Factors Impacting Why Women Stay in Marital Life with Substance dependent Husbands: A Grounded Theory Study

Received: 15 July 2021 Accepted: 10 September 202


Introduction
In recent years, divorce has gradually become a crisis affecting the family members followed by several economic, social, and psychological problems (1). There are several reasons for divorce in Iran. The substance-related disorder is one of the important factors leading to divorce. The results of some studies in Iran have indicated husband's substance dependence is one of the main causes of divorce (2,3). Many Iranian families are directly and indirectly affected by the substance-related disorder. It is one of the social problems facing families involved with this problem. The role of the husband is crucial in the social relationships of family members and his substance-related disorder leads to family breakdown and affects the relationships between the members (4). Substance abuse by a person in the family imposes a profound effect on the layers of his life and relatives, so that spouse abuse, marital conflict, and divorce are more common in families of these people (5).
Dysfunctional attitudes and lack of communication skills, feeling alienated, poor support, violence, maltreatment, chaos, and isolation decrease the resiliency of the wives of substance abusers and lead them to divorce (6,7). Studies on substance-related disorders have mostly focused on the factors affecting its occurrence (8)(9)(10)(11), rehabilitation and relapse (12)(13)(14), and its damages and complications on the substance users (15). Some studies have been also done on complications and effects of substance use on family relationships. For example, a study showed that women with addicted husbands obtained higher scores of anxieties, depression, and psychiatric disorders and lower scores on the scale related to self-esteem and self-efficacy compared to other women (16). It has been reported that these women have more problems, including substance use, infidelity, and experience of physical violence by the husband, suicidal ideation, and suicide attempt compared to other women (16,17).
Considering the importance of the marital relationship and the vital role of substance dependency in family violation and social implications of this issue (2)(3)(4) and taking into account the specific geographic location of Iran, as well as due to the need to empower the wives of substance-dependent husbands, it is required to investigate in-depth the inner experience of wives of substance-dependent husbands with qualitative approach.
According to the authors' reviews, no qualitative study was found to explore the factors affecting the spouses of substance-dependent husbands to stay married in Iran. Therefore, this study aimed to examine these factors from the women's and experts' points of view.

Method
Design: The qualitative research method of the grounded theory was used to investigate the profound experiences of spouses of substance abusers. This method is usually used in areas that have not been researched before, as well as to get a new perspective on familiar research fields (18).
Participants: This study was conducted on 20 participants (10 women with substance-dependent husbands and 10 experts in the field of substance dependence), which were selected by purposeful and snowball sampling method. Sampling was stopped as theoretical saturation was reached. Theoretical saturation of data is a term in qualitative research, mostly used in the grounded theory approach. Theoretical saturation of data means that researchers reach a point in their analysis of data that sampling more data will not lead to more information related to their research questions (18). The study was done in January, February, and May of 2019.
The inclusion criteria for women included having a husband with a history of substance dependence with at least one quit attempt, stay in a marital relationship and marriage duration of at least 5 years. This issue was considered since most divorces occur in the first 5 years of marriage (19). The inclusion criteria for the experts included having at least two years of work experience in the field of substance-related disorder and relevant education in this field. The exclusion criteria for 207 women included those who do not have addicted husbands or are divorced, or women with substance-dependent husbands who have never tried to quit, and marriage duration of fewer than five years. The exclusion criteria for the experts consisted of not working in the field of substancerelated disorder or having work experience of fewer than two years in this field. Those meeting the research criteria were invited to attend the interview. The experts participating in the research were identified and interviewed by referring to their offices, counseling, and treatment centers of substance-related disorders. The spouses of addicted people were found by referring to recovery camps and related NGOs (Nongovernmental organizations such as the Association of Anonymous Addicts and the Sixty Congress are active in the area of drug rehabilitation), or they were introduced by the experts.
