosure of sensitive information by the participants. Participants were assured of the confidentiality of their information to encourage them to participate. To ensure trustworthiness of the data, key procedures were followed to enhance credibility, dependability, transferability and confirmability (Ahmed, 2024). For example, credibility was achieved through probing the participants with question aimed at obtaining in-depth information that represents their actual thoughts and feelings, and these were transcribed verbatim to enhance dependability. Furthermore, the researcher took notes of the participants' observed behaviours. These notes in turn were used to complement the interview data and enhance the confirmability of the findings. Finally, transferability was ensured by being transparent about the full research process, including procedures with regard to participant recruitment and data analysis.

Data analysis

The audio-recorded data were transcribed and translated verbatim from Isizulu and Setswana into English by the researcher, who conducted the interviews and who is fluent with the languages. Identifying personal information was removed from the transcripts. Audio recordings were deleted after transcription. To analyse the data, an interpretive, inductive phenomenological analysis (IPA) was utilised to interpret the data and present the findings. This approach places a high value on the meanings expressed by the participants on particular experiences and state and events (Smith & Osborn, 2003). The IPA method was relevant, since it allows examination of the world from participants' point of view in detail, while also attempting to explore their personal experiences (Smith & Osborn, 2003).

During the process of analysing the data, each transcript was read several times in order to identify significant and interesting details of the participants' narratives. After that, the researcher identified the themes emerging from the initial notes that were made in the first step. The next stage involved identifying connections between the themes and clustering them together based on their conceptual similarities. The last step was to write up each of the themes, describing them and supplementing them with the relevant verbatim extracts.

 

FINDINGS

Participants' demographic information

The table below reflects the demographic details of the 13 participants who were interviewed. In this study, it was important to reflect the age and gender of the participants. These two variables were important to get an understanding of relapse patterns among different groups of which allowed for a more tailored interventions approach to support those groups could be designed.

As seen in Table 1, the majority of the participants were males. The youngest person was 21 years while the oldest was 41 years. All of the participants, except for one individual, reported being unemployed and depended on hustling to fund their substance use habit. Two participants had acquired National Diplomas, four had Grade 12 (matric) and seven dropped out of school in lower grades. All of the participants reported to have previously undergone a 6-week rehabilitation in government-funded institutions before returning to active use, and two individuals reported to have been previously rehabilitated in private institutions, where rehabilitation also lasted for six weeks. Most of the participants reported having been rehabilitated more than twice, with an exceptional case where the participant was undergoing a fifth rehabilitation session. Evidence from the data also highlighted that some of the participants had previously attended rehabilitation sessions at different institutions in different provinces of South Africa.

 

Table 1 - Click to enlarge

 

Theme 1: Factors that contributed to return to active use after multiple rehabilitations

Based on the data obtained from the participants, there were six main factors identified that were believed to be associated with returning to active use: lack of mental determination/compelled rehabilitation, incomplete rehabilitation sessions, failure to cope with stressful life events, supranatural influence, boredom, and hanging out with the same peers who are active users of nyaope. Furthermore, the participants offered ideas on strategies to prevent relapses to active use focusing on relocating to a different environment, attending aftercare sessions, and furthering their studies.

Sub-theme 1.1: Lack of mental determination/Compelled rehabilitation

Non-voluntary rehabilitation was associated with difficulties in complete abstinence and consequently the participants reported that they were unable to persevere and thus returned to their old habit of using nyaope. This implies that a lack of willpower or mental determination to quit the use of the harmful substance makes returning to active use imminent, despite successful detoxification and rehabilitation. This information is supported by the following comments from some of the participants:

That one was forced because of the person that I was staying with. I did not decide on my own that I wanted to come to the rehab, it was her (Participant1).

.... this is my third time, the first time I discharged myself. The first time I was not ready because I was forced by my boyfriend (Participant 12).

I was forced, it was not my intention to go to the rehab, I was forced by my parents. Then Ijust saidjust once, only to find that that one smoke is problematic, then during my return to active use, that's when I started to spike it on the 6th of December on starting to use the drug again (Participant 2).

