Introduction
Most of what we know today about addiction to various substances – about how
people develop excessive appetites and what it takes to break the addiction cycle
– comes from the study of treated populations. Until quite recently, very little
academic research has been published on the experiences of people struggling
with (and sometimes overcoming) these problems outside the realm of
professional or formally organised treatment. One main reason for this has been
the long-standing domination of conceptions of addiction where “self-change” or
“natural recovery” stand out as anomalies. In addition, it has often been difficult
for researchers to gain access to these “hidden” populations. However, the
situation has slowly been changing during the past couple of decades, and the
topic of untreated recovery from substance abuse has gained increasing
recognition in both scientific and professional quarters. Indeed a body of
research has now emerged which includes surveys aimed at estimating the
prevalence, in various subgroups, of self-change from various addictions, as well
as qualitative studies aimed at disentangling the web of influences guiding these
processes of change. A milestone signifying this development was the first
international conference on this topic (“Natural history of addiction: Recovery
from alcohol/tobacco and other drug problems without treatment”), in the form
of a KBS Thematic Meeting, in Les Diablerets, Switzerland, in 1999.
*
The present volume represents a further step in the effort to gain a broad and
unbiased understanding of what is involved in the human experiences that we
usually refer to as addictions, excessive appetites or dependencies. During the
summer of 2000, two of the editors of this volume began discussions on the
possibility of following up the Swiss conference. These discussions soon
expanded to take in not only recovery processes, but also the processes that
predispose or pave the way to addiction, as well as the issue of the widely
varying long-term trajectories of these problems. We were particularly interested
in the potential contributions of life course or life history research in this area. In
addition, we felt that the time was ripe to start addressing “untreated” and
“treated” recovery not as distinct entities, but rather as points on a continuum.
Finally, realising the extent to which the answers to our research questions
depend upon our conceptions and ways of defining the problem, we were
interested in discussing how our theoretical understanding of addiction has
shifted over time and place, and how this has influenced our empirical ventures
in this field.
The conference “Addiction in the Life Course Perspective” was held in
Stockholm in October 2002. This thematic meeting of the Kettil Bruun Society
5
for Social and Epidemiological Research on Alcohol (KBS) was sponsored by
NAD. The following main themes were identified in the invitation:
-
the development of addictive behaviours
the varying developmental trajectories of addictive behaviours
ways out of addictive behaviours and factors contributing to
recovery – with or without treatment
applications of the biographical and life history approach to these
issues
the conceptual basis of addiction and its historical transitions.
The conference attracted an attendance of 43 participants from 12 countries. who
represented various research traditions and perspectives: this was a truly
interdisciplinary group that included sociologists, psychologists, social
psychologists, medical and social work researchers as well as addiction care
practitioners. Judging by the discussions and the general “social climate” during
the conference, this provided a useful platform for productive interchange and
dialogue between parties who have not necessarily had enough opportunities to
meet.
Although it is true to say that all the conference participants have in one way or
another influenced the contents of this publication, this is not a traditional
conference proceedings report. Rather, its aim is to give a summary impression
of the present state of our understanding of addiction in the life course
perspective as it manifested itself during the conference. The contributions were
originally selected to cover the main themes of the conference. However, all of
them were subjected to more or less detailed revisions with a view to attaining
the aim of the publication – a process that started in spring 2003 and ended one
year later. In this editorial process we have received valuable comments,
feedback and help from both the authors themselves and other colleagues. In
particular, we wish to thank Douglas Cameron, Börje Olsson, Pia Mäkelä, Jim
Orford, as well as Maaria Lindblad and Lassi Haaranen who did the final
technical editing.
*
In the end, we decided to organise the articles into four main sections on the
basis of their basic perspective and main methodological approach.
Section I presents four conceptual models on the nature of addiction or substance
use disorders. They are based on different scholarly frameworks for
understanding addiction, ranging from “social diagnoses” of societies to
individual behaviour. In Bruce Alexander’s article the focus is on addiction or
overindulging in various behaviours in an historical perspective, as an ailment of
6
modern society, in which “the natural ties” between people have been broken or
damaged and in which this disconnectedness is one of the main driving forces
behind addiction. Robert Granfield further analyses addiction in the light of
sociological theory which stresses addiction as a cultural phenomenon, whereby
people seek out meaning making in a increasingly commodified world. Both
perspectives raise the question as to what the grounds for treatment and other
social responses should be when addictions are understood as cultural, social
and economic problems and not only as individual problems. The next two
papers take up this challenge. Jalie Tucker’s article explains how behavioural
economics can help us understand and even resolve substance use disorders. The
key starting point for the article is the notion that preference for short-term rather
than long-term rewards is a hallmark for substance abuse disorders. Anja KoskiJännes reviews several models of addiction and then sketches a more
comprehensive biopsychosocial model of addiction which could serve as a basis
for clinical work.
Section II, “Trajectories of the use and misuse in population studies” covers four
recent longitudinal and/or epidemiological projects. Thomas Hemmingsson has
looked at early risk factors for alcoholism in a prospective cohort of Swedish
conscripts. Gallus Bischof and his group present findings on remission without
formal help from the “Transitions in Alcohol Consumption and Smoking
(TACOS)” study in Germany. They also discuss several limitations that need to
be considered when interpreting retrospective data. Keith Humphreys with
Christine Timko and Rudolph Moos at Stanford analyse the role of marriage in
help-seeking with data from an ongoing 16-year follow-up of alcoholic
individuals. Michael Beenstock’s intriguing article deals with the problem of
how to distinguish between age and duration of dependence in the natural
termination of drug use in epidemiological studies.
Section III, “The social context of addiction and recovery” contains
contributions that in various ways deal with the relation between individual
courses of addiction and recovery, and the environments where they develop. Jan
Blomqvist contrasts the official Swedish “doxa” on narcotic drugs with addicts’
and ex-addicts’ own experiences of addiction and recovery, and points to some
obvious dilemmas in the country’s drug policy. Douglas Cameron addresses
what addiction may mean when viewed from different ethnic, cultural, and
historical perspectives. William Cloud and Robert Granfield explore the concept
of “recovery capital” and illustrate its relevance in theory and practice by
examples from recovering addicts. Finally, Jim Orford, trying to explain why
some manage to quit whereas others do not, discusses the interplay between
unaided personal change and expert interventions, and finds that recovery from
addiction, whether aided by professional assistance or not, is usually secondary
to personal life decisions, circumstantial changes and wider life-style alterations.
7
Section IV consists of qualitative studies of identity and change in respect to
addictive behaviours. In the first chapter Anthony Hewitt discusses the
possibility of post-traumatic growth after managing to overcome one’s addictive
behaviours. The emphasis in his paper is on growth through adversity rather than
just reintegration into normal life. Vilma Hänninen and Anja Koski-Jännes
analyse the stories of addiction and recovery by people who have recently quit
their addictive behaviours. The focus of interest here is on the role of recovery
narratives in the recovery process. Their analysis of the stories suggests a
qualitative division between resolved stories and those in which the problem of
dependency has not really been resolved. In her chapter, Dorte Hecksher uses
illustrative case studies to outline three ways of relating to one’s former
dependency. She argues that these three identity strategies simultaneously serve
as means of maintaining the change in addictive behaviours. The section is
closed by Leif Öjesjö who describes turning points in the life course of
individual addicts. He shows that in addition to positive turning points leading to
recovery, addicts may also be faced with more fatal turnings leading to rapid
deterioration or even death.
*
Although the contributions to this volume vary tangibly with regard to topics,
methodological approaches, and styles of reporting, they may be claimed to carry
a common message in showing that addiction problems are diverse, complex and
multi-faceted. Accordingly, our responses to people who get caught up in such
difficulties need to be varied and adapted to each individual case. In addition, to
learn more about the enigma that is addiction, we need to open our minds to new
ideas, we need to follow many different research paths – and we must be
prepared to listen to those concerned.
Pia Rosenqvist, Jan Blomqvist, Anja Koski-Jännes & Leif Öjesjö
8
A Historical Analysis of Addiction
Bruce K. Alexander
Introduction
About 8 years ago, having grown frustrated with the addictions field, I gave it up
“permanently”, and turned my attention to the study of history. To my surprise, I
encountered lengthy discussions of addiction in the writings of economic, social,
and intellectual historians. I found that history provides a fresh and essential
look at what addiction means, at why it has become so threatening, and at how it
can be alleviated. There is only enough space here to outline this historical
analysis and to gesture towards the body of evidence that supports it with a few
illustrative citations. A book on this topic is now nearing completion, of which
this article is a precis.
The History of the Word “Addiction“
Prior to the 19th century, the English word “addiction” had a traditional meaning
that was as old as the language itself and was very similar to the meaning of the
Latin word from which it was derived. To be “addicted”, meant either to be
legally given over to somebody as a bond-slave, or, more broadly, to have given
oneself over, or devoted oneself, to somebody or something. Shakespeare, John
Locke, David Hume, and other masters of modern English used the word
“addiction” in the broad, traditional sense, since the belief that addiction was
exclusively a disease of alcohol or drug misuse had little currency prior to the
19th century.
The traditional meaning of addiction became obscured during the 19th and 20th
centuries on the battlegrounds of the temperance movement, the campaign for
alcohol prohibition, the medicalization of treatment for addiction, and the “war
on drugs” (Berridge & Edwards 1981). Most of the new meanings that rose from
these disputes narrowed the word “addiction” to a disease of drug or alcohol
misuse. A drug-disease definition of “addiction” appeared for the first time in the
Oxford English Dictionary in the 1933 supplement, although only the traditional
definition appeared in the main text, as it had in the earlier version of the
dictionary. Although the drug-disease definition became the focus of public
concern, the traditional meaning retained its importance in the English language,
even though the addictions field sometimes dismissed it as metaphorical. Thus
compressed, confused, and contested, the word “addiction” lost its earlier clarity.
11
Today, many meanings of “addiction” must be considered legitimate, because
recognized authorities use the word in diverse ways. However, the broad,
traditional meaning is particularly significant for the 21st century and definitions
of addiction as a drug disease are best understood as special cases of it. In this
article, addiction is viewed, in accordance with centuries of usage, as the
lifestyle of a person who has given himself or herself over to any pursuit
whatsoever. The word is not used to describe minor habits, but involvements
that overwhelm and harm a person’s life.
Significance of Addiction (traditionally defined) for the 21st Century
The traditional meaning of addiction was gradually re-discovered in the last
decades of the 20th century. Not only were people recognizing the similarity
between their own addictive problems and the infamous lifestyles of alcoholics
and street addicts, but a few landmark studies showed compellingly that
overwhelming involvements with gambling or love relationships had the same
qualities as alcohol and drug addiction, could be every bit as intractable and
tragic, and could be treated in the same way (reviewed by Orford 2001)
By the beginning of the 21st century, addiction professionals had published many
case studies of devastating, occasionally fatal, addictions without drugs
(Killinger 1991). Accounts by investigative journalists and biographers (Pearson
1995) had further documented the harmfulness, prevalence, and endless diversity
of addictions. Interview studies revealed that only a small subset of addictions
involve alcohol or drugs (Alexander & Schweighofer 1988). There was a
multitude of self-help books, recovery groups, for-profit treatment regimes, and
websites addressing addictions that do not involve drugs as well as those that do.
There are many signs that the prevalence of addiction, traditionally defined, is
growing in the 21st century. As membership in community groups declines
precipitously in the U.S., Alcoholics Anonymous is expanding, as are dozens of
self-help groups based on its principles (Putnam 2000). These “12-step” groups
apply the AA analysis of alcohol addiction not only to a variety of drugs, but
also to gambling, love, sex, overwork, food, financial debt, fundamentalist
religion, excessive emotionality, “codependent” relationships and many more
addictions. At the same time, addiction to hard drugs is also claiming new
territory around the globe (National Institute of Drug Abuse 2002).
As addiction sweeps across the globalizing world, a side stream of “junkie chic”
pervades popular culture. Painfully funny accounts of mild forms of addiction
are commonplace in popular entertainment. The media publicize the not-sofunny addictions of stars, such as Elvis Presley, Michael Jackson, and Courtney
Love for a fascinated public. There is a growing genre of “underground” writing
12
devoted to celebrating the charms of addiction, e.g., the series of humorous
books celebrating the life of television addicts or “Couch Potatoes”. Goods are
sometimes marketed by direct appeal to the image of addiction, for example the
perfume “Opium”. Corporations analyze and systematically augment the
addictive potential of their customers.
In the long run, addiction is bound to lose its “chic”. Whether or not drugs are
involved, severe addictions supplant many aspects of life that both society and
the addicted person recognize as essential to a full existence. People who are
severely addicted often feel hopelessly “out of control”, and appear that way to
others. The desperate struggle to support an addictive lifestyle often incites
dangerous, sometimes fatal behavior. People who do not succeed in maintaining
addicted lifestyles often react with depression, brutality, or suicide. People who
do succeed often feel guilty or unfulfilled nonetheless.
As serious as it is, the self destruction caused by addiction may be less important
than the social destruction. Growing numbers of people abuse their positions of
influence for addictive ends. In the most extreme instances, the motives of some
murderous political fanatics and heads of ruthless, multinational corporations
have been traced to addictions to wealth, ideology, power, work, and sex (Slater
1980; Roy 2002).
The harm done by addiction extends beyond the normal materialistic boundaries
of social science. Even a socially harmless case of addiction adulterates life’s
meaning and depth. The early temperance and anti-drug movements saw the
“drunk” and the “junkie” as destined for eternal hellfire and concluded that they
must be converted to pious abstinence. In my opinion, temperance thinking – so
easy to ridicule now – was not so much wrong as parochial. The spiritual harm
produced by addiction need not be described in Christian imagery nor overcome
by Christian conversion, but can be comprehended within a variety of other
spiritual and scholarly perspectives. Moreover, the rediscovery of the traditional
meaning of addiction reveals that the worst harm arising from addiction could
continue to spread even if alcohol and drugs were successfully banished from the
earth. Temperance thinking also oversimplified addictions by denying their
genuine benefits, which explain why people cling tenaciously to them, even at
the risk of their lives.
A History-based Theory of Addiction
It seems that an adequate explanation of addiction cannot be found within the
medical/psychological nexus where it has been sought, because the search has
yielded hundreds of formal and informal theories (or “models”) of addiction,
which conflict in every imaginable way and yet all seem non disprovable. This
13
assortment of dissonant theories has spawned neither a lasting consensus, nor a
way of preventing the spread of addiction, nor a form of treatment that is much
more successful in dealing with serious addictions than no treatment at all.
However, a historical perspective on the current efflorescence of addiction
points singularly towards a “dislocation” theory of addiction which, although not
new, has remained underdeveloped in the addictions field. Although this
dislocation theory recognizes the importance of drug or alcohol addiction, it does
not use them as prototypes. It encompasses both addictions that are socially
accepted and those that require social intervention. It is not limited to, nor does it
exclude, instances that entail withdrawal symptoms, pharmacological tolerance,
a disease process, or the experience of being “out of control”. On the other hand,
this theory is not intended to explain either non-addictive drug use or excessive
appetites that do not entail overwhelming involvement.
Why are so many people in the 21st century addicted to such a multitude of
banal, dangerous and sometimes fatal pursuits? This vexing question can be
answered on the basis of three theoretical principles.
1. Psychosocial Integration is a Human Necessity
From early childhood onwards, individuals in every culture work assiduously at
establishing and maintaining interdependent relationships with several of the
overlapping subgroups that comprise their society, usually beginning with their
nuclear family. Subgroups welcome developing individuals who are eligible to
join them and allow as much lattitude as possible to their individual
personalities, within limits that allow the group and the larger society to function
well (Erikson 1963).
Establishing this pattern of interdependence enables each person to
simultaneously expand both his or her creativity and his or her capacity for
group accommodation. It enables culture both to benefit from the creative
abilities of diverse individuals and to maintain order and collective purpose. This
simultaneous individual and cultural enrichment will be called “psychosocial
integration” in this article, following the anthropological psychology of Erik
Erikson (1963; 1968).
Psychosocial integration is a natural, essential condition for a fully human
existence. It makes life bearable, even joyful at its peaks. Insufficient
psychosocial integration will be called “dislocation” in this article (following
Polanyi 1944), although it has been given a great variety of other names by other
social scientists. Severe, prolonged dislocation is so difficult to endure that it
regularly leads to suicide and depression. This is why ostracism,
14
excommunication, exile, and solitary confinement have been dreaded
punishments from ancient times until the present.
Although people frequently experience dislocation in conjunction with violence
and poverty, these two dire handmaidens often can be borne with dignity by
people who maintain their psychosocial integration. On the other hand, when
people are dislocated, providing protection and subsistence alone cannot restore
them to well-being. Human well-being requires psychosocial integration.
Dislocation can arise naturally from an individual handicap that bars a person
from participation in society or from a collective disaster that destroys a village.
It can be inflicted violently by abusing a child, by ostracizing an adult, or by
destroying a civilization. It can be inflicted inadvertently, by inculcating an
unrealistic sense of superiority that makes a child insufferable to others or by
donating cheap manufactured products that undermine a local economy. It can be
voluntarily chosen if a person is flings himself or herself through a “window of
opportunity”. But – most importantly for the 21st century – dislocation can
become the norm if a society systematically curtails psychosocial integration in
all its members.
2. Free Market Society Mass-Produces Dislocation
Although a person can become dislocated in any kind of society, dislocation has
become the norm in societies which have a single-minded commitment to “free
market” economics. To the degree that labor, land, goods, entertainment, and
credit are exclusively transacted through free, competitive markets, dislocation
becomes inescapable. This is because competitive free markets require each
participant to take the role of an individual economic actor, pursuing his or her
individual goals unencumbered by loyalty to family and friends, by obligations
to their clan, by traditions of their community, or by sacred values of their
religion, ethnic group, or nation (Polanyi 1944; McQuaig 2001). The essential
tenet of free market economics, as proclaimed by Adam Smith in the 18th
century, is that individually competitive markets regulated primarily by the laws
of supply and demand maximize everybody’s well being in the long run and
multiply the “wealth of nations”. The imperative of contemporary free market
society is that competitive markets must dominate all aspects of life and that the
primary function of government is to protect and expand them.
Because western society is now based on free market principles that massproduce dislocation, dislocation is not the pathological state of a few but, to a
greater or lesser degree, the general condition in western society. Because
western free market society provides the model for globalization, mass
15
dislocation is being globalized, along with the Internet, the English language,
and Mickey Mouse.
Of course, an individual person can become dislocated by individual
circumstances in any society. Moreover, the collapse of any society produces
universal dislocation until a new social organization appears. Nonetheless, the
globalization of free market society is creating an unprecedented prevalence,
depth, and duration of dislocation.
3. Addiction is the Predominant Way of Adapting to Dislocation
However dislocation comes about, it provokes a desperate response on the
individual level. Dislocated individuals struggle to restore psychosocial
integration – to somehow “get a life”. Often they succeed. However many of
those who do not succeed in restoring psychosocial integration construct
narrowly focused lifestyles that substitute for it. Often such lifestyles have
specific names: junkie, drunk, workaholic, miser, spendthrift, youth gang
member, fanatic, etc. But taken together they are properly called “addictions”, in
the traditional English-language meaning of the word.
Addictions may endure for days, for years, or for a lifetime, but they cannot
provide an adequate substitute for psychosocial integration. At best, addictions
can be narrowly creative and socially useful, as in the case of a bohemian artist
or high-tech wizard, but more usually they are banal and harmful, as in the case
of a thieving street junkie, an obnoxious alcoholic, a violent youth gang member,
an ego maniacal CEO, a compulsive “consumer”, or a murderous
religious/political fanatic.
Only severely dislocated people are vulnerable to addiction. Why would anyone
who was not suffering severe dislocation ever devote his or her life to restrictive,
banal, dangerous, or offensive pursuits? On the other hand, some severely
dislocated people live and die in ways that cannot be called “addiction” without
stretching the word too thin. They may instead become depressed, suicidal, or
emotionally flattened instead. Thus, dislocation is a necessary, but not sufficient,
precondition of addiction.