Procedure: Face to face, semi-structured, and indepth interviews were conducted. Before the study, to comply with ethical principles, a consent form was given to the subjects for participation in the study and recording their voices. The necessary explanations were given about the research objectives and the reason for recording and the confidentiality of their information were emphasized. The participants' demographics were cited using nicknames to keep the right to privacy. Some of the research questions included "What helped you to stay in the marital relationship?" "What are your effective and ineffective strategies for continuing the marital relationship?" "What are the roles of children, families of origin, society, economic factors, media, and organizations in helping for the survival of marital relationships?". During the interviews, the follow-up and exploratory questions were gradually raised to clarify the concept and deepen the interview process based on the data provided by the participants. The concepts derived from interviews allowed the researcher to use the subsequent participants' information concerning new concepts. Sample selection and data collection and analysis were continued until the theoretical saturation and ensuring the non-emergence of new concepts. In selecting the samples, it was considered to choose people with different economic and academic levels by considering their educational and economic levels. It is described in detail in the demographic information of the research samples.
Analysis: In this research, a systematic data analysis method of the grounded theory was used. In this method, the researcher uses a paradigmatic model to develop a theoretical framework. A paradigmatic model in Strauss and Corbin's approach (18), examines each category with causal conditions (factors leading to the occurrence of the phenomenon), intervening conditions (conditions affecting the studied phenomenon through causal conditions), action/interaction strategies (specific actions or interactions arising from the central phenomenon), contextual conditions( a specific set of conditions in which the action/interactional strategies are taken, concerning managing the core phenomenon), and the consequences (outcomes of the phenomenon involved through activities and interactions).
Based on the systematic approach of Strauss and Corbin, the data obtained were analyzed using a systematic and continuous process of data comparison. To this end, a three-step process of open coding, axial coding, and selective coding was used. After transcribing the audio files and reading the text of the interviews, the main concepts were extracted and recorded as codes, and then, similar codes were classified. In axial coding, the categories were related to their axial classes to obtain more detailed and thorough explanations of the phenomenon. Also, in the axial coding, the initial categories formed in open coding were compared to each other and those with similarities were categorized based on a common axis. Eventually, the integration and refinement of the categories were done in the selective coding and one category was chosen as the central category, based on which, the model was designed (18).
Trustworthiness of data: Different criteria have been provided in different studies for assessing qualitative research, including the research based on the grounded theory. In this study, the following methods were used to reach the reliability criterion: 1-using the trinity technique: in this study, to increase the credibility, the interviews were made simultaneously with two groups of the spouses of substance-dependent husbands and the experts in the field of substance-related disorder and family. The findings were reviewed by several researchers, and two methods of observation and interview were also used; 2-researcher selfrevision: during the process of data collection and analysis, the texts of the interviews were read several times and evaluated by the researcher; 3audit technique: in the course of the research, three experts in the field of grounded theory supervised various stages of coding, conceptualizing, and extracting the categories (20).
The data were analyzed using descriptive statistics (frequency, percentage, and mean and standard deviation). Furthermore, the constant comparative method of Strauss and Corbin (18) was used to analyze the qualitative part of the study.