The participants' responses painted a picture suggesting that the root cause of their return to active use is their failure to persevere in abstaining from the substance since the decision to go for rehabilitation was influenced by others and not their own desire. Mental determination or willpower was said to play a critical role in determining the success of rehabilitation of the active user. In a study by Guliyev et al. (2022), a strong desire to quit substance use is associated with a decreasing the likelihood of relapse.

Sub-theme 1.2: Incomplete rehabilitation sessions

Evidence from the data reflects that returning to active use was not the only possible outcome resulting from a lack of mental determination to quit the use of nyaope. Limited prospects of completing the rehabilitation were also some of the causes. This is because some of the participants reported that they could not complete the rehabilitation process, since it was not their personal decision to seek help. Participants mentioned that they found it difficult to endure the withdrawal symptoms during the first few days of the rehabilitation process. Consequently, they resorted to taking what is referred to as an SD (Self-Discharge). The SD process enables them to drop out of the treatment without completing the rehabilitation and thus return to active use immediately. This finding is reflected in the following extracts:

In 2014 I took self-discharge before I finished the programme. It was because of the withdrawals; they were troubling me. I was experiencing severe stomach cramps, sweating, I also had illusions, like I was seeing things. I was unable to sleep completely (Participant 9).

Actually, to tell you the truth I used not to complete my rehabilitation sessions, I would not stay for more than 8 days in the rehab. I was unable to persevere, sister. The drug was too much on my system you see, sister. I had cravings (Participant 8).

It was also revealed during the interviews that some of the participants were expelled from the rehabilitation centre as a result of their failure to comply with the regulations. The responses of participants 5 and 12 below demonstrate two main issues that led to their expulsion, i.e. theft and engaging in sexual relations with fellow male users who were also undergoing treatment:

So, when I came here I found this guy (name withheld) and then we started seeing each other, and then we got kicked out the two of us and that's when I started using it again (Participant 5).

...second time I was in a scheme of stealing cigarettes (Participant 12).

From the participants' responses, it is evident that a lack of intrinsic motivation was a significant barrier to successful rehabilitation. It is evident that self-motivation is important for successful rehabilitation, or else all efforts to rehabilitate them will continue to be futile. Furthermore, assisting users to manage withdrawal symptoms is crucial for successful rehabilitation (Varshney et al., 2023)

Sub-theme 1.3: Failure to cope with stressful life events

Lack of effective coping mechanisms in terms of dealing with life's stressful events was reported as one of the factors that made the participants resort once again to using nyaope to relieve the pressure of their challenges. Based on the participants' perspectives, nyaope is viewed as an easy escape route from the personal problems that participants experienced in their world. Most of them reported during the interviews that they resorted to using nyaope again once they experienced personal issues that they found difficult to deal with despite successful rehabilitation. The comments below demonstrate the participants' despondence when confronted with life difficulties:

When I scrolled on her cell phone, I saw something unpleasant (girlfriend cheating), and she was doing it with my friend, you understand me, then I started using it on the first day (Participant 1).

You see, that thing, we easily use it again because of minor things such as when someone makes you angry or you did something and you fail (Participant 3).

My Aunt passed on, I really forced myself to go and smoke, you see, I loved her dearly (Participant 11).

From the above comments, it is evident that participants return to active use because the substance acts as a coping mechanism to deal with difficult personal issues that they face in their lives. The comment from one of the participants above demonstrates how a stressful life event influenced him to opt to use nyaope to cope with the pain of losing a loved one. For some participants, seeking relief through the use of nyaope was also a strategy to avoid taking drastic steps that could lead one to commit a grave crime. For instance, for one of the participants above, smoking nyaope was perceived as better than harming the girlfriend and getting arrested. Weak coping skills among people with substance use disorders elevate the risk of relapse (Ramsewak et al., 2020). This finding demonstrates the importance of empowering the participants with skills that will assist them to cope well with stressful life events without necessarily seeking solace in the harmful substance

Sub-theme 1.4: Supranatural influence

This theme pertains to some of the participants holding the view that returning to active use is to a certain extent influenced by demonic forces, which makes the process of maintaining abstinence impossible. One of the participants even said,

This thing has got some form of devil in it, it is like when you smoke this thing, your life pauses, you must focus on that thing (Participant 12).