Dislocated people tend to become addicted because even the most harmful
addictions can serve a vital adaptive function for them: i.e., relieving the torment
of dislocation by providing a substitute form of psychosocial integration. For
example, the barren pleasures of a street junkie – membership in a exotic subculture, transient relief from pain, the excitement of petty crime – are more
sustaining than the unrelenting torment of social exclusion and aimlessness
(Chein et al. 1964). Devotion to a violent youth gang, harmful as it is to society
16
and, often, to the gang member’s own values, is more endurable than no identity
at all (Bourgois 1997). Amassing expensive merchandise and endlessly
organizing it for display and wasteful consumption can fill anxious moments for
affluent people bereft of richer, culturally based purposes (McInnis 2003).
Political/religious/ideological fanaticism provides social support and a sense of
universal truth that fills part of the gap left by the destruction of family, cultural,
and spiritual traditions (Roy 2002).
However, to say that an addictive lifestyle is “adaptive” is not to say that it is
desirable either for the addicted person or for society. Addictions do not have the
depth or breadth to substitute for psychosocial integration and so addicted people
do not find the contentment they seek there. In their desperate attempt to reduce
their dislocation, they exacerbate it either by stigmatizing themselves in society,
or by ruining their health, or by irrevocably damaging the intimate relationships
that are most important to them. Although the social damage caused by heroin
addicts and youth gang members is obvious, society might hope the the economy
will benefit from addictively overworking CEOs and addictively spending
consumers. However, the long range costs of corporate corruption, stress
diseases, and environmental destruction spoil such dreams.
Synopsis of Evidence
This section very briefly summarizes some of the evidence for each of the three
principles of this dislocation theory of addiction.
Psychosocial Integration is a Necessity
The 19th century was the golden age for the study of tribal societies and
traditional, peasant village life. Scientists, anthropologists, and explorers of the
day, seeing in these pre-modern societies the natural form of existence during
most of human history, wanted to document them before they were swept away
by the already globalizing free market society.
Charles Darwin himself studied the social life of aboriginal people both through
direct observations and through his wide correspondence with European
anthropologists and explorers. In the 20th century, Darwin’s complex analysis of
human evolution was reduced to a scenario of incessant, deadly competition of
all against in accordance with the ideology of the free market (Dawkins 1989). In
fact, however, Darwin gave individual competition a far less prominent role in
human evolution than do contemporary “Darwinists”. He observed the innate
proclivity towards what is called “psychosocial integration” in this article (he
17
used the phrases “social instinct” and the “moral sense” with meanings that,
whereas not identical, refer to much the same thing as “psychosocial
integration”). He argued that the social instinct and moral sense were
conspicuous, innate characteristics of the human species in his book, The
descent of man (1871/1981).
Another famous review of 19th century anthropology was written by the Russian
physical geographer, Darwinist, and socialist, Peter Kropotkin (1914/1972).
Summarizing his own observations of tribal people in Siberia, together with a
wealth of other 18th and 19th century studies of tribal people, Kropotkin described
the fundamentally social nature of the human species.
Kropotkin did not describe pre-modern man as a “noble savage”. He recognized
that most tribal people practiced infanticide as a means of population control and
that tribal life entailed frequent, cruel warfare against other tribes. Nonetheless,
he saw that the essential and preferred occupation of most people, most of the
time, was carrying out cooperative tasks assigned and regulated by the complex
multi-layered social organization of their own tribe – psychosocial integration.
Kropotkin’s analysis of European and Asian peasants showed that people’s
loyalties to clans, villages, and families were all-important, and that there was
little room for individual competition. Medieval cities were built around social
ties of their residents to their villages-of-origin and guilds. The markets of
medieval cities were regulated by complex social obligations for the benefit of
the entire community and had no similarity with the individualistic ideal
sanctified in the liturgy of the modern free market.
More recent anthropological reviews (e.g., Polanyi 1944) provide strong support
for the generalizations of Darwin and Kropotkin, as does the very recent
evidence on the archeology, anthropology, and oral history of the aboriginal
peoples of my own area of western Canada, whose conquest was not fully
completed until the 20th century (Tennant 1990; Carlson 1997).
However, it is not the evidence of great scientists and anthropologists that
convinces me most strongly that psychosocial integration is the natural state of
human beings and essential to their well-being. Such evidence is always
arguable. Nor does the most convincing evidence come from the descriptions of
dislocation given by addicts in treatment, for this too is subject to interpretation.
Rather, I am most persuaded by accounts of the anguish of contemporary
dislocation that I hear from reflective friends and members of my own family.
18
Free Market Society Mass-Produces Dislocation
Although various elements of capitalism existed throughout history, a form of
society which requires that virtually all social interactions involving land, labor,
products, and credit must occur in a competitive market appeared for the first
time in early modern England. By the early 19th century, England had become a
setting for incessant life and death competition among English laborers and
entrepreneurs. The transition to free market society had required a massive,
forced migration of the rural poor from their farms, commons, and villages into
urban slums and foreign colonies. Those who resisted this movement too
strenuously had been further dislocated through: forced apprenticeship of their
children, suppression of their voluntary associations and unions, elimination of
local charity to the “undeserving poor”, and by confinement in “houses of
correction” where lessons on the new realities were underscored with whips and
branding irons (Hill 1958).
The causal relationship between the free market economy and dislocation in
early 19th century England was recognized, at the time, as much by Whigs
infatuated with free market capitalism, like William Townsend and Herbert
Spencer, as by Socialists who viewed it critically, like Robert Owen and Karl
Marx.
Forced dislocation spread from England to the rest of the British world, e.g., the
“clearances” of the clan society of the Scottish highlands (Prebble 1963) and the
settlement of Australia by “transportation” of convict labor from English prisons
(Hughes 1987). Growing British economic and military power provoked the
spread of the British economic system to Europe, where it was greatly expanded
in France after the revolution of 1789 and spread across the continent during the
brief Napoleonic empire. The English could not be defeated without
industrialization and industrialization required free market economics.
Beyond Europe, European settlers, traders, and colonial administrations
reproduced their own dislocation by destroying aboriginal societies everywhere
and harnessing the energy of the dislocated “colored” people as producers and
consumers in the global free market. This contributed materially to the
degradation of pre-modern societies around the globe into what is now called
“the third world” (Davis 2003).
Because free market society now dominates the globe, the dislocation of human
beings has become ubiquitous. The growth of dislocation is still underway,
because the spread of free market society has not finished, although the emphasis
has shifted from expanding internal free markets to expanding free trade between
nations.
19
The continuing spread of dislocation is by no means confined to poor countries
and no longer requires physical removal of people from their homes. Rich
countries with already-established free market societies create ever-morepowerful management, advertising, and surveillance techniques that keep people
buying, selling, working, borrowing, lending, moving, and consuming in ways
that are optimal for “the economy”. Such human engineering inevitably
undermines what remains of traditional culture as well as new social structures
that might otherwise arise. New international agreements open up countries to
transnational corporations, and to international regulatory regimes with no real
concern for traditional culture and psychosocial integration. By the beginning of
the 21st century, for rich and poor alike, jobs disappear on short notice; families
and communities are weak and unstable; people routinely change families,
friends, occupations, co-workers, technical skills, status, reference groups,
languages, nationalities, priests, therapists, spiritual beliefs and ideologies as
their lives progress. Prices, incomes and economic growth are no more stable
than social life.
The dislocation engendered in the economically well-off is apparent in a recent
interview and questionnaire study of so-called “cutting edgers”, the 15% of the
population that is comprised of young adults working on the cutting edges of
information technology, aesthetics and design, food and drink, and personal care
and health. The study spanned 11 cities in 9 western and non-western countries.
In the words of the study’s authors:
These are not the activist antiglobalization disciples of Naomi Klein, but rather
the apolitical crew of the Starship Enterprise. They are non-ideological and nonjudgmental. They see nothing worth fighting for, no belief system, no country,
no tribe. Life for them is an undending exploration of all the micro pleasures the
world has to offer them (Adams & de Panafieu 2003, A13).
Addiction is the Predominant Way of Adapting to Dislocation
Why would people who were not suffering severe dislocation ever devote their
lives to restrictive, banal, dangerous, or offensive pursuits? Until recently, this
question could be answered with the claim that certain addictive drugs ensnare
everybody who uses them, a claim that had been made for many drugs since the
19th century, starting with “demon rum”. However, there is now abundant
evidence that this claim is false, even for crack cocaine (Alexander 1990;
Reinarman & Levine 1997). On the other hand, there is abundant historical
evidence showing that addiction is uncommon in societies where dislocation is
uncommon, and is common in societies where dislocation prevails.
The historical coincidence of mass dislocation and mass addiction in Europe is
well known. Although alcohol consumption and drunkenness on festive
20
occasions was widespread in Europe during the middle ages, and although
“inebriates” or “drunkards” were an occasional problem, there was no problem
of mass alcoholism. However, alcoholism gradually spread with the beginnings
of free markets after 1500, and eventually reached epidemic proportions after
1800 (Austin 1985).
From Charles Dickens’ observations on London gin shops (1835/1994) onward,
social historians often identified dislocation (along with poverty) as a major
cause of alcoholism. Eric Hobsbawm wrote as follows about the early 19th
century: “Mass alcoholism, an almost invariable companion of headlong and
uncontrolled industrialization and urbanization, spread ‘a pestilence of hard
liquor’ across Europe”. (Hobsbawm 1962, 202.)
In China, an epidemic of opium addiction occurred in the midst of the mass
dislocation that attended the disintegration Qing dynasty, the forced imposition
of free trade after the Opium Wars of 1839 and 1858, and undermining of
traditional culture by capitalist and Christian ideology. According to Yi-Mak &
Harrison (2001): “China had used opium since at least the Ming Dynasty (AD
1280-1326) without experiencing a drugs epidemic of the kind that overtook the
nation towards the end of the nineteenth century, when 10% of the male Chinese
populations are estimated to have been opium smokers” (p. 48).
But was the spread of addiction in such cases a consequence of dislocation per
se? Could it not also have been a consequence of poverty, disease, the
availability of new drugs, or simply change itself? The ideal historical case study
would be one in which dislocation was increased, while other possible causes
remained relatively constant. The history of Canadian “Indians” provides an
example that approaches this ideal type reasonably well.
The diverse native cultures in Canada all provided a level of psychosocial
integration that is unknown to modern people. Aboriginal people lived
communally and shared their resources within a matrix of expectations and
responsibilities that grew from their family, clan, village, and religion as well as
their individual talents. They clung to their cultures with death-defying
resolution – although they valued European trading goods, they found European
culture repellent.
This is not to say they were “noble savages”. The history of Canadian aboriginal
people, like that of the Europeans who conquered them, abounds with warfare,
cruel torture of prisoners, and slavery. Life spans were short due to incessant
warfare and intermittent famine. Murder, adultery, and insanity sometimes
occurred within Canadian aboriginal culture.
Despite all the stresses of aboriginal life, however, I have found no evidence of
any pre-contact behavior that could reasonably be called addiction, although
21
aboriginal people frequently engaged in pursuits that have proven extremely
addictive in free market societies, such as gambling, sex, smoking tobacco, etc.
Canadian natives did not have access to alcohol, but Indians in what is now
Mexico and the American Southwest did. Where alcohol was readily available, it
was used moderately, constructively, often ceremonially – but not addictively
(McAndrew & Edgerton 1969).
The history of Canadian aboriginals after Europeans arrived differs from the
mass slaughter perpetrated in the U.S. and in Latin America, although it is a
doleful story nonetheless. Because few early European settlers sought to settle in
the inhospitable Canadian climate, there was no need to displace the natives.
Early British and French trading companies in Canada established formal and
mutually beneficial fur-trading relationships with many native nations. Later, the
English colonial government formed indispensable military alliances with them
in several wars against the United States.
It would have been unseemly for the Crown, as it later began to covet the vast
native lands, to slaughter former allies. Instead, the British and later Canadian
governments quietly pursued a policy, later called “assimilation”, intended to
move aboriginal lands into the real estate market and aboriginal people into the
labor market as peacefully as possible. This policy was, however, explicitly
intended to strip the natives of their culture as well as their land. A notorious
instrument of this policy was a network of “residential schools” where children,
often forcibly taken from their parents, were harshly trained to despise their own
language and customs, often alienating them from their families in the process
(Chrisjohn et al. 1997).
Although assimilation policy very nearly succeeded in eliminating native
languages and cultural practices, it failed to integrate most natives into free
market society, leaving them utterly dislocated. As wards of the federal
government, however, they usually had food, housing, and some medical
treatment.
In recent years, the policy of assimilation has been discredited and the residential
schools have closed. However, the policy of sacrificing native culture to the free
market economy has not abated. Today, for example, wild salmon stocks that
have provided an essential economic basis of native coastal and riverine cultures
for countless centuries are being destroyed by the wholesale introduction of
salmon farms. The disastrous effects of salmon farming on the migrating wild
salmon are scientifically demonstrated; the dependence of native culture on the
wild salmon stock is undisputed; many British Columbians, white and Indian
alike, refuse to eat farmed salmon, yet the salmon farms apparently cannot be
stopped (Union of BC Indian Chiefs 2002; Hume 2003). The government argues
that the export income from farmed salmon is essential to the economy.
22
Ideologists issue eloquent defenses of free market principles, which the local
media promulgate.
The progress of alcoholism among Canadian Indians tracks the imposition of
free market society. Although some Canadian natives developed a taste for
riotous drunkenness from the time that Europeans first introduced alcohol,
centuries ago, most individuals and tribes either abstained, drank only
moderately, or drank only as part of tribal rituals (McAndrew & Edgerton 1969).
It was only during the period of cultural disintegration and assimilation that
alcoholism emerged as a universal, crippling problem for native people, along
with suicide, domestic violence, sexual abuse, and the other consequences of
dislocation. Eventually every tribal culture in Canada was weakened or
destroyed, and every tribe suffered the ravages of dislocation, including
epidemic alcoholism. The causal relationship between dislocation and alcohol
addiction was apparent both to white and Indian scholars (Alfred 1999; Tennant
1990).
There is, of course, a more popular way to explain the widespread alcoholism of
Canadian natives. They are often said to have a genetic inability to drink civilly.
However, this is false, since alcoholism was not a ruinous problem among
natives until assimilation subjected them to dislocation. Moreover, if natives
were handicapped by “the gene for alcoholism”, the same must be said of the
Europeans, since those subjected to conditions of extreme dislocation in the
Canadian wilderness also fell into it, almost universally (Alexander 2000; 2001).
Conclusion
The temperance and anti-drug movements believed that society could be saved
by converting alcohol and drug addicts to pious abstinence and by prohibiting
demon rum and devil drugs. Their’s was a simplistic logic, but, I believe, they
were correct in perceiving that addiction is a menace to many individuals and to
western society itself. I further believe that quelling this menace requires
analyzing addiction in its historical context and finding the will to act on this
analysis.
The response of western civilization to the “disease of drug addiction” that it has
perceived for much of the 20th century is sometimes said to have four “pillars”:
prevention, treatment, policing, and harm reduction. Even though historical
analysis shows that the drug misuse is only a portion of the problem of addiction
and that addiction is not a disease, it seems likely that the same four pillars will
continue to be useful, especially if they can be reconceptualized. Here are some
beginnings of such a reconceptualization.
23
Prevention of addiction can best be accomplished by fostering an awareness that
dislocation is the breeding ground of addiction. Efforts can be made to minimize
dislocation, insofar as this is possible within an economic system that massproduces it. On the other hand, there is no universal need to prevent children
from experimenting with drugs, unless such experimentation will cause
dislocation by alienating them from their families, community, and cultural
values, or by injuring their health.
Treatment of addiction is a misnomer, since addiction is not a disease.
Nonetheless, because many addicted people are struggling hard to move away
from destructive habits, an experienced counselor can offer emotional support
and information about a variety of paths that other people have successfully
followed. Even when counseling fails to help a person overcome an addiction,
the counselor can offer genuine understanding, a gift that cannot be discounted.
Policing can be a positive force, especially in the case of drug addiction. For
example, police can use existing drug laws judiciously to get deteriorating street
addicts into prison for a term where they will be well fed and allowed to recover
their health. Police can also give sharp and authoritative warnings to young
people who are becoming addicted to illegal pursuits other than drugs.
Harm Reduction measures, such as needle exchanges and safe injection sites, can
lower the death rate among hard drug addicts. The philosophy of harm reduction
might well be adapted to non-drug addictions as well. If it is granted that many
dislocated people are going to be addicted no matter what the consequences, it
remains possible to help them move from more dangerous to less dangerous
addictions. For example, efforts to move violent gang members into the
somewhat safer world of aggressive sports have long been made, and some lives
have almost certainly been saved. Although these efforts are not usually
understood in terms of harm reduction, the concept fits, and other kinds of
substitute addictions might well be encouraged in addicts.
Although the four pillars will, and should, remain in place, they are unlikely to
prove much more successful in solving the addiction problem than they were in
curing the so-called “disease of drug addiction”, and for the same reasons. They
do not address the root cause of increasing addiction in free market society.
Since psychosocial integration is a fundamental human need, since free market
society mass systematically destroys it, and since addiction is the predominant
way of adapting to the resulting dislocation, addiction is endemic in western
society and its prevalence is growing globally. There is no greater possibility of
an unrestrained free market society being “addiction free” than there is of it
being free of income disparity, environmental devastation, or unequal access to
life-saving drugs.
24
There can be no technical “fix” or “market solution” for problems that are
engendered by the fundamental principles of society itself. Instead, globalizing
free market society must either temper its free market principles sufficiently to
keep dislocation – and hence addiction – under control, or knowingly devastate
itself psychologically (in addition to environmentally, socially, and spiritually).
Although historical analysis affords optimism by clarifying the cause of the
growing menace of addiction, it also reveals that an organized program of
intervention has not yet been undertaken at the most fundamental level.
25
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Mail, p. A13.
Alexander, B. K. (1990): Peaceful measures: Canada’s way out of the “War on Drugs”.
Toronto: Univ. of Toronto Press.
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Alexander, B. K. (2001): The roots of addiction in free market society. Occasional Paper
of the Canadian Centre for Policy Analysis, Vancouver, B.C. Available in printed form
and downloadable at http://www.policyalternatives.ca/bc/roots-of-addiction.pdf.
Alexander, B. K. & Schweighofer, A. R. F. (1988): Defining “addiction”. Canadian
Psychology, 29, 151-162.
Alfred, T. (1999): Peace, power, righteousness: An indigenous manifesto. Oxford:
Oxford University Press.
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Chronological History. Santa Barbara, California: ABC-Clio Information Services.
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century England. London: Allan Lane.
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and social justice, 57-76. Berkeley: University of California Press.
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substance in the Indian residential school experience in Canada. Penticton, British
Columbia: Theytus Books.
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26
Hill, C. (1958): Puritanism and revolution: The English revolution of the 17th century.
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27
Addiction and Modernity:
A Comment on a Global Theory of Addiction
Robert Granfield
Over the years, alcohol researchers within the Kettil Bruun Society have sought
to articulate broad-based theoretical propositions regarding the social and
cultural foundations of addiction that challenge biological reductionism. While
the disease concept of addiction has reigned supreme over the years to the point
that it is now hegemonic in that it possesses its own self-legitimating ideology,
alternative conceptions of addiction that focus on the broader social contexts
have been advanced. Certainly the growing recognition of the reality of natural
recovery poses a direct challenge to the dominant disease-based narrative.1
Perhaps one of the greatest flaws of the medicalized construction of addiction
lies in its methodological individualism, that is, the tendency to focus on
individual experience to the exclusion of social context. It might be said that the
prevailing views amount to an “addiction fetishism” in which the behavior of an
addicted person is seen as though it was isolated from the social, cultural, and
historical circumstances that produced it. Not unlike Marx’s notion of
commodity fetishism that sees commodities as having an existence independent
from the social circumstances of production, so to addiction fetishism is a mode
of thought that alienates the personal experience of addiction from the broader
social forces that contribute to its development. Thus, addiction fetishism makes
an abstraction of actual people that is analogous to the abstraction of the
commodity. By abstracting the conditions of production, commodity fetishism
and addiction fetishism obscures the actual social realities, social inequalities,
and social conditions of production.
The ideology of addiction as an individual disease, the underlying assumption of
addiction fetishism, constructs an illusory form of equality and individuality.