Results
Participants' demographics: The participants' demographics are presented in Table 1. The mean age of women was 35.2 years (SD= 7.42) and the mean length of women's marriage duration was 13.2 years. Moreover, five of the experts participating in the study were female and 5 were male. Their mean age was 37.3 years (SD=7.40) and their average work experience accounted for 8.8 years. One of the experts had a bachelor's degree; 6 experts had a masters' degree, 1 expert had a Ph.D., and 2 experts were general practitioners. More information is indicated in Table 1. According to the analyses, the open, axial, and selective codes were determined, and the core category of the study was selected with a title of "A journey with fear and hope". The codes are shown in Table 3. The lack of support by the families of origin Family of origin's role The use of support resources, including families of origin, relatives, friends, non-governmental organizations (NGOs), therapeutic groups, and religious beliefs The use of supportive resources Increasing awareness about how to deal with a substance user and the nature of his problem, how to make clear boundaries with other people especially families, how to talk with children about the father's substance-related disorder, how to treat with the addicted spouse, family employment Increasing awareness Not using destructive behaviors (criticism, blaming, complaining, grumbling, punishing, humiliating, threatening, miffing, twitting, and over-controlling), boundary-making (not to mention the problem to the families of origin, negligence on the destructive comments of the surrounding people and not allowing others to enter into marital privacies) and accompanying the husband (not leaving him alone, trusting the husband after rehab, talking softly and gently) The use of constructive behaviors Divorce stigma (negative judgment of the community about divorce and its taboo nature, the fear of being ridiculed, and the society's view of women's responsibility towards the child) and the legal factors that make divorce difficult (children custody, difficulties of rules for women)

Social and legal factors
Positive outcomes of staying in the relationship. Experiencing selfefficacy, the satisfaction of the child's success, achieving personal growth and independence, being proud of helping to rehab their husbands Desirable emotions and experiences Emotions (fear, regret, remorse, fatigue, burnout) Financial problems Social problems (negative judgment and attitudes toward substancerelated disorder problems with the children's school and a negative attitude to women on how to earn money) Difficulties with husbands (verbal and nonverbal aggression, emotional and sexual neglect, lying, unreliability, dangerous and illusory behaviors, and life-threatening dangers for women) Family problems (blaming of the family of origins, pushing to divorce, and supporting of the family of origin of the man from his misconduct.

Undesirable emotions and experiences
To provide a paradigmatic model, as shown in Figure 1, the causal conditions, intervening conditions, strategies, contextual conditions, and the consequences of the study were determined as follows. In this study, the causal conditions included 1-the child as a barrier to leaving the marital relationship, 2-feeling satisfied with the marital relationship, 3-the attitudes, expectations, and feelings of the women 4-promising behaviors of the addicted husband 5-financial dependency on the husband, and 6-level of substance use disorder. The intervening condition was the family of origin's role. The women's survival strategies in marital relationships included the use of supportive resources, increasing awareness, and the use of constructive behaviors. Social and legal factors were the contextual conditions of the study. Ultimately, the consequences were desirable and undesirable emotions and experiences. These factors are shown in Figure 1, under the title of the paradigmatic model of "A journey with fear and hope". Each of the axial codes associated with this model is given along with an example of each one in the following: Casual conditions: the causal conditions included: 1-child as a barrier to leave the marital relationship, 2-feeling satisfied with the marital relationship, 3-the attitudes, expectations, and feeling, of the spouses of substance-dependent husbands 4-promising behaviors of addicted husband 5-financial dependency on the husband, and 6-level of substance-related disorder.
1-Child as a barrier to leave the marital relationship: Most participants (the women and the experts) mentioned the existence of the child as the most important factor for the survival in the marital relationship. This concept consisted of "fear of losing the custody of the child, concerns about the negative impact of separation on the child, and the 211 child's need to have a father. Many women did not get a divorce due to the fear of losing the custody of their children. Some women expressed concerns about the impact of separation on their children. Their concerns included feeling responsible regarding the children and worrying about their future, and concerns for their children's tendency to substance-related disorders.
Homa 3-The attitudes, expectations, and feelings of the spouses of substance-dependent husbands: One of the most influential reasons in several areas leading the woman's decision to continue the marital relationship was her attitude ( not considering the issue as a personal problem and trying to see it as a mutual problem, focusing on positive traits of the spouse and marital relationship, giving the spouse time to compensate) and having realistic expectations of the spouse after rehabilitation and the feelings (feeling guilty, compassion, fear of being alone, and hope for compensation).