To the participants, although they successfully completed the rehabilitation processes and left the institutions with a positive state of mind of permanently maintaining their abstinence, they found themselves being forced to go back to their old habits as they were unable to combat the spiritual influence. The descriptions of the participants are well reflected in the comments below:

... that is why I say it is a demon, it is like Satan is sent, ...it is like Satan send them to you to cause you to use nyaope again, do you get my point? (Participant 1)

...that is why I am saying that this thing has got Satan on it straight. I see with these other people who are coming from other rehabs they fight it from the physical point of view, that is why someone come from rehab today and start to use the drug again the following day (Participant 10).

...eish, that thing? that thing is satanic. you forget all its consequences, you only recall those after you have smoked (Participant 8).

What could be noted from the above extracts is that the participants perceived that there was a definite supernatural force contributing to the problem of returning to active use, suggesting that supernatural or spiritual intervention could also be required to prevent rehabilitated users from returning to active use. More information on the power of spiritual intervention to overcoming harmful use from nyaope was well elaborated by one of the participants above, whose last rehabilitation was in a private institution, but government funded. Another participant went further to say,

That is why even in the rehab that I am coming from, they do say that this thing is spiritual, there is something, it is not the only thing, that is why I don't think that except through prayer, one can win the battle against nyaope , and you should also pray (Participant 3).

The views of the participants in this study were aligned with those of the community members where the use of nyaope is associated with disconnection from religion or spiritual inclinations (Nzaumvila et al., 2023).

Sub-theme 1.5: Boredom

Another issue that emerged from the findings was that of boredom. Most of the participants mentioned that when they returned to their respective environments after completing the rehabilitation sessions, they found themselves idle, since they were neither studying nor employed. Consequently, a sense of tedium developed, and they found themselves using the substance again. This aspect is reflected by the following comments from some of the participants:

Remember the idle mind is very dangerous, so now if I can spend much time without doing anything, I get bored. Sometimes I wouldfeel the cravings when I think about it or if I see it or meet with other gentlemen, because it happens that you will meet them when you are bored or just to see them passing by, because you are bored you will decide to mingle them, and you should know that when you have quit nyaope use, it is easy for them to easily hook you into it because they give it to you freely, its like they want you to be like them and the moment you get addicted, that's when they refuse to give you (Participant 3).

There is nothing specific I can say, because I just went back to using the drug, because I was bored (Participant 4).

Mm, the thing is with us, users of nyaope , once we come back from rehab we don't have anything to do when we get back home, that's the thing(Participant 5) .

The above comments point to the implication that having free time without any plan on how to utilise it constructively can have harmful consequence; this calls for a proper post-rehabilitation plan after their release from the centres to prevent return to active use, considering that the participants are not employed or studying. It has been shown in a study by Charlton et al. (2019) that provision of sport facilities, along with other amenities, could help in alleviating boredom among youth. Although this finding is relevant for young people in general, other activities which would accommodate people of different age groups could be explored to reduce the chances of boredom, which in this case has been reported to be a contributory factor to relapse.

Sub-theme 1.6: Hanging out with the same peers who are active users of nyaope

The influence from the old group of friends was also reported to play a role in causing rehabilitated users to return to active use of the substance. The participants in this study mentioned that fraternising with their former circle of with peers whom they had previously smoked and who are still actively using the substance makes them susceptible to returning to active use of nyaope. The comments serve as illustration:

Yes, when I arrived in the township I started again because the people I used to hustle with were still smoking and were jealous that I was no longer smoking (Participant 6).

....even if you can stay for 10 years without using it and you are clean, there would be a day where you will meet with your friend whom you used to smoke with and because you once shared drugs with the person, you will develop a feeling where the cravings overpower you, not necessarily physically but in your mind (Participant 7).