Addiction fetishism places an emphasis on individualism without individuality,
on a sense of humanism without humanity, and on biology without ecology.
Addiction fetishism envisages addiction as an “equal opportunity disease”
without addressing the reality that not everyone has the same opportunity to
develop an addiction. Like commodity fetishism, addiction fetishism reduces
humans to abstractions i.e., the disease metaphor, who are then dominated by
those abstractions, never really questioning the social basis of the reified
categories or the circumstances of their lives that contributed to addiction.
1
See Granfield & Cloud (1999) for review of the natural recovery literature.
29
An attempt to de-mystify the social, cultural, and historical forces leading to
addiction has been explored by Alexander in a recent paper (Alexander 2000). In
exploring the “globalization” of addiction Alexander undertakes a socialhistorical analysis of addiction that is a once a global theory of addiction as well
as a theory of the self in modernity. While many diseases such as small pox (and
you could add many others) have been eliminated by modernity, life style
problems such as addiction and other health related ailments that increase
mortality and morbidity have grown exponentially. Alexander focuses on the
case of Vancouver, British Columbia that has shown dramatic increases in
alcoholism, heroin-related death rates, self-reported drug usage, and availability
of heroin and cocaine. This has occurred, despite the numerous and often
punitive efforts to restrict the use of these intoxicants. This is because, as
Alexander argues, addiction is mass-produced product of a free-market society
itself. Drawing on a critical social history of Vancouver, Alexander adduces the
proposition that addiction is propagated by a strong sense of dislocation, or as
Marx might say alienation from the self and others, brought on by dramatic
social transformations associated with the rise of capitalism. Alexander’s social
analysis is not unlike that of Max Weber’s who, while seeing the rise of
modernity as an unstoppable tendency within society, nevertheless considered
such societies an “iron cage” that contributes to a widespread “disenchantment
of the spirit”.
Alexander makes the point that the Canadian Indian population is overrepresented in the alcoholic population in Canada and that “Canadian Indians
have had an astronomical addiction rate” (Alexander 2000, 515). In Canada, as
in the United States, traditional native practices such as hunting, dancing, and
drumming, practices that marked one’s sense of self in the broader collective
foundations of community life, were subjugated in the wake of the vanguard
forces of modernity and the free market. Among traditional cultures, rituals of
hunting, dancing and drumming were infused with profound meaningfulness that
was tied to daily life in fundamental ways. In the western U.S., traditional
hunting practices for subsistence by local indigenous populations were subverted
by entrepreneurial values associated with tourism and economic development. In
Vancouver, as Alexander explains, these traditional and collectively based
avenues of meaning became legally unavailable.
Certainly, Indian people in the U.S. and Canada are not the only cases of social
and cultural dislocation that can be found in history. E. P. Thompson’s (1966)
classic work on the transformation of the working class in England tells the story
of dislocation experienced by the working class that, as German social historian
Wolfgang Schivelbusch (1993) points out had a dramatic impact on the drinking
practices of the new industrial proletariat. Alexander (2000) makes a similar
point when he suggests that the dominant occupations in the Vancouver area –
logging, fishing, and mining – separated working class men from their families
for months, a fact that contributed to greater cultural dislocation. Norman
30
Zinberg (1984), the late clinical professor of psychiatry at Harvard Medical
School, maintained that controlled drinking practices in America began to
subside around the time of the Revolutionary War and the Industrial Revolution.
During this historical epoch the natural regulatory norms and rituals of social life
that fostered controlled use deteriorated under the sway of rapid social change.
The Revolutionary War and the Industrial Revolution created dislocating
conditions that were ripe for alcohol abuse. In each case, men were brought
together in large numbers, away from the regulatory function of family life, and
under oppressive and fearful circumstances.
It is not surprising that, in such turbulent settings, excessive consumption of
alcohol was used to ease the psychological tension associated with wartime as
well as provide a means of escape from the proletarian drudgery and alienation
associated with factory life. Thus, for Alexander, dislocation as a cultural
condition and the related loss of self in modernity must be recognized as a
precursor to addictive practices. Indeed, Alexander sees dislocation as a cultural
norm within modern free-market society that makes individuals ripe for
addictions of all sorts. As Alexander (2000, 502) writes, “(al)though a person in
any society can become dislocated, ‘free market’ societies inevitably dislocate
their members, rich and poor, from traditional family, community, and religious
ties” (emphasis added). Paradoxically, while modernity and free-market society
may be the source of addiction, addiction to all sorts of practices may provide
the seeds of personal meaningfulness for many. As David Forbes (1994) has
pointed out in his book False Fixes addictions represent, “disturbed expressions
within this culture through which we attempt to meet our needs for power,
security, and self-expression. Addiction relations become a cultural problem as a
result of our attempt to meet those social needs through drug use and other
compulsive behaviors, since we may not be meeting them otherwise as we
mature.”
Like the American sociologist C. Wright Mills (1959), Alexander understands
that private troubles are public issues, that is, an individual’s addiction
transcends any individual in that its roots reside in the broader social and cultural
conditions that prevail in society, and might even be said to be an expression of
adaptation to prevailing social conditions. Addictions are not powerful because
they promote a kind of biological or chemical “false consciousness” that dupe
people into believing they are significant. Addictions are powerful precisely
because they provide, at least for a time, effective avenues to personal meaning
in societies in which the search for personal meaning has become increasingly
relegated to an individual project. The great struggle in modern society as
Anthony Giddens (1991) points out, is that the self has become a reflexive
project, that is, the self is no longer found within the constellation of social
institutions, but rather must be actively explored, cultivated, and constructed as a
narrative without the clarity of pre-existing traditions. In such a condition
personal problems like addiction become commonplace. As Giddens (1992, 74)
31
argues, addiction must be understood “in terms of a society in which tradition
has more thoroughly been swept away than ever before” and in which the search
for self correspondingly assumes critical importance. Addiction and dependency
become ways of coping with the personal fragmentation experienced in social
life. Thus, the dislocation experienced in modern society contributes to addiction
because for many, addiction becomes a potent source of meaning in advanced
society. As Norm Denzin (1993, 369) and others have asserted, addiction might
even be characterized as a narrative of social critique in that addiction reveals a
kind of “felt truth of the culture and the times”. In this sense, addictions of all
sorts provide individuals with comfort and security in a world that is
increasingly experienced as being out of control.
Alexander argues that addiction is a political problem. It is this and more.
Addiction is a cultural problem in which people currently seek out meanings in a
world in which meaning making has become increasingly commodified. Is it
really any wonder that there are addictions to all sorts of things when people are
sold a bill of goods that promises that they will experience greater satisfaction in
life if they use product A or product B? Individuals in advanced modern society
more and more identify themselves on the basis of their material possessions and
the images they are able to create through the products they consume. In the U.S.
during the 1990’s cigar smoking became increasingly popular due to the elevated
status associated with it. As one comedian said, people smoke cigars because
they are unable to fit a BMW in their mouths. In such a cultural condition, the
use and abuse of intoxicants in the pursuit of pleasure, status, and meaning
becomes inevitable.
Over the years, many social critics have described a kind of cultural devolution
that has been taking place within advanced capitalist societies like the United
States. This “cultural logic of late capitalism” (Jameson 1991) is characterized
by the collapse of established patterns of social and institutional life. As a result,
post-modern societies have seemingly lost their core as more and more people
feel their world is spinning out of control (Wolfe 1991). As David Harvey (1989,
65) has commented, the contemporary condition of cultural life has produced a
“profound shift in the structure of feeling” where individuals increasingly
experience their lives as fragmented, ephemeral, disconnected, and chaotic. In
such a cultural condition, the self becomes increasingly “saturated” and
temporary.
A sense of social isolation and loss of community characterize this pervasive
crisis of meaning. For many, the social institutions of family, work, religion, and
education no longer provide the comfort, support and continuity that are
necessary to foster meaning and satisfaction. Dramatic population shifts, along
with raging culture wars, unpredictable upward and downward mobility, major
technological change, and the globalization of markets have produced increased
levels of fear and vulnerability within society that have left people feeling
32
increasingly dislocated and disconnected. This sense of dislocation is further
exacerbated by the continuing market revolution that “undermines local
communities as jobs are moved off-shore or to wherever else capital can earn its
highest return; families are uprooted; and workers are laid off in the name of
corporate downsizing” (Fukuyama 1995, 312). As a result of these dramatic
changes, modern society has been eulogized as being in the “twilight” of
collective social life (Gitlin 1995). No longer do individuals feel a sense of
community and commonality with others that naturally produce conditions of
mutual trust and commitment. For the most part, there has been a collective
turning inward, a kind of mass privatization of social space that inhibits the
expression and experience of community.
From this more global perspective, solving addiction cannot be accomplished by
treating people for their “disease”. In fact, the reification of addiction as a
disease, a concept that is fundamentally lodged in liberal, free-market thought,
i.e., that individuals are sovereign entities existing independent from social and
cultural conditions within which they are embedded, may even be part of the
problem. As Alexander argues, addiction can’t be “treated” away in the
conventional sense. Treatment, while beneficial for some, may do more to
further mystify addiction by reducing it to individual pathology and by
proclaiming that treatment experts are the single best source for effective
recovery.
Nor can we punish away addiction! It is ironic that the conference that gave rise
to this book took place in a former prison in Stockholm. Prisons are warehouses
for individuals considered to be threats to society. Prisons are powerful
institutions not merely because they represent the power that the State has to
relieve someone of their freedom and even their life. As Foucault (1977) has
suggested, prisons represent power in that they embody a construction of the
body as deficient, dangerous, and deviant.2 Prisons express the governing image
that individuals must be changed to accommodate society, rather than the other
way around. As Alexander points out, it is the minority perspective that sees
individuals as being at the mercy of a troubled society confronted by an
assortment of social, cultural, and political problems. Perhaps increased attention
to the contextual factors associated with addiction will not only contribute to
better understanding of how conditions present in a person’s life course can
develop into an addiction, but also contribute to a less demonized view of drug
use and addiction. Such a perspective might lead to a normalization of addiction
within modern society, one that focuses more attention on widespread social
transformation. Perhaps then we could make greater progress in the area of
recovery, and turn more prisons into hotels and conference centers.
2
It should be noted that while Alexander attributes addictive behaviors to dislocation
and alienation associated with free-market forces in modern society, he does not
consider how addiction as a concept was and is produced by the entrepreneurial forces
within a free-market. In other words, the concept of addiction is itself a “product” that
has been packaged, commodified and sold to the public. Thus, the growth of addiction
in modern society is, at least in part, due to the manufacture and intense marketing of
this canonical “product” within the free-market.
33
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Schivelbusch, W. (1993): Tastes of Paradise: A Social History of Spices, Stimulants, and
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Haven, CT.: Yale University Press.
34
Contributions of Behavioral Economics for
Understanding and Resolving Substance Use
Disorders
Jalie A. Tucker1
Preference for short-term rather than longer-term rewards is a hallmark of
substance abuse and other addictive behaviors. Persons with such problems overengage now in immediate rewards (e.g., drinking, eating, drug use) that later lead
to long-term costs, and they under-engage now in adaptive activities (including
treatment) that would later lead to long-term benefits and adaptive functioning.
The key to successful recovery is to reverse this preference by shifting behavior
allocation away from the addictive behavior and toward engaging in adaptive
behaviors that increase the probability of receipt of delayed rewards that are
contingent upon reducing or eliminating the addictive behavior.
Behavioral economics provides a framework for conceptualizing and
investigating this central “now vs. later” dynamic in the addictive process (e.g.,
Green & Kagel 1996; Bickel & Vuchinich 2000; Vuchinich & Tucker 1988,
2003). Theory-driven research on the behavioral economics of addictive
behaviors, especially substance abuse, has matured sufficiently to yield insight
into addiction and recovery processes and to guide interventions to facilitate
recovery in individuals and to reduce the aggregate harm of addictions at a
population level (Tucker & Simpson 2003). This chapter summarizes these
developments, with emphasis on the applied connections with substance abuse.
Doing so requires an initial description of the basic behavioral science that
underlies behavioral economics and its application to addiction. This is followed
by sections on the implications for promoting recovery.
Origins of Behavioral Economics
Beginning in the early 1970s and following in the operant tradition, a laboratorybased literature on choice behavior developed that investigated how animals
allocated their behavior to obtain reinforcers (e.g., food, water, drugs) that were
made available under different constraints, or schedules of reinforcement. A
prototypic experiment would involve multiple sessions in which pigeons or rats
1
Manuscript preparation was supported in part by grants no. K02 AA00209 and R01
AA08972 from the U.S. National Institute on Alcohol Abuse and Alcoholism. The
author acknowledges and thanks her research collaborators, Dr. Rudy Vuchinich and
Dr. Paula Rippens (now deceased).
35
could choose to switch back and forth between two variable interval schedules of
reinforcement that controlled access to food pellets, and the main dependent
measure was their relative response allocation on each schedule. A general,
quantifiable relation known as the “Matching Law” emerged from this research
on behavioral allocation (Herrnstein 1970): Behavior is allocated to the
alternative schedules of reinforcement in proportion to the amount of
reinforcement that can be obtained from each schedule. For example, if two
schedules of reinforcement provide 25% and 75% of the total food available in
an experiment, over several sessions animals will come to distribute their
responding on the two schedules in the same proportions. That is, their relative
rates of responding will “match” the relative rates of available reinforcement.
Over the last 30 years, this relation has been replicated and generalized across
species (including humans), reinforcers, and settings (Rachlin & Laibson 1997).
The Matching Law highlights both the “context dependence” of choice behavior,
as well as the “molar” level of behavioral organization (Vuchinich & Tucker
2003). Specifically, this work showed that preference for a given alternative
depends on what other alternatives are available and on the relative constraints
on access to each alternative. Thus, for example, individuals’ preferences for the
same amount of the same drug will vary over time depending on the availability
of and constraints on the other response options in the surrounding environment.
The empirical basis of the Matching Law further showed that “molar”
regularities between features of the surrounding environment and patterns of
responding emerged over extended periods of time that encompassed multiple
discrete responses, even if such regularities were absent at a molecular level of
individual responses. By comparison, molecular theories of behavior seek to
explain the occurrence of individual responses, rather than patterns of
responding. The context dependence and molar quality of behavioral allocation
were major departures from earlier learning theories (e.g., Hull 1943; Skinner
1938). Those theories focused on individual stimulus-response-reinforcer
connections, placed the determinants of behavior in properties of stimulus events
that immediately preceded or followed (i.e., reinforced) the behavior, and largely
ignored the surrounding context.
Soon after these developments in the basic behavioral science on choice,
connections were made with similar concepts in the field of micro-economics
that is concerned with consumer demand for different commodities (e.g., Hursh
1980; Rachlin et al. 1976). Both areas of inquiry focus on the same basic
question of what determines how consumers allocate limited resources, be it
money, time or behavior, to gain access to activities or commodities of variable
value that are available under variable constraints (e.g., price, response
requirement). The merger of concepts from microeconomics with the theory and
methods of the behavior analysis of choice became known as “behavioral
economics”. As discussed next, the perspective has guided a growing body of
research on the behavioral economics of substance use and abuse.
36
Behavioral Economics of Substance Use and Abuse
Behavioral economics has been extensively applied in the substance abuse field
(e.g., Bickel & Vuchinich 2000; Green & Kagel 1996; Vuchinich & Heather
2003; Vuchinich & Tucker 1988, 2003). The perspective directs attention toward
investigating how patterns of substance use and abuse emerge, develop, and
change over long periods of time as a function of changes in the surrounding
environmental context. Relevant research has focused on three main empirical
questions: (1) How do preferences for substance use vary with changes in the
direct constraints on access to the substance (e.g., through price increases or
supply restrictions)? Studies of this type manipulate the direct constraints on
substance access and then measure how preferences for substance use change,
typically while holding access to other activity opportunities constant
(DeGrandpre et al. 1992; DeGrandpre et al. 1993). (2) How do preferences for
substance use vary with changing constraints on access to other valued activities
(e.g., work, leisure, or time spent with a loved one)? Studies of this type hold
access to substance use constant, manipulate access to and the constraints on
alternative reinforcers (e.g., money, water, food, or social interaction
opportunities), and then measure preferences for substance use (Carroll 1996;
Vuchinich & Tucker 1988). (3) How does behavioral allocation change when
consumers choose between outcomes that vary in the amount as well as in the
delay to when they are received? Such studies of “intertemporal choice” are
more complex and assess preferences for substance use under experimental
conditions that make varying amounts of the substance, other commodities, or
both available at varying delays (Ainslie 1975; Bickel & Marsch 2001).
This body of research has yielded three well-supported generalizations that
follow from the questions posed above. First, preferences for substance use vary
with features of the surrounding environmental context. Specifically, preferences
for substance use vary inversely with constraints on access to the substance (e.g.,
price), and directly with constraints on access to the alternative rewards
(DeGrandpre et al. 1992, 1993; Vuchinich & Tucker 1988). Furthermore, the
latter relation is probably more important in natural environments, where
substance use opportunities are abundant and relatively constant, whereas the
availability of alternative rewards is more variable. For example, in a prospective
study of the determinants of relapse after alcohol treatment (Vuchinch & Tucker
1996), life event occurrences that signaled increased constraints on access to
valued non-drinking activities (e.g., vocational or marital stability) were
associated with more serious drinking episodes compared to episodes associated
simply with an increased availability of alcohol.
Second, the value of all rewards increases sharply as their availability becomes
imminent or, put another way, reward value decreases with increasing delay to
availability (e.g., a dollar received today is worth more than a dollar received
37
next week or next month). Change in reward value as a function of delay is
termed “temporal discounting”, and the relation has been well researched in
behavioral economics generally (Ainslie 1975; Rachlin 1995) and in applications
to substance use (Bickel & Marsch 2001). This work indicates that a hyperbolic
function fits the data well, which means that the rate of discounting is greater at
shorter delays than at longer delays (cf. Madden & Bickel 1999). Thus, there
will be a sharp increase in reward value shortly before reward availability, and
preferences will shift in favor of an immediately available reward, no matter how
much a larger later reward may have been preferred when the point of choice
was more distant in time.
This empirically supported discount function is critically important for
understanding addictive behavior patterns that involve abrupt shifts in preference
for drug taking or remaining sober. Even if a substance abuser is highly
motivated to quit drug use most of the time (e.g., because of marital or job
problems), preference for drug use and for improved life-health functioning will
shift over time simply as a function of the delay to reward availability. Temporal
discounting also speaks to why addictive behaviors are so difficult to change:
One must do something now (e.g., quit drinking) that will “pay off” at some
future time (e.g., improved relationships, job performance), but the value of that
distant payoff is less now than when it is received in the future.
Third, individuals exhibit differences in the extent to which they discount future
rewards (Mazur 1987; Simpson & Vuchinich 2000). The greater their degree of
temporal discounting, the more they prefer more immediate rewards. Typical
experimental preparations have participants make repeated choices between
hypothetical money amounts available over a wide range of delays, and the data
are fit to the well established hyperbolic discount function that represents the
relation between reward value and delay (Mazur 1987): vi = Ai/(1 + kD i), where
vi, Ai, and D i represent the present value, amount, and delay of the reward,
respectively. The k parameter is an individual difference variable that is
proportional to the degree of discounting.
Using this approach, a robust finding is that substance abusers exhibit greater
degrees of temporal discounting than non-abusers (reviewed by Bickel & Marsch
2001). Greater discounting (reflected in higher mean k values) among substance
abusers has been found in studies that compared normal controls with problem
drinkers (Vuchinich & Simpson 1998), opiate abusers (Bretteville-Jensen 1999;
Kirby et al. 1999; Madden et al. 1997; Petry et al. 1998), smokers (Bickel et al.
1999; Mitchell 1999), and compulsive gamblers (Petry & Casarella 1999).
Greater discounting among substance abusers indicates that their patterns of
behavioral allocation are organized over relatively shorter “time horizons”.
Naturalistic studies have found similar relationships between substance use and
the conceptually related variable of “time perspective”, which reflects the extent
to which people orient their lives toward the past, present, or future. For
38
example, in elementary school students, having a present time perspective was
positively related to substance use, whereas having a future time perspective was
inversely related to use (Wills et al. 2001). Among alcohol and drug dependent
clients in treatment, those with a longer time perspective were more likely to
finish treatment compared to those with a shorter perspective (Coffey et al.