Nazanin: "See, in case of users with a heavier amount of substance-related disorder or longer time of use, we can't expect a person that has just completed his treatment period to go to work a day after and for example work 8 hours a day. They aren't able to do that; it is hard for them. But, well, the person must learn slowly to accept the responsibility of his life. His wife should tell him I'm not expecting you to go to work eight hours a day; you can go four hours a day." 4-Promising behaviors of addicted husband: Having promising behaviors by the man, such as voluntary communication and asking for help, stability, and sustainability in rehabilitation, and trying to build trust, helped their wives to work harder and more resolutely to improve and continue the relationship.
Fariba: "I had a doubt, but he told me then. He told me I want you to promise me. Don't deal badly with me; don't leave me alone. He said, "I use opium. I just ask you not to leave me. I don't want anyone to know. I'm scared then he told me by himself, I calmed down a bit, and decided to help him to quit." 5-Financial dependency on the husband: Economic factor was described by both the experts and the wives of addicted people as one of the main reasons for the continuation of the marital relationship. This concept consists of the satisfactory financial situation of addicted husbands and the woman's unfavorable financial situation. The couples who had no financial problems were more eager to continue the relationship.
Farzaneh 6-Level of substance-related disorder: the type, extent, and severity of used substance were also mentioned as important factors Shahab: "The stimulants have a worse effect on perception. Those who use opium and heroin have less power and strength due to hangovers. The synthetic substance reduces the level of perception and the user becomes more aggressive than those who use the traditional substance. In such conditions, their families also leave them or make an emotional divorce. The wife may take her child and go back to his father's house." Intervening conditions: The intervening condition was the family of origin's role.
1-Family of origin's role: the participants said that the lack of support by the families of origin of men and women was effective in divorce by the women. Women who did not have the support of their family of origin were less willing to divorce.

Azar: "I'm limited, where can I go? We went to court for divorce, I wanted to get a divorce. Then, my father told me not to bring my son if I want to get a divorce. I did not get a divorce because of him. I've been stuck in this marriage for ten years."
Strategies: strategies refer to certain actions or interactions that originate from the central phenomenon (25). The women's survival strategies in marital relationships included 1-the use of supportive resources, 2-increasing awareness, and 3-the use of constructive behaviors. 3-Using constructive behaviors: The participants in the study, admitted that not using destructive behaviors (criticism, blaming, complaining, grumbling, punishing, humiliating, threatening, miffing, twitting, and overcontrolling), boundary-making (not to mention the problem to the families of origin, negligence on the destructive comments of the surrounding people and not allowing others to interfere with marital privacies), and accompanying the husband (not leaving him alone, trusting the husband after rehab, talking softly and gently ) were useful for the relationship.
Shirin Contextual conditions: The social and legal factors were the contextual conditions of the study.
Social and legal preventers of divorce: divorce stigma (negative judgment of the community about divorce and its taboo nature, the fear of being ridiculed, the society view regarding women's responsibility towards the child), and the legal factors that make divorce difficult.
Zohreh: "I would say to myself if I divorce, what will happen. The entire village will laugh at me. I will be ashamed. I didn't like divorce. My sister got divorced. Everyone used to tease her. They look at her strangely." Zahra: "In the past, divorce was considered taboo by many families. It had some obscenity, and many tolerate any situation to not experience the divorce shame. Now that's not the case. Divorce has become more common than before, especially in higher social classes. However, as of now, it varies much in Iranian culture from a community to another. I believe that our country has a wide range of cultures. The cultures of different parts of Iran are different." Consequences: the consequences were desirable emotions and experiences, and undesirable emotions and experiences: 1-Desirable emotions and experiences: Several participants referred to their desirable emotions and experiences, which were categorized as positive outcomes of staying in the relationship.
They experienced, self-efficacy, the satisfaction of the child's success, achieving personal growth, and independence. Some were proud of themselves because of rehabbing their husbands.