...and you find it is those people whom that time when you were using nyaope, they would never buy you but then a person is able to buy you on seeing that you are clean (Participant 1).

It was also noted from the findings that it did not matter how long the person abstained from using nyaope after rehabilitation, participants are more likely to submit to the influence of their former friends whom they used to share the substance with, which shows a strong link between peer influence and returning to active use of nyaope despite multiple rehabilitation sessions. This aligns with the findings of a study by Suwanchatchai et al. (2024), which highlighted that socialising with friends and being around close relatives who are using substances significantly increased the risk factors of substance use relapse. This finding resonates with the notion expressed by participants in our data that their friends who are still actively using nyaope do not take it well or become jealous when one of their peers has been rehabilitated and so they try to hook the rehabilitated user by offering free hits.

In a nutshell, the findings of this study showed both internal and external factors are perceived to influence a return to active use amongst the participants. Yet the participants continued to offer suggestions for preventative strategies.

Theme 2: Suggested strategies to prevent return to active use

Apart from narrating the factors that influenced return to active use after rehabilitation, the participants suggested possible strategies that could help in preventing return to active use. Three themes were identified in this regard, namely change of environment, enrolling for after-care and rehabilitation sessions, and lastly, furthering their education.

Sub-theme 2.1: Change of environment

To some of the participants, leaving their homes of origin was the most appropriate way to maintain their abstinence since, according to them, going back to the same environment almost guarantees return to active use. The participants emphasised that relocating to a different place altogether could assist them in starting new lives, since they would have been separated from influential forces such as the former users' friends who are still actively using nyaope. The comments below represent some of the participants' responses in this regard:

I have even told my mother that when I leave here, I will go to Bloemfontein, to her young sister's place... because the same environment again, I am going to use the drug again (Participant 2).

I would be relocating from my place to go and stay with my mother, so that I can finish a year or two still thinking about my life (Participant 1).

When I stepped out of the rehab, I was excited that I stopped using it but as soon as I stepped into Carletonville, eish, eish, things became somehow, there is something which pushes you to say go and have only one, you will be fine and not get out of the way. I don't know but I feel like, when I look at it, I will have to move out of that place (Participant 11).

The participants' responses above suggest that returning to their social environment predisposes them to return to active use, hence a change in the physical environment is associated with minimising the risks after rehabilitation.

Sub-theme 2.2: Enrolment and taking part in after-care sessions

Enrolling and attending after-care sessions were some of the suggestions made by the participants as a means of overcoming temptation to return to active use, which shows the value attached to these services by the participants. The comments below reflect the determination of the participants to ensure that the assistance they received from the rehabilitation institutions is sustained:

I will go to after-care sessions and then I am sure they will keep us busy, and even when I go back home, I will think of doing the washing, and my boyfriend would have come back from work, and now he is working night shift, so I will never get bored during the day (Participant 12).

I am not going home, I have applied for an after-care at half-way house. I will be attending the one located in Mamelodi (Participant 8).

The findings above show the importance of ensuring that users are not released from the rehabilitation centre without a proper plan for after-care programmes that will continue to address the needs of the participants after their rehabilitation to avoid the likelihood of returning to active use.

Sub-theme 2.3: Furthering their education

All the participants who took part in this study dropped out of their educational activities but revealed during the interviews that they planned to continue their studies, since this was viewed as one of the mechanisms to overcome the possibilities of returning to active use. This is shown by the following comments from the participants:

I will see what will happen, but if there are possibilities I might go back to school, I like the law profession (Participant 3).

..mm, I will go to school, with afternoon classes (Participant 13).

It is apparent from the participants' responses, as reflected in the above quotes, that they are confident that studying further is one of the solutions to keep them occupied and thus escape the impulse to return to active use of nyaope.