1999).
Whether greater discounting and shorter time horizons are a cause or a
consequence of substance abuse is unknown. Nevertheless, degree of
discounting may have prognostic value for identifying a person’s level of risk for
developing substance-related problems, or for resuming abusive use after a
resolution attempt. For example, prospective research on predictors of natural
and treatment-assisted resolution attempts have supported the latter relation
using problem drinkers (e.g., Tucker et al. 2002). As discussed next, the
discounting-substance abuse relation also points to the potential benefits of
interventions for substance abuse that reduce discounting and lengthen time
horizons.
Applied Connections
Behavioral economics directs attention toward understanding the contextdependence of preference for substance use and abuse, with “context” defined in
terms of temporal relations among the availability of, and constraints on access
to, drug and non-drug-related reinforcers. The perspective thus suggests that
interventions should produce beneficial changes if they (a) reduce access to the
abused substances, (b) increase access to valued alternative activities that are
incompatible with substance use and abuse, and (c) reduce temporal discounting
and lengthen the time horizon around which substance abusers organize their
behavior patterns. Examples of all three strategies can be found in the prevention
and treatment literatures, and their further development holds promise for
improving intervention strategies and outcomes.
The first strategy is epitomized by the reductions in smoking and drinking that
occur following price increases within certain boundary conditions (e.g.,
Ohsfledt et al. 1999). Price increases tend to have a greater effect in reducing
demand for alcohol and cigarettes among persons with less well established
habits (e.g., youths, nondependent substance users). Furthermore, if the price
increases are excessively large, economic incentives are created for the
development of a black market that undercuts the demand reduction effects of
more modest price increases. Therefore, the strategy is not highly effective in
isolation, but if properly implemented, is a viable part of a comprehensive drug
control policy that includes additional strategies aimed at reducing demand for
39
drugs and increasing access to prevention and treatment services (cf. MacCoun
& Reuter 2001).
The second strategy seeks to reduce demand for substance use by “enriching” the
environment with alternative activities that compete, or are incompatible, with
substance use (Carroll 1996). The strategy is illustrated by the effective
Community Reinforcement Approach that makes access to valued non-drug
reinforcers (e.g., free housing) contingent upon sobriety (Higgins 1999). Another
example is making treatment available on “demand” when clients seek services,
which capitalizes on their shifting motivation away from substance use toward
taking steps to resolve the problem (Tucker & Davison 2000).
Examples of the third strategy are less obvious, but certain applications with
established effectiveness appear likely to reduce temporal discounting and to
lengthen the time horizons around which substance abusers organize their
behavior patterns. Behavioral economics suggests that problem resolution should
be facilitated by interventions that increase the impact of future events on
present behavior. This can be accomplished by helping substance abusers
formulate their choices as involving long-term behavior patterns with variable
costs and benefits, rather than as a choice between discrete acts available in the
near future. When the objects of choice are viewed as temporally extended
patterns of acts with a high overall value, current behavior will be allocated in a
“self-controlled” fashion that supports the long-term pattern. When the objects
of choice are viewed as discrete acts, current behavior will be allocated in an
“impulsive” way that undermines the long-term pattern. Therefore, viewing
one’s choice as being between an intoxicated vs. sober lifestyle with lesser and
greater benefits, respectively, over the long run should facilitate resolution
compared to viewing one’s choice as being between discrete acts available
shortly, such as a night out drinking with friends vs. staying home sober.
Two current clinical applications, motivational interviewing (MI) (e.g., Miller &
Rollnick 2002) and extended self-monitoring (SM) (e.g., Helzer et al. 2002), can
be regarded as having therapeutic effects through these processes. MI strives to
create ambivalence about substance abuse by conversing with clients about the
likely course of their lives over the long-run if they do or do not continue the
abuse. According to Miller and Rollnick (2002), motivation for change derives
from clients’ perception of a:
discrepancy . . . between their present status and a desired goal, between what is
happening and how one would want things to be . . . . The larger the discrepancy,
the greater the importance of change. . . . [I]t is ambivalence that makes change
possible (pp. 22-23). . . . A goal of MI is to develop discrepancy -- to make use
of it, increase it, and amplify it until it overrides the inertia of the status quo. . .
[T]he discrepancy is between current behavior and goals or values that are
important to the person. (p. 39)
40
Put another way, MI encourages clients to view the objects of choice as
temporally extended patterns of acts rather than as temporally circumscribed
discrete acts.
Extended SM appears to serve the same function. SM can reduce problem
behaviors, at least for a time, an effect that has been exploited for therapeutic
purposes (e.g., for eating disorders [Wilson & Vitousek 1999] and management
of children’s health [Peterson & Tremblay 1999] and behavior [Shapiro & Cole
1999] problems). SM is an integral part of models of behavioral self-regulation
(Kanfer 1970), which view successful regulation as involving an ongoing
process of SM, self-evaluation, and self-reinforcement. Engaging in SM provides
information essential for effective regulation and, like MI, highlights the
discrepancy between current discrete acts and long-term patterns of acts. As
aptly stated by Rachlin (2000):
Just smoking a cigarette that happens to be the twenty-fifth cigarette smoked that
day is quite different from smoking a cigarette that is known to be the twentyfifth cigarette smoked that day. In the former case, the act of smoking stands
alone as the most valuable alternative available within the next five minutes; in
the latter case, smoking this cigarette is part of a larger pattern that is much less
highly valued. (pp. 145-146)
The idea that problem-focused assessment can reduce problem behavior also has
been entertained as a possible contributor to the lack of treatment differences
and treatment-matching effects in Project MATCH (Clifford & Maisto 2000;
Clifford et al. 2000). The extensive assessments may have promoted study-wide
reactive reductions in drinking that obscured such effects. The assessments
presumably increased participant awareness of problem behavior patterns and
may have included other elements similar to MI adaptations that use the
FRAMES model (feedback, responsibility, advice, menu, empathy, self-efficacy)
employed in the MATCH Motivational Enhancement Therapy intervention
(Miller et al. 1992).
Finally, a noteworthy feature of these applications is that they appear to have
beneficial effects by promoting naturally occurring processes and events and do
not require the introduction of external contingencies or non-drug-related
reinforcers. This makes them well suited for use in non-clinical settings with the
majority of substance abusers, who have mild to moderate problems and will not
cross the clinical threshold for care.
Conclusions and Future Directions
Behavioral economics provides a comprehensive framework within which to
organize, understand, and investigate a range of drug control strategies that are
variously part of policy, community public health, and clinical initiatives. The
41
perspective supports and organizes drug control strategies that involve drug
supply restrictions (e.g., through taxation) and drug demand reduction (e.g.,
through environmental enrichment, improved access to services). The terms and
concepts are common in economics, behavior analysis, and public health, which
supports greater interdisciplinary exchange and provides a foundation upon
which to formulate comprehensive scientific approaches to the problem of
substance misuse.
In addition to these general contributions, behavioral economic research
indicates that temporal discounting is a key behavioral process in the self-control
problem of addiction (Bickel & Marsch 2001). This suggests that successful
resolution will likely involve reducing the discount rate and lengthening the time
horizons around which substance abusers organize their behavioral allocation.
Lower threshold interventions like MI, extended SM, and other problem-focused
assessment procedures appear to have beneficial effects by facilitating such
changes. Making further connections between the behavioral economic literature
on discounting and the development of interventions for substance abuse
warrants empirical attention. Three potential connections can be identified based
on available research.
First, the degree of discounting among substance abusers may have prognostic
value with respect to recovery attempts and the outcomes of interventions
(Tucker et al. 2002). Persons with relatively longer time horizons and lower
discount rates may be more likely to achieve stable resolutions. Measures of
discounting could suggest targets for intervention and aid the prediction of
outcomes. Importantly, basic science research has shown that discount rates can
be modified and are not necessarily static (Vuchinich & Simpson 2000).
Second, substance abusers’ discount rates may interact with the effects of
interventions. Those with relatively higher discount rates and shorter time
horizons may benefit more from interventions like extended SM that repeatedly
highlight the choice at hand as being between long-term behavior patterns with
varying utility. More time-limited interventions like MI may be sufficient to
yield positive change among persons with lower discount rates and longer time
horizons. This suggests a basis for treatment matching that is conceptually
different from the client characteristics (e.g., gender, conceptual level,
psychiatric severity) found to be ineffective matching variables in Project
MATCH (1997).
Third, there is an established overall positive association between the length, but
not the intensity, of substance abuse treatment (Milby et al., 2004), which should
be further investigated in light of what is known about temporal discounting
processes in addiction. This work supports recent recommendations (Humphreys
& Tucker 2002; Stout et al. 1999) to make limited intervention resources
available less frequently, but over longer intervals (much like AA functions),
42
rather than massing their dispensation in the form of intensive, time-limited
clinical treatment. Further study of individual differences in discounting process
may help formulate decision rules about which individuals would benefit from
interventions of varying duration, frequency, and intensity. This knowledge
would guide rational allocation of limited intervention resources and help reach
more affected persons with a range of services that better match the range of
need in the population with substance-related problems.
In conclusion, behavioral economics provides a framework to address the “now
vs. later” dynamic that is the crux of the behavior allocation patterns that
comprise substance abuse and other addictive behaviors. Other theoretical
perspectives may better handle other features of addiction (e.g., genetic and
biological components, intra-personal processes and influences), but behavioral
economics provides a powerful organizing scheme and viable methods to
conceptualize and study the environment-behavior relations over time that
constitute patterns of addictive behavior. Although this level of analysis is not
the only pertinent one, it is a fundamental one and merits inclusion in a
comprehensive account of addiction.
43
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Vuchinich, R. E. & Tucker, J. A. (1996): Life events, alcoholic relapse, and behavioral
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47
In Search of a Comprehensive Model of Addiction
Anja Koski-Jännes
Introduction
The last few decades have witnessed a proliferation of new findings and theories
on addiction and craving (Blane & Leonard 1987; Addiction - Supplement 2,
2000; Addiction - Suppl. 1, 2001; Addiction, no. 4, 2002). Less has been done to
pull these scattered threads together into an integrated conceptual model that
could be used as a basis of clinical work with addicted individuals. Clinicians
are, therefore, forced to rely on models that are either out-of-date with regard to
recent research, or out-of-line with regard to the problems of their clientele.
My aim in this paper is, first, to provide an overview of various competing
models of addiction and to assess particularly those that have been used as a
basis for clinical work in this field. Drawing on this analysis I will try to sketch a
revised and more comprehensive model for the purposes of multidisciplinary
clinical work with addicted individuals.
“Why” and “How” Models of Addiction
Psychological models of addiction can roughly be divided into “why-models”
and “how-models”. The former focus on the function and motivation of
addictive behaviours, the latter concentrate on the structure and processes of
these behaviours. Some models combine elements of both, but the emphasis
usually seems to be on one or the other.
Early conceptual models were limited to specific forms of addictive behaviour,
such as alcoholism. From the 1940s to the early 1980s, the basic interest was in
motivational models, such as the Tension-Reduction theory of alcoholism
(Cappell & Herman 1972; Cappell & Greeley 1987), the Power Motivation
theory (McClelland et al. 1972), the Self-Handicapping model (Berglas 1987),
the Self-Awareness model (Hull 1987) and the Self-Medication hypothesis
(Khantzian 1985). All of these models tried to account for addictive behaviour
on the basis of internal motivational concepts.
During the past three decades increasing emphasis has been placed on the
process of addictive behaviour and the mechanisms of change more generally.
The social learning theory (SLT) of Albert Bandura (1977) has served as an
49
important inspiration for this orientation. The SLT rejects the notion that any
kind of behaviour could be adequately understood only by reference to
underlying motivational forces. Instead, it posits that personal factors,
environment and behaviour are reciprocal determinants of one another, and
among personal determinants it emphasises the role of cognitive factors in
explaining learning and behaviour (Abrams & Niaura 1987). When applied to
addictive behaviours, the SLT formed the basis of the relapse prevention models
of Alan Marlatt (1985) and others (Annis & Davis 1991; Niaura 2000). The
cognitive model of Beck, Wright, Newman & Liese (1993) provides another
example with a somewhat similar orientation. The Transtheoretical model of
change by Prochaska and DiClemente (1982) is not a model of addiction per se,
but it describes people at various stages of change in addictive behaviours. All of
these models are process oriented and regard addictive involvements as
comparable to other kinds of learned behaviour. Therefore they also apply more
or less similar methods in attempts to intervene in these dysfunctional
behaviours.
Models based on behavioural economics, again, start from the operant tradition
and focus on the “now vs. later” aspects of addiction and its relation to
environmental factors (see Tucker in this volume). One example of this tradition
is George Ainslie’s (1986) Picoeconomic theory that explains addictive
behaviour by the tendency to hyperbolically discount the later bigger rewards of
abstinence in relation to the immediate positive consequences of indulgence.
Ever since the 1980s the concept of addiction has been widened to take in nonsubstance dependencies as well (e.g. Peele 1985; Orford 1985). Jim Orford’s
(2001a & b) recently revised “Excessive Appetites” model on the development
of various forms of substance and non-substance attachments combines both
process and motivational aspects of addictive behaviours.
According to this model the formation of excessive appetites is based on the
development of appetite-specific schemata (expectancies, attributions, images,
and ways of coping) through various forms of learning. These primary processes
are amplified by such secondary processes as acquired emotional regulation
cycles, exemplified by the “abstinence violation effect” (Marlatt 1985) in
substance abuse and “chasing” in gambling. Excessive appetites also involve
many conflicts. However, most attempts to reduce the dissonance only serve to
amplify the problem rather than resolve it, as can be seen in such phenomena as
demoralisation, guilt, defences, justifications, secrecy and blaming others.
Sometimes the conflict between inclination and restraint may, however, result in
a change of addictive behaviour. Orford (2001b, 25-29) thus regards giving up
excess as a natural consequence of the development of a strong appetite and the
conflicts to which it gives rise. He also notes that the moral and social context of
the person can speed up, slow down or even turn around the development of
excessive appetites.
50
Lately, with the advance of biological research and the revival of evolutionary
perspectives, there has been a new interest in the functional and motivational
aspects of addiction. These approaches look at addictive behaviours from the
perspective of reproductive competition (e.g. Newlin 2002). Some of the
conclusions of evolutionary psychologists are rather similar to such societal
approaches as the dislocation theory of Bruce Alexander (2000, and article in
this volume) or the ideas of Anthony Giddens (1995) on the breakdown of
traditions as the main cause for the spread of addictive behaviours in
contemporary society. Both evolutionary and sociological theories regard
environmental instability and family unpredictability as one potent factor behind
these tendencies.
Most of the above mentioned theories and models aim at a general description of
the condition and how it develops, but their impact on clinical practice has
remained modest. Therefore, the discussion below concentrates on those models
that have had a significant influence on contemporary treatment practices.
Models of Addiction as a Basis of Clinical Practice
One of the first and still widely applied “how-models” in clinical practice is the
Relapse Prevention model of Alan Marlatt (1985; see Figure 1). It suggests that
if people know how to cope in high-risk situations, their self-efficacy and
probability to stay in control will increase. But if they do not have coping skills,
their self-efficacy will decrease and positive outcome expectancies increase,
often leading to a lapse in addictive behaviours. The initial lapse gives rise to the
dissonance and demoralisation of the Abstinence Violation Effect, which then
easily triggers a full-blown relapse.
Figure 1. Cognitive-behavioral model of the relapse process (Marlatt 1985, p. 38)
51
Marlatt also suggests that more global and covert lifestyle factors usually
precede high-risk situations (see Figure 2). These antecedents start from a
lifestyle imbalance caused by too many obligations (‘shoulds’) and too few
chances for personal satisfaction (‘wants’). Lifestyle imbalance induces the
desire for immediate gratification, which is intensified by positive drug effect
expectations and urges as well as by rationalisations, denial and “apparently
irrelevant decisions” that set the stage for a high-risk situation. The model
suggests that awareness of these antecedents should signal the time to resort to
alternative means of coping. It also presents a number of different tools of
avoiding relapse at each stage of this process. The main message of this model is
that clients should be taught alternative coping skills and helped to reach a more
balanced lifestyle.
Figure 2. Covert antecedents of a relapse situation (Marlatt 1985, p.48)
This model has its obvious merits and it has been widely used. However, there
are also some problems and limitations. For example, the notion of a lifestyle
imbalance in terms of ‘shoulds’ over ‘wants’ as the main precursor of high-risk
situations may well fit the experience of middle-class professionals, but it has
less relevance for street addicts or unemployed alcoholics. And while this model
certainly provides a nice “toolbox” of ideas on how to intervene in problem
behaviour, the decisive issue is how to get people to use them. That is, one of the
characteristic problems of addiction is that even though people may know how to
cope, they do not always apply their skills and knowledge to that end. In regard
to motivational issues, then, this model is less well articulated. I would also
hesitate to put so much emphasis as it does on self-efficacy expectations, since
these can easily get mixed with a false sense of control. This could be one reason
52
why the predictive role of self-efficacy expectations has not been confirmed in
Finnish studies (Koski-Jännes 1992; Kallio 2000).1
The cognitive model of Aaron Beck and his colleagues (1993) nicely displays
the circular, self-serving nature of addictive behaviour (see Figure 3). It starts
from the external and internal cues that activate drug beliefs, automatic thoughts,
and consequently also craving and urges. However, permissions are needed for
the instrumental action to take place, leading to continued use or relapse, which
then provides new cues for substance use.
Figure 3. Complete model of substance use (Beck, Wright, Newman & Liese 1993,
p. 47)
In this model the consequences of indulgence are, however, reduced to activating
stimuli for further use. In my view it is a clear weakness of this model that it
bypasses the special role of the immediate consequences for the dynamics of
addiction and by so doing turns the problem of motivation into a side issue. Most
other cognitive-behavioural approaches regard the consequences of addictive
behaviour as decisive in its regulation as its activators (see e.g. Sanchez-Craig
1984).
Furthermore, it should be noted that large parts of the addiction cycle may also
get automatised, producing several shortcuts in the model. For example, Tiffany
1
Helen Annis has further developed self-efficacy and relapse prevention ideas by
creating an instrument for detecting risk situations typical of each client. The idea is to
map out these risk situations and teach clients efficient ways to cope with them.
Creating individualised risk profiles can be useful for people who are prone to excess
only in certain situations (differentiated profile). With severely dependent individuals,
however, almost any situation can involve the danger of relapse. Their risk profiles
are, therefore, often flat across the eight typical drinking situations. This makes it hard
to make plans for how to avoid relapse. Annis and Davis (1991) have addressed but
not really solved this problem.
53
(1990) has shown that drug abusers do not necessarily experience craving before
their use. Similarly, it could be thought that facilitating beliefs or permissions to
use are called for only when people experience external pressure to abstain.
Otherwise these beliefs are not really needed.
Raymond Niaura (2000) has presented another related model of drug use and
relapse. As the previous model, it starts out from contextual cues and affective
states that trigger physiological activation, urges and drug-related outcome
expectations. As in Marlatt’s model, these instigating factors are curbed by selfefficacy expectations and coping attributions. The consequences of a lapse or
relapse are here depicted as emotions that may start a new cycle. What appears
rather strange about this model is that the use of substances does not seem to
have any effect on contextual cues, and even though the model focuses on
mental phenomena (affects, urges, expectations and attributions) the role of
defences, rationalisations and other facilitative beliefs in precipitating relapse is
missing.
Figure 4. Dynamic regulatory model of drug relapse (Niaura 2000, p.158)
Among the motivational models of addictive behaviours, the Self-Medication
hypothesis of Edward Khantzian (1985; 1997) merits a note because it has been
used as the basis of modified dynamic group therapy for substance abusers
(Khantzian et al. 1990). According to the self-medication hypothesis, people use
psychoactive substances to relieve psychological suffering and to control their
confusing and distressing affective states; they also prefer certain substances to
others on the basis of their particular emotional problems and difficulties in self54
regulation. For example, it is claimed that antisocial addicts with violence and
trauma experiences prefer opiates to attenuate their rage and aggression; that
those suffering from anxiety, isolation and emptiness caused by overly rigid
defences prefer alcohol; whereas people with energy problems are said to prefer
cocaine (ibid., 10-11).