Maryam: "My daughter had the national university exam. I tried to cheer up the house atmosphere. I did not let her feel annoyed; whenever she asked me about it, I would say to her that you just study. I always sent her to my mother's house or the library so that she would not see her father's condition. Thank God, she was accepted into the state university. I always thank God for my child's success. " 2-Undesirable emotions and experiences: The women mostly experienced negative feelings and experiences like fear, regret, remorse, fatigue, burnout, and financial problems. They had social problems like overall negative judgment and attitudes toward substance-related disorders, problems with the children's school, and negative attitudes to women on how they earn money. They had difficulties with their husbands, such as verbal and nonverbal aggression, emotional and sexual neglect, lying and unreliability, dangerous and illusory behaviors, and life-threatening dangers for women. They had family problems like blaming the family of origin and supporting the family of the origin of the man from his misconduct. Many families who were aware of the difficult circumstances of their daughter's life, particularly families that could support women after the divorce, used to blame the woman and push her to separate and leave her marital life.
Farzaneh: "I'm so afraid that sometimes they will learn to use by themselves. Anyway, they are boys. They may imitate." Muhammad: "See, there is a pre-judgment about women with substance-dependent husbands; especially those with heavy dependence. Generally, they have difficulty earning money. Unfortunately, society is prejudgmental on how they get money. There is a bad opinion about those women. These women also say that when we go shopping or somewhere, they look at us badly."

Discussion
In this study, the core category of "A journey with fear and hope" was selected. Staying married is a path with many fears and hopes that these women experience with a substance-dependent husband.
The most important factor for staying in the marital life and not getting divorced was having children. The role of cultural factors and the traditional view of society regarding the duties and responsibilities of women concerning their children can be mentioned in this context. Accordingly, from the point of view of the public, a good woman is a woman who, despite all the difficulties and problems and even with her husband's substance-related disorder, will not leave her children. In addition to the community view internalized by these women, they did not get divorced due to fear of losing their children's custody and being concerned about their future. According to the laws, the mother gains custody of her child after separation only until the age of seven, and then, the father gains custody of the child (21). They were afraid of their children's judgment in the future as well as the likelihood of their tendency to substance-related disorders due to the absence of their mothers. An individualistic culture is a culture in which people view themselves as unique and separate entities, a culture that focuses on oneself. The collectivist culture is a culture in which people tend to think about themselves concerning others, a culture that focuses on others (22). The findings of Fernandez et al. (23) showed that individuals in these communities stress the loyalty to the ascribed groups and responsibilities towards families. In such a culture, the family and its surroundings, including children, are of great importance and can affect individuals. In other words, the judgments and opinions of others matter, and the fear of judging by others leads to certain restrictions and conditions (24). As can be seen, the role of cultural and social factors in women's decision to divorce or stay in a relationship is very strong and effective. In the qualitative research of Hassani et al. (25), the concerns about the future of children have been reported as one of the consequences of divorce among divorced women.
Marital satisfaction was another reason for continuing the marital relationship. Those with satisfactory emotional, and sexual relationships experienced a relationship based on respect, with problem-solving skills had less willingness to separate, and made more effort to maintain and continue the relationship. It can be concluded that substance-related disorders alone cannot be a reason for divorce. Staying in marital life becomes more probable when the couples have a positive and acceptable background in their relationships, that is, they make the necessary emotional investment in the life and have communication and conflict resolution skills. Other research findings have indicated that lack of conflict resolution is one of the characteristics of marital disturbance (26). Fathi et al. (26) reported that effective communication is one of the intervening conditions for satisfactory marriage.
The attitudes, expectations, and feelings of the spouses of addicted husbands were effective in their decision to stay in the marital life. Researchers (27) have concluded in their study that the divorce applicant couples are different from other couples in features, such as consensus, problem-solving, and behavior management.
Women with lower education and without jobs and income, due to their financial dependence on men, might think less about divorce. The results of a study (28) indicated a significant and direct relationship between women's education levels and tendency to divorce. Most women who participated in the research were housewives or had lowincome jobs. Therefore, they were not economically independent and could not manage their life and were faced with many problems in getting a divorce. For this reason, even in conditions that their husbands did not have a significant income, they preferred to adapt to the conditions and not to leave their marital life in order not to lose this least money.