 

DISCUSSION

The study explored and discussed the factors that affected a return to active use of nyaope after completing rehabilitation from the perspectives of the users themselves. Furthermore, the participants themselves suggested possible solutions that they perceived could help them in preventing them from returning to the use of nyaope. The findings of this study show that despite the participants undergoing a 6-week in-patient rehabilitation programme multiple times, overcoming the possibility of returning to active use has proved to be the most difficult process for the participants. This is because the majority of the participants indicated that even though they underwent rehabilitation multiple times, they returned to active use again and again despite completing rehabilitation sessions. Based on the participants' narratives, it is concluded that undergoing the process of rehabilitation in itself did not guarantee permanent abstinence from the substance. Although the participants mentioned various factors that they said contributed to or caused their return to active use, maintaining abstinence for users of nyaope is a battle that is hard for them to deal with.

The findings of this study showed that lack of mental determination (mainly a consequence of coerced/forced rehabilitation) is associated with a return to active use, since the participants were not yet mentally ready to be rehabilitated. This finding is consistent with those of the Ngoepe (2016) study, where it emerged that return to active use occurs in instances where treatment was initiated by loved ones, doctors or employers as opposed to the desire of the individuals themselves. A study that was conducted by Mahlangu (2016) on the after-care needs of users of nyaope and their significant others also found that return to active use was high because of coerced rehabilitation by parents. The finding that quitting the use of nyaope use requires personal mental determination by the users was also reported in a study by Mokwena (2015). Hence, it is crucial to conduct readiness assessment for rehabilitation to produce positive outcomes. Rehabilitation initiatives should therefore ensure that rehabilitants are mentally prepared and ready for rehabilitation, so that current rehabilitation interventions are not futile. This could be achieved by engaging with community development organisations that support active users of nyaope to seek rehabilitation.

The findings also show that incomplete rehabilitation sessions cause by different factors played a role in return to the active use of nyaope. Some of the participants also flagged that they returned to active use of the substance because they left rehabilitation centres prematurely as a result of issues such as failing to endure withdrawal effects, while some were expelled for failure to adhere to the rules in the centre. A study conducted by Ndou and Khosa (2023) concurred with this finding, which identified that terminating the services prematurely was one of the contributory factors to returning to active use. This finding shows the need to put a measure in place to assist the participants to deal with withdrawal symptoms that result from not smoking/injecting the substance. For instance, methadone could be administered to the users for the first few days to provide an analgesic effect and manage withdrawal symptoms, thus encouraging users not to prematurely exit the rehabilitation process. During the preparation stages, users should also be encouraged and supported to follow the treatment centre rules to avoid expulsion before completing their treatment sessions.

Failure to cope with life's stressful events was also identified as one of the determinants leading to continued active use of nyaope. The participants reported that the struggle to cope with painful life events such as the loss of loved ones, failures and relationships that did not work out also contributed to their return to active use of the substance. A similar finding in this regard emerged from a study conducted by Motsepe (2022), who found that unprocessed trauma related to aspects such as death/loss, failed relationships and individually perceived failures predisposed rehabilitated users to return to active use. This finding was confirmed in a study by Mogoale (2021), who found that when users faced stress or specific stressors, they struggled with coping and consequently used substances to cope with personal issues. This shows the need to incorporate and/or strengthen the psychological modality of the rehabilitation programmes to equip rehabilitated users with robust coping mechanisms that will help to avoid a return to active use of nyaope.

The issue of supranatural influence was flagged as one of the reasons some participants returned to active use of the substance. Some of the participants blamed demonic forces for both their initial use of nyaope and return to actively using the substance after rehabilitation. To those participants, any rehabilitation intervention that did not address the spiritual dimension would not bring any solution to the problems that are associated with the use of nyaope. A study by Nene et al. (2024) observed that some family members of persons who use nyaope seek spiritual and religious solutions. Nzaumvila et al. (2023) noted that some participants were convinced that persons who use nyaope were demon-possessed, hence their strange behaviour which they believed could not be associated with any physical cause. Considering the association between spiritual beliefs, the harmful use of nyaope and returning to active use as reflected in the findings, it is important to take into account the spiritual dimension in addition to the professional intervention. Mahlangu and Geyer (2018) also demonstrated that there is a need to incorporate spiritual support during rehabilitation and after the participants have been discharged from the rehabilitation centre to assist the users in maintaining abstinence. However, this should be done with caution, since the approach might resonate only with those participants who are spiritually inclined.