Even though the idea of self-medication makes clinical sense, it is relatively
blind to the role of contextual factors in addictive behaviours. For instance, the
use of heroin increased rapidly among Finnish drug abusers in the 1990s mostly
due to its greater availability, lowering prices and towering unemployment
particularly among young people. Drug preferences thus seem to reflect many
environmental, social and economic realities (see Tucker in this volume), which
calls for caution in interpreting them as a sign of a particular individual
psychopathology. Moreover, psychoactive substances are also used to enhance
positive emotions and not just to relieve pain even among many chronic alcohol
and drug abusers. So, addictive behaviours seem to serve a more general purpose
of manipulating one’s internal state, either by making the negative state more
tolerable, or by enhancing positive emotions, or just to “get out of it all”.
Any review of clinical models of addiction would be incomplete without a
comment on the 12-step movement and its view of addiction as a moral or
spiritual disease. The addicted individual is here seen as suffering from an illness
of the whole person. The illness manifests itself in the form of a physical
disease, immature and self-centred personality and a spiritual sickness. (Keene
1994, 70-71.) The cure can be found by “hitting rock bottom”, surrendering to
the Higher Power, attending mutual support groups (AA, NA, etc.), and working
with the 12-steps programme. While the model was developed in the context of a
lay therapy movement, making it more practical and ideological rather than
scientific, it could be regarded as evidence-based in its consequences (Keso
1988; Project Match Research Group 1997). Its ideological tenets and the strong
emphasis on group participation, nevertheless, only appeal to a limited segment
of people with addiction problems.
General Comments on Existing Models
To sum up, most of the models described above obviously have relevance for
addictive behaviours, but this relevance often remains limited to certain issues or
conditions (e.g. the Power Motivation Theory, the Self-Awareness Model, etc.).
More general models, on the other hand, often provide a holistic explanation of
the condition but leave out concrete ways of dealing with it (e.g. evolutionary
and sociological models). Conversely, many of the treatment related models (e.g.
relapse prevention models) focus on the techniques of change without noticing
55
that various environmental, motivational and interpersonal factors also play a
role in maintaining the trap of addiction.
One general problem seems to be that most of these models start out from a too
narrow-band theory of human activity. Behavioural models build mostly on
classical and operant conditioning, cognitive models capitalise on expectations
and beliefs. Economic models emphasise the role of perceived utility, etc.
Biological theories are no better in this respect. Addictions cannot be understood
only on the basis of neurotransmitters and other brain processes. Truly
”biopsychosocial” models are thus hard to find. This is an obvious limitation in
a clinical context, where dependence problems are usually treated by
multidisciplinary teams comprising social workers, psychologists, nurses and
medical practitioners.
In my view, what we need to have is an integrated model that can be understood
by all treatment providers, whatever their field of expertise. The model should
also be clear enough so that it makes sense to the clients. By using a shared
model, clients and treatment providers would be better equipped to work
together towards a common goal. It was for these reasons that I set out to search
for a revised model of addiction for clinical purposes. The one I present here is
still “under construction”. I hope it serves as an invitation for further discussion
and critique.
Revised Model of Addiction for Clinical Purposes
Addictive behaviours can be seen as fixed activity patterns that are characterised
by immediate rewards but problems in the longer run, conflicted ways of
thinking and acting, and changes in the neuropsychological processes of the
brain. The main feature of addictive behaviour, however, is its tendency to be
repeated even against the best intentions of the person and despite its obvious
negative consequences. In this sense it could be described as a trap that is to a
considerable extent maintained by processes outside of our immediate
awareness. Let us first take a look at these more or less automatic aspects of
behaviour regulation in addiction (Figure 5).
56
Figure 5. Core processes in the maintenance of addictive behaviours
It is generally agreed that addictive behaviour is learned and reinforced by its
immediate positive consequences. When relevant associations have been formed,
a proper combination of external and internal cues (e.g. a drink for a thirsty
animal) creates in the organism a general readiness or set to perceive, think, feel
and act in a certain way (Uznadze 1966). Perceptually, this means that the
salience of things related to the desired object increases, causing the tendency
selectively to perceive things related to one’s addiction (McCusker 2001). In
terms of thoughts, it means the activation of expectations concerning the positive
effects of the appetitive behaviour. Emotionally and physiologically, it may be
experienced as craving. Motor readiness is revealed by the tendency to approach
the desired object and start the behaviour. None of these processes necessarily
requires voluntary planning of behaviour. They occur spontaneously and in that
sense they can be rather similar in mice and men.
The immediate effect of most psychoactive substances in animal studies is
increased locomotion and exaggerated responsiveness to environmental stimuli
due to the activation of the mesolimbic dopamine circuitry (Wise & Bozarth
1987). This initial stimulation is observed even with depressants, such as alcohol
due to its bi-phasic effect. In humans, similar reactions have also been noticed
with non-substance addictions such as gambling. The dopamine system is also
activated by eating, drinking, sex, and even some stressful and novel stimuli, all
of which are involved in the basic survival activities of the organism. It has been
suggested, therefore, that the persistence of addictive behaviours may be due to
their ability to “hijack” this basic adaptive and survival enhancing system in the
brain. (Newlin 2002.) This notion is not challenged by the fact that several other
neurotransmitters also participate in the regulation of addictive behaviour.
Yet human beings are also able to reflect on what they are doing – at least
occasionally. This reflective activity adds a new level on the basic cycle of
appetitive behaviour displayed by the outer circle in Figure 6. So, while the inner
circle depicts the spontaneous and automatic aspects of behaviour regulation in
57
addiction, the outer circle displays those aspects that are more available to one’s
awareness. They consist of various thoughts and beliefs built around and
supporting these somehow satisfying appetitive behaviours. Some of these
thoughts are preconscious fleeting images and interpretations of situations. Other
thoughts may result from more conscious deliberation.
Figure 6. Biopsychosocial processes maintaining addictive behaviour
(neurobiological automatic processes in the centre, cognitions available to
awareness in the outer circle, and facilitating social circumstances outside the
circle)
Schneider and Shiffrin (1977) have made a distinction between automatic and
controlled human information processing, which is related to the levels in Figure
6. Controlled processing depends on attention. It is relatively slow, serial,
flexible, and subject controlled. Automatic processing, then, is independent of
attention, fast, stimulus bound, and parallel. Much of it is learned through earlier
use of controlled processing, and once established, it is difficult to suppress or
modify. Generally behaviour regulation shifts between automatic and controlled
processing, depending on situational requirements. Controlled processing is
mainly called for when there are obstacles to automatic action patterns or when
the external conditions change. As Tiffany (1990) has claimed, addictive
behaviour is usually so well learned that much of its regulation is automatic. A
drug addict who is preparing to shoot heroin or a drinker who downs his glass of
vodka may do so without much further thought or even craving. These automatic
aspects of behaviour provide one source of momentum in addiction.
58
Our reflective skills and the ability for conscious processing provide an
opportunity for changing dysfunctional behaviours, but in the case of excessive
appetites a large part of these skills are applied to enabling, defending and
justifying our right to continue the problem behaviour. This is particularly
common if we feel that significant others disapprove of this behaviour. Verbal
“explanations” are then fabricated to bolster rather than to change the behaviour.
Especially if the appetitive behaviour serves as a substitute for some of our basic
needs (such as the need for safety, love, company, self-respect, etc.), we can
usually find any number of good reasons to keep up this activity.
In other words, our ability consciously to regulate behaviour is no guarantee
against misguided action that ends up in a “trap”. According to Anthony Ryle
(1990, 4), the founder of Cognitive-Analytic Therapy, “traps are things we
cannot escape from. Certain kinds of thinking and acting result in a ‘vicious
circle’, when however hard we try things seem to get worse instead of better”.
Traps are common in many mental health problems such as phobias, anxieties
and depression. For instance, people who are afraid of social encounters may try
to keep their fear down by avoiding these situations. This helps to fend off the
fear temporarily, but when confronted with other people or the need to perform
in a public place, the fear returns with the same or even increased intensity.
Addictive behaviours often form on the basis of similar short-sighted means of
dealing with challenging situations. For example, if a depressed person chooses
to self-medicate his or her depression by drinking or taking drugs, the immediate
result may be positive but later negative consequences often make the situation
even worse. This again calls for repeated attempts to “repair the damage”, and
sooner or later one is hooked in the self-perpetuating circle of addiction. (KoskiJännes 1992, 20-21.) So, in addition to the automatised and habitual aspects of
behaviour regulation, these trapped and self-serving ways of thinking and acting
provide another source of momentum in addictive behaviours.
Because of our meaning-making capacities, we may also attach various
secondary rewards (e.g. glory, adventure, distinction from others) to the
immediate satisfaction generated by a substance or behaviour. These appetite
supportive views along with self-protective thoughts may eventually create a
thick “capsule” around the problem behaviour along with related neural and
social adaptations. Lende and Smith (2002) also point out that dependence
problems often develop in people with insecure attachment. These individuals
tend to prefer “closed models” that are not receptive to new information, which
may also prevent changes in the acquired behavioural patterns. And even if a
person has been confronted with the need to change, these over learned and
fossilised thoughts, feelings and self-protective beliefs may keep pulling him or
her back to the trap of addiction.
59
In addition to the concept of trap, Ryle (1982; 1990) has suggested two other
useful terms for describing mental obstacles to change. “Dilemmas” are
situations in which we see our alternatives in too limited a manner (“If I abstain
I’ll have no friends”), while “snags” are situations where we abandon
appropriate goals, either believing that they will be disapproved by others or as if
they were somehow dangerous or forbidden (“I would like to change, but...”).
These barriers to reaching our goals may stem from childhood experiences, or
they may reflect the views of our current significant others. Some people also
unknowingly arrange their failure on account of their guilt feelings and other
self-destructive beliefs (Ryle 1997, 13; Goldberg 1999). For example, Rohsenow
et al. (1989) found that “feeling doomed by the past” was the best predictor of
both frequency and quantity of drinking after treatment.
The outer circle in Figure 6 is surrounded by external conditions that support
addictive behaviours or serve as additional obstacles to changing them. They are
here summarised as facilitating social circumstances. They include cultural
beliefs, norms and values supportive of heavy involvement in addictive
behaviours as well as social and economic factors that serve as barriers to
change. The latter are exemplified by the lack of housing, employment, and
social support for sustaining change. The presence of these barriers to and
lacking incentives for change in the addicted person’s life and social
environment can seriously interfere with resolving the problem. For example, if
the drinking buddies of an addicted individual are the only community that
accepts him and makes him feel good about himself, there is no real incentive to
change the state of affairs.2 In the treatment of addictive behaviours these (sub)
cultural factors as well as social and communal dimensions of addiction are
often underestimated, as the problem is defined only in personal and clinical
terms.
In the above schematic presentation of the biopsychosocial processes
maintaining addictive behaviours, the focus of attention was on the factors that
tend to prevent success in attempts at change. It should be noted, however, that
there are of course lots of people whose excessive appetites are not so beset by
defensive structures and whose social circumstances are more supportive for
change. Quitting addictive behaviours is easier for these people because it does
not require a great deal of cognitive restructuring or the adoption of totally
different lifestyles. For example, despite the strength of the habit, smoking
cessation can be rather uncomplicated in this regard (Koski-Jännes 2002). Some
people also have more “recovery capital” at their disposal (Granfield & Cloud
1999; see also articles in this volume). Quite a few spontaneous recoveries as
2
60
In other words, even though they recognize the potential pitfalls of their choice of
action, people may choose to continue their excessive behaviours because it seems
there is no better option. This kind of “wide-eyed akrasia” (a term suggested by
Douglas Cameron) probably explains why many people also actively resist the idea of
change.
well as “treatment successes” probably belong to these less complicated cases
with more social resources for change.
Basic Processes in Breaking Out from the Trap
In line with the biopsychosocial nature of the present model, the physiological,
psychological and social aspects of problem behaviour are here seen to form an
integrated whole in which a change in any one of these components will be
reflected in the state of the whole person. Consequently, medication may also be
necessary to help the person sober up and reach a sufficient balance in order to
be able to benefit from therapy or other kinds of support. This applies mostly to
some chemical addictions, in the case of which neuroadaptation3 in the form of
withdrawal symptoms also plays a role. Yet medication should never be the main
focus of treatment because that may further solidify the cognitive biases of
addiction (“I am helpless without drugs”).
A psychological implication of this model is that by increasing awareness of all
the factors maintaining addictive thoughts and behaviours, we are increasing the
prospects of voluntary control of our activities and thereby avoid falling back
into the trap of addiction. This task is rarely easy, though. Gaining awareness of
personal cues for addictive behaviours may require a lot of reflective skills.
Identifying self-justifying ways of thinking may also pose problems because
people sustain their commitment to excessive appetites by ignoring contradictory
information and its implications (Baumeister 1991, 300). Many treatment
techniques have been developed to aid in this process (e.g. Socratic questions,
self-monitoring, etc.). In cognitive-behavioural therapy these techniques focus on
the clients’ dysfunctional ways of thinking and behaving, and the aim is to help
them find more adaptive ways of coping. In the 12-step groups the focus is more
on becoming aware of the moral and spiritual aspects of one’s life and deeds,
and the goal is to improve in those respects.
Yet awareness can also be gained in less predictable ways by changing the
external conditions. For example, accidents may sometimes bring the person to
full awareness of the destructive aspects of addiction (see e.g. Öjesjö in this
volume). Similarly, more positive changes in the external conditions may open
up avenues for change. Moreover, in some “unguarded” moments addicted
individuals may suddenly see their thoughts and behaviours from the perspective
of another person, be it one’s child, spouse or anybody of some personal
3
Nick Heather (1994) has distinguished three levels in drug addiction: 1)
neuroadaptation, 2) a strong desire to use the drug, and 3) weakness of will. In the
current model the emphasis has been on the latter two levels shared by both chemical
and behavioural addictions, whereas neuroadaptation in the form of withdrawal
symptoms is relevant only to some chemical addictions.
61
importance. The therapist’s genuine reactions to the client’s accounts may have
the same effect by serving as a mirror from which the person can see him or
herself through the eyes of another person. (Koski-Jännes 1998.) Sharing life
stories in mutual help groups may indirectly serve the same end. Hearing about
other people’s experiences, the person can learn to identify with them and give
up some of his or her self-justifying perspectives. Whether the change is initiated
suddenly like a “crystallization of discontent” (Baumeister 1991) or more
gradually, the person will usually start to see his or her previous life and
activities in a new light. At the same time a new self-narrative will begin to take
shape (see Hänninen & Koski-Jännes as well as Hecksher in this volume).
Increasing awareness is a way of increasing chances for behavioural control, but
to really want the change, more is usually needed. To find the motivation for
change, one has to resolve the conflict between inclination and restraint that is
typical of addictive behaviours (Miller & Rollnick 1991).
Two things can be decisive here. Defensive processes usually hinder any
balanced weighing of pros and cons of addictive behaviours. The experience of
unconditional acceptance by a Significant Other - such as an empathic friend,
counsellor, or peer group member - decreases the person's need to defend his or
her maladaptive behaviours thus opening the door for balanced reflective activity
and new life decisions.
Finding alternative sources of satisfaction and meaning in life is another
important condition for change. Constructive changes in one’s social
relationships or other positive social incentives are, however, often required for
this because most of the sources of meaning in life are overtly or covertly social
in nature. People find new meanings mainly by entering into new relationships,
commitments and obligations (Baumeister 1991, 297). For example, members of
the 12-step movement often say that feeling part of something greater is a strong
motivational force in their recovery. New horizons of meaning can also be found
from parenthood, work, helping others, creative activities, spending time in
nature, or realising one’s long lost dreams. Meaningful activities are not just
ways of preventing relapse. They are valuable in their own right and provide
motivation for self-regulation.
Overcoming addiction usually involves smaller or larger changes in lifestyle.
The more fundamental these changes, the more identity work they require.
Mutual help groups and other forms of social support for change provide an
important frame for this kind of activity. Along with these lifestyle and identity
transformations, old beliefs and values supporting addictive behaviours are
replaced by new ones that are more in line with the new identity.
62
Changing our deeply rooted thoughts and behaviours usually takes time. To
provide time for individual transformation, it is also necessary to create a
commitment to change. Temporary meaning vacuums may occur after old
attachments are given up. Time is needed to establish new ones. The
commitment to change may also require finding oneself worthy of becoming a
“winner”. The social relationships of the person can be decisive for such feelings
of worth. The client-therapist relationship provides one important arena in which
feelings of worth may be built (or destroyed).
Discussion
When looking at exit processes from addictive behaviours, treatment remains
one of those stages where explicit attempts at change are usually made.
Therefore it is not irrelevant how the problem is understood in that situation and
how the clients are assisted in reaching their goals. My aim here was to discuss
the ways in which addictive behaviours and the means of intervening in them
have been conceptualised thus far and on the basis of this scrutiny to delineate a
revised model for clinical purposes. The goal in building this model was
primarily to guarantee that the multidisciplinary treatment team as well as the
clients could work in the same direction. To achieve this end, this common
model has to be in accordance with the scientific evidence that has been gathered
thus far, comprehensive enough to satisfy the claims of a genuine
biopsychosocial approach, and clear enough to make it understandable for both
treatment personnel and clients alike.
This outline for a new model was built on empirical and phenomenological
research as well as clinical experience. It is in line with the developmental ideas
of Jim Orford (2001), and it could be seen as a revised and extended version of
the models by Marlatt (1985) and Beck et al. (1993). However, this revised
model should not be seen as a causal chain of process components, but rather as
a heuristic device that aims to illustrate the factors maintaining the vicious circle.
It suggests that much of the cognitive and emotional regulation of addiction
takes place without awareness, and even when conscious processing does occur,
it often serves the purpose of defending and bolstering the destructive
attachment. Increasing awareness of all these factors may, however, also open up
ways to intervene in this process.
Many models of addiction could be criticised for failing to attend sufficiently to
social and environmental factors (Copello & Orford 2002). Even though the
focus here is on biological and psychological processes, social factors are also
included in this model through learning, perceiving and interpreting the world
about us as well as through the person’s social relationships and larger cultural
environment. Even our defensive structures are largely reflections of the
63
experienced social pressure from the side of our significant others. These
structures are not equally necessary and impervious in every environment. So,
despite its focus on the individual, this model is in no way at variance with the
more environmental views of, for instance, Jalie Tucker or Bruce Alexander in
this volume.
However, this model also makes explicit that due to the self-serving trap-like
nature of excessive appetites and the evolutionary survival mechanisms
(mesolimbic dopamine circuitry) that they manage to utilise, these problem
behaviours can be much more resistant to change than regular habits. As noted
by Orford (2001b), the conflicts caused by them may, however, also prepare the
ground for resolving the problem. Treatment should be seen as a means of
facilitating, stimulating and promoting this natural process of change.
64
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67
The Relative Importance of Childhood
Experience and Adult Social Circumstances for
the Development of Alcohol Abuse and
Dependence in Adulthood
Tomas Hemmingsson
Introduction
The direct relation between socio-economic position and health has been
observed for centuries. During the past few decades a corresponding relation has
also been reported for alcohol-related problems. In western countries, alcoholrelated mortality or alcohol-related hospitalisation is more common among
manual workers than among non-manual (Öjesjö et al. 1983; Romelsjö &
Lundberg 1996; Harrison & Gardiner 1999; Mäkelä et al. 1997; Behm & Wallin
1980). Socioeconomic differences in health, and in psychiatric disorders in
particular, have most commonly been viewed as resulting from either social
circumstances or social selection (Dohrenwend et al. 1992). During the past ten
years a life-course perspective on adult health has attracted considerable
attention (Kuh & Ben-Shlomo 1997), from which perspective childhood and
adolescent living circumstances could influence both health and social
achievement. A life course may thus come to include elements of both causation
and selection (Vågerö & Illsley 1995). To estimate the influence on risk of adult
alcohol problems from circumstances in different phases of life, longitudinal
data is required. The present study uses data from adolescence on substance use
and mental well-being, and data on adult social circumstances indexed by
socioeconomic position at ages 34-36.