Some women stayed married due to fear of loneliness. In their study, Hassani et al. (25) stated that women are grown more dependent than men due to their sociability and this causes women to face some problems where they are in a divorce situation. The feeling of loneliness is one of the consequences of divorce for divorced women, leading them to stay married.
The promising behavior of the addicted husband played a role in the sustainability of the couple's relationship. One of the most important reasons for persuading women to continue their relationship was the man's action to rehab and his stability in this path. A study (14), suggested that re-trust of the family members and the pleasure of being with the family as one of the consequences of successful rehab, which indicates the importance of substance dependence withdrawal in the continuation of a couple's relationships. Furthermore, men who treated well with their wives and did not treat aggressively both verbally and nonverbally showed more willingness to continue their relationship. Male violence against a wife, in all its dimensions, is related to divorce (29). Therefore, it can be concluded that the promising behaviors of men can be effective on their wives stay married.
The level of a substance-related disorder, the type, extent, and severity of the substance use were also mentioned as important factors by women affecting the decision to stay or leave the marriage. The level of substance-related disorder and the type of substance can determine the social behavior, the ability to work, violent behavior, illusions, and hallucination of the substancedependent so that it can have an important impact on the survival of the marriage.
In addition to the mentioned causal conditions, the intervening condition was also effective on the survival of the couple's relationship through the causal conditions, which was the family of origin's role. Those who had emotional or financial support were more likely to stay married. Hosseini et al. (2) concluded in their study that family interference can lead to increasing the divorce rate.
The women who stayed in their marital relationship used a series of strategies to improve the quality of their marital life, such as the use of supportive resources, increasing awareness, and using constructive behaviors. Due to the cultural characteristics of Iranian society, the role of families of origin is very significant and prominent. Thus, based on the experiences of the participants in the research, it was considered as a strong source and an effective strategy. Other strategies like increasing awareness and using constructive behaviors can be beneficial to the marital relationship (2,24).
The contextual conditions were social and legal factors. A study (29) indicated that women who are the victims of violence, as mothers and wives had struggled to live in their abusive marriages because of their children (would otherwise suffer from the stigma of a 'broken home'). The community view of divorce and divorce stigma for women are preventive factors of divorce. Spouses of substance-dependent husbands suffered from depression, obsessive thoughts, hypochondriasis, and interpersonal sensitivity (30). The legal difficulties of divorce especially the custody rules of children also affected them to stay married. These conditions lead the women closer to stay married.
Sustainability in a marital relationship and staying in marriage were associated with positive and negative consequences for them. Some women stayed forcefully in the relationship for different reasons, such as having a child, lack of economic support, and lack of support from the family of origin, and in fact, due to the greater costs of divorce than its benefits and its greater negative consequences. However, those who chose to stay in the relationship by themselves experienced fewer negative outcomes. Abbasi (14) also concluded in his study that after rehab, people establish more useful and effective communication with family and friends. These results are somehow consistent with the results of this study suggesting the women are exposed to positive outcomes after substance-related disorder withdrawal by their spouses and experience the negative consequences in case of not quitting.
This study was limited to Muslim women in Iran society, the research can be done in the sociocultural context of women in other societies. Also, the experiences of the women in this study were not compared with women who did not stay in the marriage, so it is suggested to add divorced females and compare them with those who stayed married.

Conclusion
Women living with addicted husbands face many ups and downs. Clinicians can use the results of this study to understand the experience of women with a substance-dependent husband, help them decide on staying or leaving the marital relationship, educate them on realistic expectations from a husband who is spending recovery period, help them work on their marital relationship, teach them strategies to work on their relationship and ask help from families about the couple's situation. Using the benefits of social support like NGOs can be helpful. Furthermore, as the role of the family is important in Iran, they should be educated about constructive support while keeping the couple's situation. Also, the results of this study can help understand the impact of the stigma of being divorced or being the spouse of a substancedependent husband.