Furthermore, the findings showed that boredom, resulting from free available time with no plan for utilising it productively, is one of the reasons for the participants' return to active use. The participants reported that since they are neither working nor studying, they found themselves with a great deal of available time and thus became bored, which contributed to them returning to active use. This finding is in line with the study by Mogoale (2021) where boredom and loneliness were identified as factors that influenced return to active use among participants. Creating opportunities that would prevent the idling of minds after rehabilitation should be one of the focus areas during or after rehabilitation to reduce the possibility of returning to the use of the substance. South Africa is currently faced with the problem of unemployment, with the unemployment rate reported to be at 32.9% in the first quarter of 2023 (Statistics South Africa, 2023). Therefore, it is critical to capacitate the nyaope users in rehabilitation with, for example, vocational education to equip them with skills that could be used to create self-employment and ensure that they are kept occupied, thus minimising the possibilities of returning to the active use of nyaope.

As the participants indicated, socialising with the same peers who are actively using nyaope influences them to return to active use of the substance and thus relapse. A study by Fernandes and Mokwena (2020) reported that many participants admitted that they started using nyaope because of the influence of their friends. This shows that the influence of peers and/or friends plays an important role in relapse.

Based on the findings of this study, the six key determinants of returning to active use that were identified by most of the participants had to do more with individual factors than external factors. For instance, while a few participants mentioned spiritual issues and spending time with substance-using friends as other contributory factors, it was the lack of mental determination, boredom, failure to cope with stressful life events and uncompleted rehabilitation sessions that were reported to be major contributors to return to active use. The participants of this study further demonstrated their willingness to sustain their abstinence from nyaope use. This was evident when participants suggested three possible strategies, namely relocating to a different environment, attending aftercare sessions, and furthering their studies. Some of the participants were concerned that returning to the same environment after rehabilitation exposes them to, or increases their chances of, returning to active use. A similar study by Mousali et al. (2020) also showed that the participants believed that the location where they used substances and/or had easy access to substances played a crucial role in their return to active use. Therefore, this is a call for selecting partners to deliberate on the issue of the physical environment and come up with possible solutions to this challenge. The participants also believed that after-care programs could help them overcome returning to active use of nyaope. The need for after-care programmes has been identified as important in preventing return to active use after rehabilitation (Mahlangu & Geyer, 2018). This suggests the need for adequate after-care programmes that will address the needs of the post-rehabilitation users to prevent a return to active use.

The results of this study revealed that all the participants dropped out of their studies, but after rehabilitation believed in furthering their studies so that they do not remain idle. In their study, Mphahlele et al. (2022) observed the level of poor academic performance, which often leads to student dropouts. Furthering education was perceived by the participants to be one of the important aspects that would keep them away from returning to the use of nyaope. This reflects the need for the rehabilitation centres to collaborate with relevant interested parties, especially the Department of Education in this case, to cater to the needs of those who would like to continue with their schooling, which could assist them to stay away from the use of nyaope.

 

STRENGTHS AND LIMITATIONS

The strength of this study rests in the fact that a previously overlooked population of users of nyaope who had relapsed multiple times has been studied and gave first-hand information about factors that, according to them, make it difficult to quit the use of the substance despite rehabilitation. The main limitation of this study was that the data were collected from one public sector rehabilitation centre (FF Ribeiro Treatment Centre) and thus care should be taken when generalising the findings to the whole population of nyaope users. The sample size of 13 participants may be perceived to be on the small side, but should be seen in the context of a population that experiences difficulties making their voices heard. In future research, data from similar samples from other sites should be analysed, and the perceptions of users from private sectors who have been previously rehabilitated should be included to gain different insights and compare such findings with those who underwent government-sector rehabilitation treatment.