Several circumstances from childhood and adolescence predict alcohol-related
problems appearing in early adulthood (Hawkins et al. 1992). Such
circumstances include factors related to childhood environment and personality
factors. The number of instances of alcohol intoxication before the age of 16 is a
strong predictor of adult abuse (Clapper et al. 1995). It is also suggested that
adolescent problem drinking is an integral part of a general adaptation to self, to
others and to circumstances; rather than being an isolated activity (Donovan &
Jessor 1978; Andréasson et al. 1993). For some young persons, such earlyestablished drinking patterns can continue into adulthood and lead to adult
drinking problems (Kilty 1990). Alcohol consumption normally starts at 18 and
peer influences seem to be important in predicting initiation (Kandel & Andrews
1987). The most intense use of alcohol most often declines after the age of 22.
71
This decline may reflect a process of psychosocial maturation and is related to
an adjustment to adult roles such as getting married, starting work force or
becoming a parent (Kandel & Yamaguchi 1985). The outcome of this adjustment
process depends partly on personality and life-style factors (Pritchard & Martin
1996). It is not necessarily adolescent alcohol use that predicts adult abuse;
rather a constellation of adolescent behaviour and experience (Clapper et al.
1995; Donovan & Jessor 1978; Andréasson et al. 1993).
Unfavourable life-style factors established in adolescence such as alcohol
consumption, but also smoking and low physical activity, also relate to low
future social position (Glendinning et al. 1995; Koivusilta et al. 1998;
Hemmingsson et al. 1998). Such factors are also associated with an increased
risk of an alcoholism diagnosis in early adulthood (Hawkins et al. 1992;
Andréasson et al. 1993; Hemmingsson et al. 1998). It is suggested that
personality factors established in adolescence are related to alcoholism in early
adulthood but may be of less importance later in life (Cloninger et al. 1988;
Bates & Labouvie 1997). We have previously reported that risk factors for
alcoholism established in late adolescence (such as risk use of alcohol, smoking,
psychiatric disorders, low emotional control, parental divorce and behaviour
problems) were more common among young manual workers and that they could
explain a main part of the socioeconomic differences in alcoholism among men
aged 24-34 (Hemmingsson et al. 1998). We lack studies on the importance of
risk factors from childhood and adolescence for later alcoholism (Bates &
Labouvie 1997), and on the distribution of such factors by socioeconomic group.
The present aim was to investigate how far individual risk factors, present when
entering adult working life, may explain differences between socioeconomic
groups in the occurrence of alcoholism among men aged 35-45 years. We
examined the socioeconomic distribution of alcohol misuse and other individual
risk factors for alcoholism diagnoses among young men (at age 18-20) entering
adult employment and estimated the importance of these factors for later
differences in alcoholism diagnoses between socio-economic groups.
Two questions were addressed:
1) Are known risk factors for alcoholism established already in late adolescence
more common in lower socioeconomic groups than in higher, among men 34-36
years of age?
2) Are there differences in relative risks of alcoholism between socio-economic
groups among men 35-45 years of age? If so, could these differences be
explained by differential recruitment to socioeconomic group, governed by risk
factors for alcoholism?
72
We used data on alcohol consumption and other individual characteristics
collected on call-up for compulsory military training in 1969/70 among Swedish
men born 1949-51, data on later socioeconomic group from the 1985 census, and
follow-up data on alcoholism diagnoses between 1986-96.
Methods
Study Population
The study was based on data from a nation-wide survey of 49 323 young
Swedish males, born 1949-51, who were called up for compulsory military
service in 1969/70. The background of the Swedish conscription surveys and the
variables included are presented in detail elsewhere (Andréasson et al. 1993;
Larsson et al. 2002). Only 2-3 % of all Swedish men are exempted from
conscription, in most cases due to severe handicaps or congenital disorders. The
study population accounted for 97.7% of all conscripts in 1969/70, the remaining
2.3% being born before 1949.
Risk Factors for Alcoholism in Adulthood Measured in Late
Adolescence
On call-up all completed two questionnaires. The first concerned social
background, behaviour and adjustment, psychological factors and health. The
second dealt specifically with substance use, e.g. alcohol and tobacco smoking.
All the conscripts were seen by a psychologist for a structured interview and
assessment of intellectual capacity, social maturity, emotional control, and a few
other predetermined scales. The psychologists’ ratings were regularly checked
for inter-rater reliability. The conscripts were also seen by a physician who
diagnosed any disorders according to the Swedish version of the ICD, 8th
revision (ICD-8). Those reporting or presenting psychiatric symptoms were seen
by a psychiatrist, whose diagnoses were also recorded according to ICD-8.
Eight variables from the call-up examination were included in the analyses since
they were previously known risk factors for the present outcomes (Andréasson et
al. 1993; Larsson et al. 2002). Alcohol consumption in grams 100%
alcohol/week was calculated on the basis of the answers to the questions on
drinking frequency and average consumed volume of beer, wine, and strong
spirits. A composite variable, risk use of alcohol, included at least one of the
following factors for problem drinking: consumption of at least 250 gr 100%
alcohol/week, to have taken a “hair-of-the-dog” for a hangover, to have been
apprehended for drunkenness, or to have been drunk “often” (the questionnaire
73
alternatives were “often”, “fairly often”, “sometimes”, and “never”). An index of
social integration during adolescence was constructed using questions on
relations to parents, feelings of insecurity in company, relation to school-mates,
close relations with friends, and difficulties in establishing contact with others.
Respondents with two or more negative answers (20%) were considered to have
a weak social integration during adolescence. The variable “emotional control”
was judged by a psychologist on call-up at one of five levels (1 and 2 formed the
lowest 20%=exposed), as a summary assessment of mental stability, emotional
maturity, and tolerance of stress and frustration. Information on parental divorce,
collected on call-up, was used as an indicator of conflicts among family
members. Respondents who smoked at least five cigarettes/day were considered
as smokers. The variable ‘contact with police and child-care authorities’ (at least
once) indicates problem behaviour and is strongly related to later psychiatric
diagnosis (Allebeck & Allgulander 1990). The psychometric tests performed
included tests on general intellectual ability, verbal ability, visuospatial ability,
and technical reasoning. They were ranked 1-9 where 1,2 and 3 formed the
lowest 20% (low ranking on the psychometric test), and 7,8 and 9 formed the
highest 20% (high ranking on the psychometric test).
Data on Socioeconomic Group in 1985
Information on socioeconomic group for each conscript was obtained through
record linkage with the 1985 National Population and Housing Census held by
Statistics Sweden. The census had a response rate of 98 %. The classification
into eight socioeconomic groups was conducted at Statistics Sweden and based
on information on occupation and the educational level it required. The
following socioeconomic classifications were used: 1) unskilled workers, 2)
skilled workers, 3) assistant non-manual employees, 4) non-manual employees at
intermediate level, 5) non-manual employees at higher level, 6) farmers, 7)
entrepreneurs, 8) unclassified since no occupation had been reported.
Alcoholism Diagnoses 1986-1996
The Swedish personal identification number system permitted record linkages
with the National Board of Health and Welfare Psychiatric Inpatient Care
Register between 1986-1996. This register records all hospital episodes for
patients treated in any hospital (mental as well as general) in Sweden. Diagnoses
are recorded on discharge. In the follow-up we used the following alcoholism
diagnoses: alcohol psychosis (ICD-8 291), alcoholism (ICD-8 303), and alcohol
intoxication (ICD-8 980) 1986-1996.
74
Those given an alcoholism diagnosis on call-up or in the Inpatient Care Register
between 1973 and 1985 were excluded from the study population. The primary
and the secondary diagnosis at any discharge during follow-up between 1986and
1996 were used to identify an alcoholism diagnosis; but only the first diagnosis
was chosen for each individual.
Data Analysis
For each socioeconomic group in 1985 the proportion of men with a risk factor
reported on call-up in 1969/70, was calculated.
The association between socioeconomic group in 1985 and alcoholism diagnoses
between 1986-96 was calculated in univariate and multivariate models using the
SAS logistic procedure. Odds ratios were used as approximations of relative
risks. In the multivariate models the relative risk associated with being in a
particular socioeconomic group in 1985 was estimated, controlling for the effect
of all risk factors measured on call-up in 1969/70. The relative risks, and the
proportions with risk factors, presented by socioeconomic group were calculated
for the 44.722 conscripts who contributed full information concerning all the
variables included in Table 1.
Table 1. Proportion with risk indicators on call-up among those whom the 1985
census reported as being in different socio-economic positions*.
NMH NMI NML SW USW ENT FAR
NE
6089 7898 4061 8746 8402 2189 1016 4644
N=
Risk use of alcohol
5.6
7.7
9.7
15.9
16.4
15.1
4.8
21.5
Limited social
network
Low emotional
control
Parental divorce
9.7
11.3
10.8
12.0
14.2
9.9
14.6
15.2
21.8
22.5
28.2
29.5
35.8
27.6
22.1
40.3
5.6
6.8
8.7
9.5
10.6
9.4
2.3
15.0
Contact with police
or child care
Smoking
14.9
20.3
24.4
34.1
33.3
34.1
12.9
39.3
32.1
38.4
46.3
53.8
53.9
54.0
25.5
54.9
Psychiatric diagnosis
at conscription
Low ranking on
psychometric test
High ranking on
psychometric test
6.4
7.4
10.9
11.1
14.8
10.2
7.2
21.0
1.6
5.1
12.4
25.2
32.9
20.3
21.5
22.4
41.4
28.1
15.1
5.8
6.6
10.6
12.5
16.1
* Non-manual employees at high level (NMH), Non-manual employees at intermediate level
(NMI), Non-manual employees at low level (NML), Skilled workers (SW), Unskilled workers
(USW), Entrepreneurs (ENT), Farmers (FAR), and Not employed (NE).
75
Results
Risk Factors for Alcoholism Measured at Ages 18-20 and
Socioeconomic Group at Ages 34-36
Several early-established risk indicators, i.e. risk use of alcohol, low emotional
control, parental divorce, psychiatric diagnosis on call-up, smoking, contact with
police and child care authorities, and low ranking on psychometric test, were
more common among those who were to become manual workers, as reported in
the 1985 census, than among those who were to become non-manual employees
(Table 1).
Socioeconomic Differences in Alcoholism Diagnoses at Ages 35-45 and
Relation to Risk Factors Measured at 18-20
Those who contributed full information concerning all the relevant variables
included 779 men with an alcoholism diagnosis at discharge from in-patient
psychiatric care between 1986-96. Considerable differences in risks were found
between socioeconomic groups, with the highest relative risks for those not
employed, followed by unskilled workers. Skilled workers and entrepreneurs
showed very similar relative risks. There was also a socioeconomic gradient
among the non-manual employees although with lower risks than in other
groups. Farmers showed a significantly lower risk than higher non-manual
employees (Table 2).
Table 2. The relative risk of an alcoholism diagnosis in the Register of Diagnoses
at discharge from inpatient care (n=779) among those who received their first
diagnosis during 1986-1994. Univariate and multivariate analysis (logistic
regression analysis) with 95% confidence interval (CI). In the multivariate model,
the risk indicators established on call-up (as reported in Table 1) are adjusted for.
Univariate
Multivariate*
SEI (number of cases)
RR
CI (95%) RR
CI (95%)
Non-manual high (36)
1.0
------1.0
------Non-manual intermed. (74)
1.6
1.1-2.4
1.4
0.9-2.0
-33%
Non-manual low (58)
2.4
1.6-3.7
1.7
1.1-2.7
-50%
Skilled worker (155)
3.0
2.1-4.3
1.8
1.2-2.6
-60%
Unskilled worker (217)
4.4
3.1-6.3
2.5
1.8-3.7
-56%
Entrepreneurs (43)
Farmers (3)
Not classified in SEI (193)
3.4
0.5
7.7
2.1-5.2
0.2-1.6
5.4-11.0
2.0
0.5
4.2
1.3-3.2
0.2-1.6
2.9-6.1
-58%
------52%
* Risk use of alcohol, limited social network, low emotional control, parental divorce, contact with
police and child care authorities, smoking, psychiatric diagnosis at conscription, and ranking on
psychometric test.
76
In the multivariate analyses, including all variables presented in Table 1, the
increased relative risks for the lower socioeconomic groups were considerably
reduced (for unskilled and skilled workers by 55-60%). But all groups with
significantly increased relative risks in the univariate analysis, except nonmanual employees at intermediate level, still showed significantly increased
relative risks (Table 2).
Adjustment for childhood socioeconomic group also had no effect on the risk
estimates, and childhood position is therefore not included in Table 2.
Discussion
In this longitudinal study we found evidence that the recruitment to
socioeconomic groups among young men in the 1970s and 1980s was highly
selective concerning several health-related factors, e.g. risk use of alcohol and
mental well-being. At age 18-20, more young men who were to be outside the
labour market or in manual jobs 15 years later reported risk use of alcohol, and
showed other characteristics related to later abuse, than did young men who were
to end up in higher socioeconomic strata. The risk factors used here, measured in
late adolescence, could explain a substantial part of the differences in relative
risks of alcoholism between the socioeconomic groups at ages 35-45.
Misclassification of Outcome Data
A differential misclassification of outcome would occur if persons from lower
social strata, given comparable symptomatology, more easily received an
alcoholism diagnosis than persons from higher social strata. It has been
suggested that such misclassification does occur, e.g. due to physicians’ attitudes
(Wolf et al. 1965). However, such misclassification is probably limited.
First, socioeconomic differences in alcohol-related mortality in Sweden show the
same pattern as for alcoholism diagnoses from inpatient care (Romelsjö &
Lundberg 1996). Secondly, studies from other countries, with similar
socioeconomic patterns concerning mortality, show that risk use of alcohol and
dependence are more common among manual workers (Parker & Harford 1992).
Such evidence is also reported from the Swedish Lundby study where virtually
the entire population of a rural community was examined with a psychiatric
interview. Among manual workers a higher proportion met the criterion of
alcohol abuse and dependence than among other groups (Öjesjö 1980). Thirdly,
the risk factors for alcoholism diagnoses used in this study, including risk use of
alcohol, were more common among those who became manual workers, and a
77
substantial part of the relative risk differences between the socio-economic
groups could be attributed to precisely these factors.
Cases of alcoholism were identified through the Register of Diagnoses at
Discharge from Inpatient Care. Probably, only severe cases of alcoholism are
diagnosed in inpatient care whereas less severe forms are not identified. It seems
likely that subjects in the cohort with undiagnosed and less severe forms of
alcohol-related problems were more common among manual workers at start of
follow-up in 1986 as well as later on, simply because the risk indicators for
alcoholism diagnoses, such as high alcohol consumption, as measured at the
conscription examination, were more common among manual workers.
The Relation Between Socioeconomic Positions in Childhood and In
Adulthood
In the multivariate analysis in Table 2 we first included several risk factors for
later alcoholism established at ages 18-20. These risk factors were of great
importance in explaining risk differences between the socioeconomic groups
followed-up after 1985. Adjusting for childhood socioeconomic position (based
on father’s occupation) had no effect on the risk estimates and childhood
position was, accordingly, not included in analyses. This seems to indicate that
what should be captured by childhood social circumstances in terms of risk for
later alcoholism is well covered by the specific risk factors measured at age 1820. However, this is only partly true. When we adjusted only for childhood
socioeconomic position, the relative risk differences were only slightly reduced.
Our finding indicates that the risk factors measured in late adolescence acted in a
process of health-related selection from childhood to adult social position. We
have previously shown that social mobility between generations is related to the
risk factors for later alcoholism discussed in the present study and that social
mobility (from childhood to adult position) contributes to increased
socioeconomic differences in alcoholism (Hemmingsson et al. 1999).
Early-established Risk Factors for Adult Drinking
Our findings indicate that factors established before entering working life are
strongly related to the risk, for men, of getting an alcoholism diagnosis up to the
age of 45 years. In a previous study, investigating the men in this cohort at 25-33
years of age, we showed that 70-80% of this increased risk among manual
workers compared with higher non-manual employees could be explained by the
early-established risk factors (Hemmingsson et al. 1998). The importance of
early-established risk factors in explaining socioeconomic differences in
alcoholism seemed to be slightly less for them at age 35-45 years. This could
78
indicate that with age factors related to adult experience become more important
for developing problem-drinking. However, the importance of factors established
in late adolescence is shown in the fact that they still explained almost 60% of
the increased risk among manual workers.
People are not randomly assigned to different educational paths. As the present
study shows, the likelihood of ending up in a certain social class seems to differ
between individuals according to background factors. Even early in life,
behavioural and educational trajectories start to lead to different positions in
relation to adult health and social class (Glendinning et al. 1995; Koivusilta et al.
1998; West et al. 1990; Aarnio et al. 1997). This might indicate that adolescent
life-styles are strongly associated with school ability and reflect future social
class. Thus for most individuals it is unlikely that high alcohol consumption
during adolescence is compatible with educational achievement. Moreover, risk
factors for alcoholism, as measured in late adolescence, probably stem from
previous childhood experience (Davey Smith et al. 2002).
Our study cannot prove what kind of childhood experience is linked to risk
factors in late adolescence. There is evidence, although weak, between alcohol
problems in early adulthood and behavioural differences observed among
children as young as two years (Caspi et al. 1996), and to childhood personality
factors such as low harm avoidance and high novelty seeking (Cloninger et al.
1988). Childhood adversities relate strongly to negative social, behavioural, and
health outcomes in adult life (Kessler et al. 1997; Felitti et al. 1998; Maughan &
McCarthy 1997). Since the negative behavioural factors in this study (e.g.
smoking and heavy alcohol consumption) were measured in adolescence, it is
likely that they can be regarded partly as outcomes of previous childhood
circumstances. Smoking and high alcohol consumption in adulthood are
associated with childhood experiences such as emotional, physical, and sexual
abuse, parental divorce and parental substance abuse (Anda et al. 1999;
Hemmingsson & Kriebel 2003). We have shown in this cohort that number of
cigarettes smoked at age 18-20 is strongly related to prevalence of low mental
health (psychiatric diagnosis, low emotional control and self-reported use of
drugs for nervous problems), other substance abuse (alcohol and drugs) and
parental divorce (Hemmingsson & Kriebel 2003). Glendinnings et al. (1995)
found that those with a negative attitude towards school at age 16, and who most
probably ended up as manual workers, drank more alcohol at the age of 18. This
pattern resembles the present one where those who were manual workers at age
34-36 had higher alcohol consumption, and more often reported other risk
factors at age 18-20, than did the non-manual groups.
Our findings highlight the importance of a life course perspective for
understanding the development of alcohol-related problems. Some factors
established early in life, i.e. before start of working life, seem to be important
predictors of alcohol-related problems at least up to the age of 45 years.
79
It has been suggested that socioeconomic differences in mortality and morbidity
are determined mainly by unhealthy behaviour, such as smoking and heavy
alcohol consumption (Droomers et al. 1999; Najman 2001). Still, little is known
about the mechanisms of socioeconomic difference in unhealthy behaviour
(Droomers et al. 1999; Najman 2001). The present focus was the determinants of
socioeconomic difference in in-patient alcoholism diagnosis, for which heavy
alcohol consumption should be a prerequisite. As we show here, such unhealthy
behaviour as heavy consumption of alcohol seems to be strongly determined by
circumstances in childhood and adolescence. It is very likely that such
circumstances, since they also influence future socioeconomic position, affect
socioeconomic differences in several health outcomes, including mortality. The
present findings indicate that there is a potential for reducing such problems by
targeting the childhood and adolescent environment with preventive efforts.
Conclusion
Several risk factors for later alcoholism diagnosis were found among young men
identified in manual occupations fifteen years later, or unemployed. A
pronounced socioeconomic gradient concerning alcoholism diagnosis was also
found among the men followed-up between 35-45 years of age. The increased
relative risk of alcoholism diagnosis among manual workers compared to higher
non-manual employees decreased by 55-60% when risk factors established in
late adolescence were controlled for, although the manual workers still showed
significantly increased relative risks. The results suggest that a substantial part of
socioeconomic differences in alcoholism diagnosis among men can be attributed
to circumstances from childhood and adolescence.
Acknowledgment
This study was financed by the Swedish Council for Working Life and Social
Research (Project No 2001-1057).
80
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83
What Triggers Remission without Formal Help
from Alcohol Dependence?