 

IMPLICATIONS FOR SOCIAL WORK PRACTICE AND OTHER STAKEHOLDERS

It is important for social workers preparing users of nyaope for rehabilitation to conduct a comprehensive assessment to determine the readiness of the users for such an intervention. The results of the assessment should inform the final decision on rehabilitation. This is because rehabilitating users who are not mentally prepared for the process presents challenges that render the process futile, since they either return to active use or opt not to complete the process. It is during this preparation phase where users will be able to develop an understanding of the nature of rehabilitation and also what is expected of them in the process. Furthermore, preparation will also help the users to prepare themselves mentally for the challenges that they will face during the rehabilitation process. Social workers could, for instance, incorporate motivational interviewing techniques during the preparation phase, since this will help users to develop a positive attitude towards rehabilitation. In addition, it would be important for social workers to collaborate with other stakeholders to ensure that the process of detoxification begins as soon as the user is ready for rehabilitation, i.e. before the actual rehabilitation process. This will reduce the likelihood of quitting rehabilitation because of an inability to cope with the withdrawals symptoms that come with quitting the substance. This in turn calls for the intervention of the Department of Health to administer and manage the detoxification process during the preparation phase of the participants. This will also ensure that users fully engage with the rehabilitation process immediately, as opposed to spending the first week trying to deal with the withdrawal symptoms, since this cuts into the time of the actual six weeks that should be spent on the programme.

Adequate after-care programmes should be part of the intervention to address other factors that might lead to return to active use after the successful completion of the rehabilitation process. It is in these after-care programmes where the different needs of users will be identified and addressed to prevent users from returning to active use of nyaope. Therefore, the Office of the Premier in Gauteng province, in collaboration with the Department of Social Development, should also invest in making resources available to address the after-care needs of the rehabilitated participants as part of the relapse-prevention strategies for successful long-term rehabilitation.

Incorporating the spiritual/religious approach into therapeutic intervention selectively during the rehabilitation and after rehabilitation should also be considered, as some users' perceptions were that demons and evil spirits are behind both harmful use and return to active use of nyaope. Thus, government should collaborate with various faith-based organisations to provide the spiritual/religious intervention to those participants who would require such spiritual intervention as part their rehabilitation.

 

CONCLUSION

The current study contributed towards the scientific literature on the factors that lead to a return to active use of nyaope among participants with a history of multiple rehabilitation. Based on the findings, it is concluded that successful detoxification in an in-patient institution does not guarantee complete abstinence from nyaope. The participants' narratives reflected the need for rehabilitation intervention to address factors that were reported as contributing towards a return to active use. Rehabilitation interventions should focus not only on detoxification and therapy, but also on identifying risk factors that can in turn function as target points for intervention programmes to promote resilience in former nyaope users before they return to society.

 

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Article received: 28/08/2024
Article accepted: 10/12/2024
Article published: 13/06/2025

 

 

AUTHOR BIOGRAPHY
Azwihangwisi Tshiangwana is a doctoral student currently affiliated with Maastricht University in the Netherlands, in the Faculty of Psychology and Neuroscience. Ms Tshiangwana is currently working in the Monitoring and Evaluation Chief Directorate of the National School of Government in Pretoria.
Kai J. Jonas is a full Professor of Applied Social Psychology at Maastricht University. He is an endowed chair with a specific focus on LGBTQI+ diversity and health. His current research interests are on self-regulation and effective approaches in the area of health and discrimination as well as risky decisions. Professor Kai is the supervisor of this PhD trajectory. He provided full guidance and supervision during the initial drafting of the paper. He reviewed and edited the paper until its completion.
Rob A.C. Ruiter is the Chair of Health and Psychology in the Faculty of Psychology and Neuroscience, Maastricht University. His core research and teaching interests are in systematic development, implementation and evaluation of theory, and evidence-based change interventions with a special interest in the application of psychological theory to understand and provide solutions for societally relevant problematic human behaviour in the domains of health, environment and safety. Professor Ruiter is the supervisor of the PhD trajectory. He was fully involved in the initial drafting of the paper, reviewing and editing the paper until its finalisation.