Findings from the TACOS-Study
Gallus Bischof, Hans-Jürgen Rumpf, Christian Meyer,
Ulfert Hapke & Ulrich John
Introduction
Based on the disease model of addiction, natural (unassisted) recovery from
alcohol dependence has been ignored as an area of study by the addiction field
(Klingemann et al. 2001). This has changed in the recent past, when a growing
number of studies on recovery from substance use problems without help have
been published (e.g. Vaillant 1982; Klingemann 1992; Sobell et al. 1992; Tucker
& Gladsjo 1993; Humphreys et al. 1997; Blomqvist 1999; Russell et al. 2001).
Several reasons for studying self-change processes of addiction have been
mentioned. As self-change contrasts with traditional concepts of addiction like
the disease model, such studies might provide important information for our
conceptual understanding of the addiction process. Furthermore, epidemiological
studies in various countries give evidence that the majority of changes in the
addiction field take place unassisted, revealing rates of unassisted recoveries
between 66.7% from alcohol dependence in Germany (Rumpf et al. 2000b) and
77% from problem drinking in Canada (Sobell et al. 1996).
Studies on remission from dependence without formal help therefore might help
deepen our knowledge on the natural history of alcohol use disorders.
Furthermore, it has been assumed that studies on remission without formal help
might help us improve formal treatment, develop new treatment approaches for
people who otherwise would not be willing to seek treatment and alert
professionals to the need to consider contextual influences on the recovery
process.
The history of research on remission without formal help can be described as a
process divided into two stages; at first, the main topic of research has been to
prove that remission without formal help is an apparent phenomenon. These
studies usually argued from a descriptive level without taking control groups into
consideration (e.g. Tuchfeld 1981; Stall 1983). In the early 90s, a second wave
of research started to analyze processes of natural recovery using treated
85
remitted individuals and untreated, unresolved subjects as control groups (Sobell
et al. 1992; Tucker & Gladsjo 1993; Blomqvist 1999). One of the main topics in
this line of research has been the identification of triggering factors of natural
recovery. Most analysis included severity of alcohol-related problems,
psychosocial stressors and psychosocial resources.
One of the aims of our study “Transitions in Alcohol Consumption and
Smoking” (TACOS) that was conducted in northern Germany from 1996 to 2000
has been to take up findings of earlier studies using control groups and replicate
these results using standardized instruments and bigger sample sizes. Another
objective was to examine some methodological issues in order to improve future
research in this field.
The aim of the present paper is to give an overview on the current knowledge on
natural recovery from alcohol dependence and to put the findings of the TACOSstudy into perspective of previous research. After a brief description of the
TACOS-study, findings on triggering factors of natural recovery from alcohol
dependence will be compared to the current knowledge in the field.
The TACOS-Study
As part of the project “Transitions in Alcohol Consumption and Smoking”
(TACOS), individuals who remitted without formal help were personally
interviewed assessing triggering and maintenance factors of the recovery
process. Remission without formal help was defined as meeting DSM-IV
(American Psychiatric Association 1995) or ICD-10 (WHO, 1993) criteria of
alcohol dependence lifetime but not within the last 6 months, not exceeding
limits of risky alcohol consumption according to the British Medical Association
(1995), defined as 30g/alcohol daily for men and 20 g/alcohol daily for women,
neither inpatient nor outpatient treatment, and no psychotherapy of comorbid
psychiatric disorders within 2 years prior and one year after remission. We
included early remitters to analyze maintenance factors in a longitudinal design
(2 year-follow-up). Two groups with respect to utilisation of minor formal help
were separated:
a) Almost no formal help: attendance of no more than two self help group
meetings like AA and no more than one counselling sessions by a physician.
b) Minor formal help: attendance of no more than nine self help group meetings
or no more than five counselling sessions by a physician. A previous analysis
revealed no substantial differences between completely treatment free subjects
and participants who received minor formal help (Bischof et al. 2002). The
majority of subjects were recruited by media advertisements heading “The
86
University of Luebeck seeks individuals who have overcome a drinking problem
without formal treatment”; in addition, a sample of 32 natural remitters was
derived from a general population survey. Because media recruited individuals
and subjects derived from the general population survey yielded differences in
triggering and maintenance mechanisms (Rumpf et al. 2000a), analyzes on
factors influencing processes of remission have been restricted to subjects
revealing the same recruitment methods, leading to considerable differing
sample sizes (see Table 1).
As control groups, the study design includes untreated, unresolved alcohol
dependent individuals from a general population survey, inpatient treated alcohol
dependent individuals from a motivational enhancement programme at the
Departement of Psychiatry and Psychotherapy of the University of Luebeck, and
self-help group participants who attended at least 50 self-help group meetings
which were recruited by media advertisement (Rumpf et al. 1998). Media
advertisement for self-help group participants headed “The University of
Luebeck seeks individuals who have overcome a drinking problem by regular
attendance in self help groups”.
The basic interview differentiated three time frames: (1) Two years prior to the
remission; (2) one year after remission and (3) the year before the interview. In
90% of all interviews, collateral interviews could be conducted to confirm data
according to the alcohol dependence syndrome, utilisation of formal help, date of
remission and alcohol consumption since remission. If obvious inconsistencies
between respondent and collateral report occurred, respondents were excluded
from the study (2.2%; n=5). Subjects participated in a comprehensive interview
(mean length: 142 minutes, SD: 34.5) and were paid the equivalent of 20$.
Payment was not announced in advertisements and mentioned for the first at the
end of the interview. Interviews were conducted by psychologists. We assessed
variables that have been found to be related to remission without formal help or
help seeking behaviour (e.g. Sobell et al. 1993b; Tucker et al. 1994; Finney &
Moos 1995; Tucker 1995) using a series of standardized instruments. Variables
assessed included sociodemographic data and social support prior to recovery
and at the time of the interview, reasons for not seeking help, severity of alcohol
dependence, adverse consequences from drinking, social pressure to quit
drinking, life-events and their relationship to recovery, quantity and frequency of
alcohol consumption, satisfaction with life, perceived resolution maintenance
factors, coping behaviour, self-efficacy in remaining abstinent and sense of
coherence. Assessment instruments are described in detail elsewhere (e.g.,
Rumpf et al. 2000a).
87
What Triggers Natural Recovery from Alcohol
Dependence?
One important issue in research on natural recovery has been to examine what
life circumstances trigger natural recovery. In the TACOS study, triggering
mechanisms of natural recovery were analyzed using untreated active alcohol
depent individuals, self-help group participants, and residential treatment
subjects. An overview on TACOS-results concerning triggering factors can be
found in Table 1.
Table 1. Overview on main findings of TACOS on triggering and maintenance
factors of natural recovery.
Author /
year
Objectives
Bischof et al. 2000c
Bischof et al. 2000a
Bischof et al. 2001
To analyze triggering and
maintenance factors of
natural recovery
compared to self-help
group participants
93 natural remitters (NR)
and 42 self-help group
(SHG) participants
To analyze triggering
factors of natural
recovery compared to
inpatient treatment
Main
findings
Concerning triggering
factors of recovery, SHG
revealed a higher severity
of dependence, fewer
health and financial
problems and more
driving under the
influence. As
maintenance factors, they
informed more
individuals about their
drinking problems and
sought social support
more often.
NR revealed a higher
severity of dependence,
less social pressure from
family and significant
others and a more stable
occupational situation
prior to remission; treated
subjects revealed more
unsuccessful abstinence
attempts
Conclusion
SHG mainly revealed a
higher social engagement
to maintain their
recovery. More
commonalities than
differences exist between
SHG and NR.
Psychosocial resources
play an important role in
natural recovery from
alcohol dependence
To analyze triggering
mechanisms of
unassisted recovery in
a general population
sample
32 naturally remitted
subjects and 26
current alcohol
dependent subjects
from a general
population survey
Remitters revealed a
higher nonphysiological severity
of alcohol
dependence, less
social pressure to quit
drinking, and more
incidents of driving
under the influence.
They tended to report
a higher satisfaction
with work and
occupational situation
and lived more often
in a stable partnership
Psychosocial
resources are an
important enabling
factor of natural
recovery. Social
pressure is not a
prerequisite for
natural recovery
Samples
and
Subgroups
88
230 natural remitters
were compared to 230
patients in treatment
After a brief description of methodological factors which need to be considered
when comparing results from studies on natural recovery, an overview on
findings concerning triggering factors of natural recovery will be given.
Methodological Caveats
When comparing studies on natural recovery, differences in methodological
approaches have to be taken into account. The majority of studies that provide
in-depth information on triggering mechanisms of natural recovery are based on
volunteers recruited by media advertisement (Sobell et al. 1992; Tucker &
Gladsjo 1993; Blomqvist 1999; Tucker et al. 2002a). Our sample of natural
remitters from a population survey enabled us to analyze the potential bias
resulting from this recruitement strategy. Analysis revealed that media solicited
subjects compared to the representative sample were more severely dependent,
had a longer duration of dependence, were more often abstinent after remission
and showed higher scores in a coping behavior measure. In addition, regarding
reasons for not seeking help, media solicited subjects gave less emphasis to the
statement that they felt that drinking was not causing that many problems and
they more often regarded pride as a reason for not seeking help (Rumpf et al.
2000a). Variables concerning triggering and maintenance facors were less
affected when controlling for differences in the severity of dependence (Rumpf
et al. 2000a).
Furthermore, different definitions of treatment were utilized in previous research
on natural recovery, ranging from a maximum of two self-help group meetings
(Sobell et al. 1992) to regular self-help group participation (Humphreys et al.
1995). Another analysis focusing on the impact of varying definitions of
treatment revealed that remitters from alcohol dependence who received some
minor help were comparable with remitters who received no help at all, and that
both groups differed from regular self-help group participants (Bischof et al.
2002). This finding might have two implications when comparing results of
studies on natural recovery. On the one hand, studies including some minor help
should provide similar results to studies using a more rigorous definition of
natural recovery. On the other hand, considering regular self-help group
participation as natural recovery might diminish differences to treated recovery
processes. The same effect can be expected if no criteria exceeding minor formal
help are defined for inclusion in a treated control group.
While almost no differences between treated and untreated subjects were found
in the study of Sobell et al. (1993b), other studies have revealed differences in
resources and stressors between treated and untreated recoveries (Tucker &
89
Gladsjo 1993; Blomqvist 1999; Bischof et al. 2000a; Bischof et al. 2000c).
These differences might result from different recruitment strategies utilized in
these studies; treated study participants of Sobell et al. have responded to an
advertisement seeking subjects who have overcome their alcohol problems
without help, indicating that they received treatment (although no information is
available about the average amount of treatment received) but did not find this
beneficial for resolution. In the original study, this sample was not intended to
serve as a control group (Sobell et al. 1992). In the study of Tucker and Gladsjo
(1993), treated subjects were recruited by the same advertisement focusing on
the current drinking status (“Have you overcome a drinking problem…”) than
natural remitters (Tucker & Gladsjo 1993). In later studies of this research
group, advertisement variously asked for research participants who had
overcome a drinking problem with and without treatment (Tucker et al. 2002a).
A similar method of recruitement has been utilized in one of the comparison
groups in TACOS (Bischof et al. 2000c). Other studies showing differences
between treated and untreated subjects recruited their treated subjects at
treatment programs (Bischof et al. 2000a) or from a follow-up of a voluntary
inpatient alcohol misuser treatment programme (Blomqvist 1999).
Triggering Factors of Natural Recovery; Previous Research and the
TACOS-Study
The following overview is restricted to studies that have used treated control
goups and have provided in-depth assessment of different triggering factors of
natural recovery. An extensive overview on studies on remission without formal
help published until the year 2000 can be found in Klingemann et al. (2001).
The first study on natural recovery using treated and untreated control groups
found modest differences between treated and untreated remitters and, therefore,
explained natural recovery by a cognitive appraisal process (weighing the pros
and cons of alcohol use) prior to recovery (Sobell et al. 1993b). However,
cognitive appraisal processes have also been found in treated alcohol abusers
with long-term recovery (Amodeo & Kurtz 1990), indicating that cognitive
appraisal processes are not specifics of recovery without treatment.
Other studies on natural recovery using control groups (Tucker & Gladsjo 1993;
Tucker 1995; Tucker et al. 1995; Blomqvist 2002; Blomqvist 1999; Tucker et al.
2002a) identified a number of differences between treated and untreated
recoveries, which might be important precedors of an appraisal process. We will
summarize which evidence currently exists for problem severity and
psychosocial resources as predictors of natural recovery and put the findings of
the TACOS-study into this perspective. In order to make the summary as
parsimonious as possible, differences identified in life events are integrated into
90
the problem or resources category. According to studies on predictors of help
seeking, we distinguish between severity of alcohol use disorders and negative
consequences in psychosocial functioning (Hingson et al. 1982; Thom 1986;
Thom 1987).
Severity of Drinking Problems and Health-related Problems
A number of studies have revealed that the higher the severity and/or chronicity
of alcohol problems or -dependence, the more likely subjects might undergo
formal treatment instead of recovering without formal treatment (Saunders &
Kershaw 1979; Armor & Meshkoff 1983; Sobell et al. 1992), however, other
studies found no differences between natural recoverers and treated remitters
(Tucker & Gladsjo 1993; Blomqvist 1999) or even a higher severity in natural
remitted subjects (Tucker & Gladsjo 1993). Recovered subjects revealed higher
amounts of drinking and/or more severe alcohol-related problems compared to
active problem drinkers in several studies (Sobell et al. 1993b; Tucker & Gladsjo
1993; Blomqvist 1999; Russell et al. 2001). Furthermore, comorbid
nonprescribed drug use consistently was more prevalent in treated recoverers
(Tucker & Gladsjo 1993; Blomqvist 1999). On the other hand, studies showed
that natural remitters revealed more health-related problems compared to treated
subjects (Tucker et al. 1995; Blomqvist 1999), however, this finding again was
not consistently replicated (Sobell et al. 1993b; Tucker et al. 2002a).
The same ambiguity as in previous research was also found in the TACOS-study.
While natural remitters revealed a higher severity of dependence compared to
untreated, unresolved subjects (Bischof et al. 2001) and to inpatient alcoholdependent individuals (Bischof et al. 2000a), their severity of alcohol
dependence was lower compared to remitted self-help group participants
(Bischof et al. 2000c). Concerning health, natural remitters reported more
problems compared to self-help group participants (Bischof et al. 2000c),
however, no differences were identified between natural remitters and
unresolved subjects (Bischof et al. 2001).
Psychosocial Consequences
Concerning psychosocial consequences (including life events) of drinking, the
relationship to natural recovery is somewhat more pronounced. Studies indicate
a positive relationship between some social problems (work, legal, interpersonal
problems) and treatment entry (Tucker & Gladsjo 1993; Blomqvist 1999).
Treated subjects revealed more consequences from drinking in the study of
Sobell et al. (1993b), assessed by a questionnaire that mainly consisted of
psychosocial consequences, although also dependence-related consequences
91
were included (Sobell et al. 1993b). Compared to unresolved subjects, natural
remitters reported less social pressure to change their drinking behavior (Russell
et al. 2001). However, in one study, natural remitters more strongly attributed
their resolution to family problems compared to treated individuals, indicating
more psychosocial problems in this area (Tucker et al. 2002b). According to the
TACOS-data, natural remitters revealed less psychosocial problems compared to
inpatient alcohol-dependent individuals (Bischof et al. 2000a), but more
psychosocial problems compared to self-help group participants (Bischof et al.
2000c). Furthermore, concerning psychosocial consequences from drinking,
natural remitters did not differ from untreated, unresolved alcohol dependent
individuals (Bischof et al. 2001).
Psychosocial Resources
One issue of special interest in research on natural recovery has been the
analysis of social resources (educational level, social support, employment,
positive key elements). Research based on narrative data from natural remitters
without using control groups has especially pointed out the relevance of social
resources (Klingemann 1991; Granfield & Cloud 1996).
Psychosocial resources conceptualized as facilitating certain action of
individuals in a given social structure include, among others, education, work
situation, social support, and satisfaction with life.
Studies using treated control groups have shown that natural remitters revealed
more social resources than treatment assisted remitters prior to remission in
terms of employment, education, positive key experiences, and employment
level (Blomqvist 1999). Other studies did not replicate these findings (Sobell et
al. 1992; Tucker et al. 1995). Compared to unresolved subjects, natural remitters
showed a relatively stable work situation prior to recovery (Tucker et al. 1994).
Data from the TACOS-study revealed no differences compared to self-help
group participants, but clearly elevated resources in comparison to inpatient
treatment individuals (Bischof et al. 2000a). Compared to untreated, unresolved
subjects, natural remitters more often lived in a stable partnership and showed
more satisfaction with work and their occupational situation, again indicating the
relevance of resources for natural recovery (Bischof et al. 2001).
Taken together, no specific pointers of remission without formal help have been
consistently identified in published studies so far. On the other hand, data
suggest that both stressors and resources need to be taken into account for
understanding processes of natural recovery. Although it is possible that the lack
of consistent findings might result from restrictions concerning the selection of
variables, it can be assumed that such an archimedes’ point simply doesn’t exist.
92
If there are specific pointers to remission without formal help, it is likely that
these variables differ between various subgroups of natural remitters. Alcoholdependent individuals in the general population are known to be a rather
heterogeneous group. If we take into account that the majority of this group
manages to recover without formal help, it is especially likely that natural
remitters also differ in aspects of resources, severity of dependence, and so on.
This assumption is supported by longitudinal data indicating two different
pathways out of drinking problems without utilization of professional treatment;
one group of low socioeconomic status and severe drinking problems targeting
abstinence and another group with higher socioeconomic status and more
support at baseline targeting drinking moderation (Humphreys et al. 1995). It has
to be noted that this study was based on individuals recruited at a detoxification
unit or alcohol information and referral center and that AA-participation was
included as remission without formal treatment. Furthermore, the group that
became abstinent relied more strongly on AA as a maintenance factor, although
other studies have revealed differences in triggering mechanisms between selfhelp group participants and natural remitters (Blomqvist 1999; Bischof et al.
2002). Therefore, homogeneous subgroups should also be retrievable in natural
remitters without extensive self-help group participation in order to build a
model that may explain inconsistencies in previous studies including our own
findings on triggering mechanisms of natural recovery.
A Person-oriented Approach to Natural Recovery
In order to identify homogeneous subgroups of natural remitters, we have taken a
cluster analytic approach. Cluster analysis is a statistical approach that aims to
classify subjects according to underlying, pre-defined characteristics. As pointed
out in above, studies on predictors of natural recovery have produced
heterogeneous results concerning severity of problems (directly alcohol-related
and psychosocial) as well as psychosocial resources. We have taken up a
typology of natural remitters derived on grounds of qualitative data by
Klingemann (1991) and have considered severity of alcohol dependence, adverse
consequences from drinking, social pressure to change drinking behavior and
social support to form the clusters. In addition, we have considered age at onset
of dependence as a variable highlighted in general typologies of alcohol
dependence (Cloninger et al. 1981). The analysis covers one hundred seventyeight media recruited remitters without formal help (including subjects who
received minor formal help). Statistical analysis are described in more detail in
Bischof et al. (2003). As displayed in Figure 1, cluster analyzes yielded three
groups of natural remitters: One cluster with a high severity of dependence, low
alcohol-related problems and low social support (“low problems - low support”
LPLS ; n= 65), one group characterised by high severity of dependence, high
alcohol-related problems and medium social support (“high problems – medium
93
support”; HPMS n=37), and a third group which consisted of subjects with high
social support, late age of onset, low severity of dependence, and low alcohol
related problems (“low problems - high support”; LPHS n=76).
Figure 1. Clusters of remission without formal help from alcohol dependence;
LPLS: Low Problem-Low Support; HPMS: High Problems-Medium Support;
LPHS: Low Problems-High Support (taken from: Bischof, Rumpf et al. (2003)).
Cluster solutions were confirmed using discriminant analyses. Groups showed
considerable differences in socio-demographic variables; LPLS had the highest
rate of females, followed by LPHS and HPMS. Concerning educational level,
LPLS revealed more years of schooling compared to both other groups.
Furthermore, LPHS subjects were older at the time of the interview. LPLS
subjects revealed a higher unemployment rate compared to both other groups and
a higher daily alcohol consumption prior to recovery, which was not surprising
due to their higher severity of alcohol dependence. ANOVAS revealed further
considerable group differences on other triggering factors of remission.
Compared to both other groups, LPHS subjects revealed higher satisfaction with
partnership, family, friends, and financial situation prior to recovery.
Furthermore, they reported more satisfaction with their living conditions
94
compared to LPLS subjects. HPMS subjects gave more emphasis to financial
and legal events compared to both other groups and attributed a higher impact of
partnership on their remission compared to LPLS subjects.
Our LPHS group best represented what would be expected on grounds of
previous findings on natural recovery: low unemployment rate, high social
support, low problem severity concerning alcohol-related and psychosocial
problems prior to recovery. However, this group represented less than fifty
percent of our total sample of natural remitters. With respect to both other
groups, we identified an interaction of problem severity and social support; for
subjects with a high severity of alcohol dependence, natural recovery appears to
be a viable pathway as long as psychosocial problem severity is low even if
social support is low. However, as alcohol-related problems increase, a minimum
of social support is necessary to overcome alcohol dependence without
utilization of formal help.
Towards a Model of Untreated and Treated Recovery
Although remission without formal help has been regarded as a central issue in
broadening our understanding of alcohol dependence and in improving formal
treatment, only a few consistent differences have been identified in previous
research. According to data from the TACOS-study, these weak relationships
might be explained by the heterogeneous nature of processes of natural recovery.
Based on the findings from our own study and other studies in the field, the
impact of various factors differs concerning their strenght of relationship to
natural recovery or help seeking on the one hand, while on the other hand these
independent variables seem to interact in a complex way. Based on these
findings, we would like to suggest a model of recovery with and without
treatment. This model should be able to differentiate processes from remission
and maintenance of addictive behaviors (thus incorporating findings of
comparisons between active drinkers and remitted subjects) and should be able
to differentiate between treated and untreated exit processes. According to our
cluster solution, problems therefore need to be separated into problems that are
directly related to alcohol consumption (severity of dependence, health
problems) and social problems (legal problems, social pressure etc.). An
overview on the model can be found in Figure 2.
95
Figure 2. A model of triggering factors of recovery from alcohol dependence
indicating a positive (+) or negative (-) influence compared to unresolved alcohol
dependent individuals; the dotted lines indicate an effect on natural recovery if
psychosocial problems and psychosocial resources both are high (+/+) or low (-/-).
Severity of alcoholrelated problems
or dependence
Health problems
Psychosocial
Problems
+/+ -/-
+ (+)
++
Treated
recovery
+
++
-
+ (+)
Natural
recovery
+ (+)
Social resources
As described in our overview on triggering factors of natural recovery, severity
and/or chronicity of alcohol-related problems or dependence are predicitive for
recovery independent of help-seeking status, being more pronounced in treated
subjects. This means that usually alcohol-related problems need to be developed
untill a certain degree before behavioral changes are considered. A separate area
of problems are health problems, which mainly assist natural recovery.
Concerning psychosocial problems, higher problems are predictive for treatment
seeking, while psychosocial problems show a weak relationship to natural
recovery compared to untreated, unresolved subjects. Concerning psychosocial
problems and psychosocial resources, an interactive term is hypothesized on
grounds of data from the TACOS-study. For the subgroup of natural remitters
who reveal some psychosocial problems, a minimum of social support appears to
be necessary for untreated remission, as indicated by the dotted curve.
Concerning psychosocial resources, a negative relationship to treatment
utilization and a strong relationship to natural recorvery is hypothesized.
However, there it has to be considered that for subjects with lower psychosocial
resources, natural recovery is a viable pathway in the absence of psychosocial
problems, again indicated by the dotted curve. Data from the TACOS-Study
96
strongly suggests that in future studies we need to broaden our focus to the
interaction of the independent variables which have been found to influence
remission without formal help, as remitters without formal help seem to be a
rather heterogeneous group. This is supported by findings on gender differences
in natural recovery (Bischof et al. 2000b) as well as by studies on natural
recovery suggesting that the temporal relationship of independent variables to
processes of recovery influences their relative impact (Sobell et al. 1993a;
Blomqvist 1999). Furthermore, as the impact of several factors associated with
the course of alcohol use disorders like e.g. genetics, psychiatric comorbidity or
personality traits on remission without formal help has not been investigated yet,
expanding the sample sizes in future research on natural recovery might become
a crucial milestone for the development of a fully fledged model on processes of
natural recovery.
It has to be taken into account that the model consists of contextual variables that
influence remission with and without formal help which can’t be directly
influenced by therapeutic interventions. Further research is needed to determine
factors directly utilizable for improving formal treatment. For this aim,
especially cognitive factors appear to be a promising approach. Studies on
grounds of qualitative data suggest that processes of forming a postaddict
identity or new meaning in life (Klingemann 1991; Granfield & Cloud 1996) are
important mediators of natural recovery. On the other hand, data from the study
of Sobell et al. (1992, 1993b) suggest that treated and untreated recovery
processes both are triggered by a cognitive appraisal process. Commonalities in
cognitive appraisal would be in line with the Transtheoretical Model of behavior
change (Prochaska et al. 1992). The question whether cognitive factors differ in
processes of treated and untreated recoveries from alcohol dependence should be
analyzed more precisely with longitudinal designs using untreated control
groups.
In order to overcome limitations of previous research, including the TACOSstudy, based on recruitement processes, natural recovery should be included in
the designs of future epidemiological studies, where these processes might be
examined prospectively by conducting follow-ups with alcohol dependent
subjects for a period of 5 to 10 years.
Finally, data on natural recovery to date are restricted to specific cultural
conditions. One study on natural recovery revealed differences within ethnic
subgroups (Cameron et al. 2002), and the impact of different treatment systems
might influence remission without formal help (e.g. Blomqvist 1999). Therefore,
although several findings from studies conducted in the US or in Sweden could
be replicated in the TACOS-study, cross cultural studies might also broaden our
knowledge on remission without formal help.
97
Acknowledgement
This study is part of the German research network “Analytical Epidemiology of
Substance Abuse” (ANEPSA Research Group 1998) and was supported by the
German Federal Ministry of Education, Science, Research, and Technology
grant no.: 01 EB 9406.
98
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101
Gender Differences in the Influence of Being
Married on Help-Seeking and Alcohol Abuse
Keith Humphreys, Christine Timko & Rudolf Moos
Many researchers and clinicians have argued that alcoholic women encounter
greater social and psychological problems than do alcoholic men, including
greater societal disapproval, lower income, higher rates of co-morbid
psychopathology, and an alcohol treatment system that is male-biased and
insensitive to women’s needs (e.g., Beckman & Amaro 1986, Burtle 1979). Yet
studies of treated and untreated alcoholic samples usually show that women’s
outcomes are similar to or better than men’s (Hasin et al. 2001; Haver 2001;
Hesselbrock 1991; Humphreys & Weisner 1999; O’Connor et al. 1993; Timko et
al. 2002; Toneatto et al. 1992; Vannicelli 1984). This paradox may result from a
lack of attention in the alcohol field to some variables that convey a prognostic
advantage for alcoholic women and a prognostic disadvantage to alcoholic men.
This paper examines one such variable – being unmarried – exploring in
particular whether and how it may benefit alcoholic women but not alcoholic
men.
Our focus on gender differences in how being married affects the course of
alcoholism has conceptual and empirical bases. The social-relational context
maximizes gender differences across a range of behaviors (Maccoby 1999).
Studies conducted by San José et al. (2000), Romelsjo et al. (1991), Wilsnack et
al. (1991) and Moos et al. (1990) have shown that the same type of social
relationship can have different consequences for men’s and women’s drinking.
Marriage seems a particularly useful focus for research in this area because the
marital relationship is a common and enduring influence on the behavior of most
adults, and usually has more impact on drinking behavior than do other social
relationships (Leonard & Mudar 2003). Further, the influence of marriage may
vary by gender. For example a wife’s drinking pattern may be more influenced
by her husband’s than the reverse (Leonard & Mudar 2003; Wilsnack et al.
1984).
Finally, in a prior longitudinal study of treated alcoholic patients conducted from
the mid-1970s through the early-1980s, our research center (Moos et al. 1990)
found striking gender differences in 6-months post-intake abstinence rates by
marital status, specifically:
103
Married
Unmarried
Males
45% Abstinent
18% Abstinent
Females
28% Abstinent
42% Abstinent
These results were clearly not a result of differences at treatment intake, at
which time unmarried women had more severe alcohol problems than did
married women (and indeed, also worse than the men). By the standards of most
predictive relationships in alcohol treatment research, this finding qualifies as a
sizable difference, and seems to indicate that being unmarried is good for
women’s alcohol outcomes but not for men’s. The reason why such a gender
difference would give an advantage to alcoholic women as a group may not be
intuitively clear at first, until one recalls that the alcoholic population has an
unusually low rate of currently being married. In most alcohol treatment studies
for example, the vast majority of entering adults are currently unmarried (Moos
et al. 1990). When a factor strongly predictive of better outcome in females and
worse outcomes in males is prevalent in a population, that conveys an overall
relative advantage to females in that population.
The present project is one of a series generated from an ongoing, 16-year
longitudinal study of alcoholic individuals who had not sought treatment prior to
recruitment. The study is based at the Center for Health Care Evaluation in Palo
Alto, California and its principal investigator is Rudolf Moos. At this writing,
follow-ups have been completed at one, three, and eight years after baseline
recruitment. Several studies of gender differences already completed in this
research program have shown that despite starting with similar or more serious
alcohol problems as men at baseline, women had better outcomes over time on a
range of variables. This result appeared consistently, even though at each wave
samples were somewhat different depending on who had been located, and
different analyses examined somewhat different outcomes (see Humphreys et al.
1997; Skaff et al. 1999; Timko et al. 2002; for a full description of these
findings). We have yet to examine whether marital status helps account for these
findings. After attempting to replicate in this sample our center’s prior finding of
gender differences in the influence of being married on the course of alcoholism,
we evaluate four hypotheses that may help explain its effect.
Hypothesis 1: For alcoholic women but not alcoholic men, being unmarried
facilitates entering treatment and/or beginning to participate in self-help groups
Hypothesis 2: For help-seeking alcoholic women but not help-seeking alcoholic
men, being unmarried facilitates more extensive participation in treatment or selfhelp groups.
Research conducted in Canada and in the U.S. suggests that if alcohol treatment
is scored as a dichotomous variable (i.e., yes/no), women’s rates of receiving it
104
are similar or perhaps slightly lower than men’s (See Timko et al. 2002 for a
review). Yet women might still receive a higher amount of treatment because
relative to males, they tend to adhere more closely to health care regimens and
medical advice. In support of this conjecture, a study conducted in Poland found
that women inpatients stayed in the program longer than did male inpatients
(Wojnar et al. 1997), and this finding was replicated in the present sample by
Timko and colleagues (2002). Timko and colleagues (2002) also found that
women were more likely to attend 12-step self-help groups than were men,
replicating similar findings in other studies (Alford 1980; Humphreys 2004;
Humphreys et al. 1991).
None of the above studies examined whether the above findings were affected by
marital status. Married women may have a particularly hard time staying in
treatment for extended periods because of pressure from family responsibilities
(Gomberg 2003). We divide our analysis into two hypothesis because the factors
affecting who initially enters treatment or self-help groups (Hypothesis 1) may
differ from those that explain who among help-seekers persists in the
intervention for an extended period (Hypothesis 2). We speculate that relative to
married women, unmarried women may have more freedom to stay in treatment
and self-help programs for extended periods. In contrast, we do not see any
reason to hypothesize a priori that married status would significantly affect
whether men enter treatment or participate in it extensively.
Hypothesis 3: Among help-seekers, unmarried women and married men benefit
more from alcoholism treatment and self-help groups than do married women and
unmarried men, respectively.
Women’s response to alcohol treatment is a much understudied topic (Smith &
Weisner 2000). As mentioned, unmarried women may stay in treatment and selfhelp groups longer than do married women. As length of treatment tends to
predict better outcome (Finney & Moos 1998; McKay 2001), this would suggest
better outcomes for unmarried women than for married women. In contrast, most
studies of male alcoholic samples find that being married predicts being
abstinent after treatment (Monahan & Finney 1996; Schneider et al. 1995).
Hypothesis 4: The marriages of alcoholic men differ from the marriages of
alcoholic women.
Support from a spouse can aid recovery from alcoholism whereas harsh criticism
may undermine it (Moos et al. 1990; Yoshioka et al. 1992). The presence of
children can also influence outcome, either by providing a motivation for
continued abstinence (Koski-Jännes 1991) or by creating a source of stress and
disagreements. Although it has been minimally studied, the length of marriage
105
may also affect the course of drinking, in that commitment both to the
relationship but also to long-term behavior patterns may strengthen over time. If
the marriages of alcoholic men and women differ significantly in any of these
respects, for example if husbands of alcoholic wives are more harshly critical
than wives of alcoholic husbands, it could produce gender differences in the
prognostic value of marital status.
Method
Research Program Sample and Background
The overall sample in this research program comprises 628 alcoholic individuals
from the greater San Francisco area. Participants were recruited at detoxification
centers and alcoholism information and referral services and asked to complete a
self-administered inventory (see Finney & Moos 1995 for details). Participants
were followed one, three and eight years later and asked to complete the
inventory again. Follow-up rates for those not known to have died (n=53 by 8year follow-up) were over 80% at all waves. Attrition analysis showed no large
demographic differences between those located and not located across waves,
except that at some follow-ups those re-contacted had higher rates of baseline
employment and education levels than those not located.
Importantly for present purposes, the sample contains an unusually high
proportion of women, being roughly evenly divided by gender. At baseline,
about one-fourth of the sample was married. This by itself is remarkable,
especially given that the U.S. is the most maritally-oriented Western society: In
the birth cohort in which the participants are included, over two-thirds of adults
of the participants’ age are currently married (Krieder & Fields 2002). Just over
80% of respondents were Caucasian. At baseline, the average participant was 34
years old and had completed 13 years of education. No one in the sample had
received formal treatment for alcohol problems prior to baseline. Nevertheless,
almost all (95%) participants reported experiencing alcohol dependence
symptoms such as shakes, fevers, delirium, hallucinations, and blackouts in the
six months before baseline. Thus, our research program is unusual in capturing
the first help-seeking effort of individuals with severe alcohol problems.
Measures
In addition to demographic information, the inventory gathered extensive data on
respondents’ problems. Total ethanol consumption on drinking days was
calculated in ounces based on the respondent’s report of consumption of hard
liquor, wine, and beer on typical drinking days in the past month. Participants
106
also reported on whether they had been completely abstinent in the past six
months. Alcohol dependence symptoms (range 0-44, alpha = .88) experienced in
the past six months were measured using 11 items (response range from 0 =
“Never” to 4 = “Often”) from the Alcohol Dependence Scale (Skinner & Allen,
1982), and Alcohol-related problems were measured using a scale composed of
nine 5-point items ranging from never to often that asked about adverse
consequences of drinking experienced at home, work, and with the law (Moos et
al. 1992). Collateral reports were obtained for a subsample of participants and
tended to confirm their reports of alcohol consumption and problems (Finney &
Moos 1995).
Help received by participants was measured at each follow-up. Participants
reported on how many weeks they had participated in inpatient treatment
(including residential treatment and halfway houses), outpatient treatment, and
Alcoholics Anonymous mutual help groups.
Finally, consistent with our focus on intimate relationships, all participants
reported on whether they were currently married. Marital relationship quality
was measured by a 10 item scale (range 0-40, alpha = .91) adapted from the Life
Stressors and Social Resources Inventory (Moos & Moos 1994). Positively
scored items on this scale include “Can you count on him/her to help you when
you need it?” and “Do you get along well with him/her?”; reverse scored items
include “Does s/he expect more from you than he/she is willing to give?” and
“Does he/she critical or disapproving of you”. Number of children and length of
current marriage were also measured.
Results
Replication of Moos et al. (1990)
Of the 458 individuals who were located at 8 year follow-up, only 23% were
married at baseline. To examine gender differences in the prognostic meaning of
being married, we examined whether 6-month abstinent rates at the 1-year and 8year follow-up differed for married males (n=59), unmarried males (n=171),
married females (n=50), and unmarried females (n=178) who had been followed
at both points. As shown in the top part of Table 1, Moos et al’s (1990) results
were replicated, with married men having higher abstinence rates than unmarried
men at both 1-year and 8-year follow-ups, and unmarried women having higher
abstinence rates than married women at 8-year follow-up.
107
Table 1. Rates of being abstinent from alcohol in the past six months by single
males, married males, single females, and married females.
Overall rates
One-year follow-up
Eight-year follow-up
Rates by help-seeking status
Help-seekers, 1-year follow-up
Non-help-seekers, 1-year follow-up
Help-seekers, 8-year follow-up
Non-help-seekers, 8-year follow-up
Single
Men
(n=171)
Married
Men
(n=59)
Single
Women
(n=178)
Married
Women
(n=50)
25.7%
45.6%
33.9%
55.9%
36.0%
62.9%
36.0%
50.0%
34.9%
9.7%
50.7%
20.7%
47.4%
9.5%
60.9%
38.5%
45.5%
6.8%
68.2
33.3%
44.4%
14.3%
58.5%
11.1%
Differences in the predictive role of marriage for men and women may be shaped
by initial differences in alcohol problems (Moos et al. 1990). Accordingly, t-test
comparisons on baseline alcohol problem measures were conducted. Among
men, unmarried status was significantly ( p < .01) associated at baseline with
consuming more ounces of ethanol on drinking days (Mean 14.1, SD 11.3 versus
Mean 9.9, SD 9.7 for married men, t =2.56), having higher scores on the Alcohol
Dependence Scale (M 10.3, SD 7.6 versus M 7.2 SD = 6.6 for married males, t =
2.75), and experiencing more drinking-related problems (M 9.8, SD 6.0 versus M
7.4, SD 5.4 for married males, t = 2.70). A similar pattern of significant (p < .05)
differences held among women, with unmarried status being associated at
baseline with consuming more ounces of ethanol on drinking days (Mean 12.8,
SD 9.7 versus Mean 9.9, SD 9.9 for married women, t = 1.88), having more
severe alcohol dependence (M 13.0, SD 8.7 versus M 10.2, SD 7.8 for married
women, t = 2.00), and experiencing more drinking-related problems (M 10.6, SD
7.2 versus M 6.8, SD 4.9 for married women, t = 3.55).
Like Moos et al. (1990), this study also found unmarried status associated with
worse initial problems at baseline for both genders. This pattern was maintained
among male participant throughout the 8-year follow-up, suggesting that being
married conveys a prognostic advantage to alcoholic men. In contrast, the
ranking by married status among women reversed over the course of the study.
At 1-year follow-up, unmarried women “caught up to” married women with an
equal abstinence rate, and by 8-year follow-up, unmarried had clearly superior
outcomes. This suggest that being married conveys a prognostic disadvantage to
women.
108
Hypothesis 1: For alcoholic women but not alcoholic men, being unmarried
facilitates entering treatment and/or beginning to participate in self-help groups
Chi-square analysis was used to determine whether married status was
differently associated by gender with entering professional treatment or
remaining untreated. Among males, there was no significant difference between
the rate of entering treatment by marital status over the first year of the study
(49.2% of married men, 49.1% of unmarried men) or over the first eight years
(66.1% of married men, 69.0% of unmarried men). In contrast, unmarried
women were somewhat more likely than married women to enter treatment. This
difference in rate of treatment entry approached significance over the first year
(46.0% of married women, 58.4% of unmarried women, Chi-square = 2.44, p
=.12), and over the first eight years (60.0% of married women, 73.0% of
unmarried women, Chi-square = 3.17, p =.07) of the study.
About half (52.3%) of men sought help from Alcoholics Anonymous (AA) in the
first year of the study and 63% had done so by 8-year follow-up, but attendance
rates were almost identical for married and unmarried men. Women had higher
rates than men of having attended AA at one-year (57.0%) and eight-year followup (70.6%), but like men showed no difference in AA attendance rates by
marital status.
Hypothesis 2: For help-seeking alcoholic women but not help-seeking alcoholic
men, being unmarried facilitates more extensive participation in treatment or selfhelp groups.
Help-seeking married and unmarried people were compared within gender at 1year and 8-year follow-ups on weeks of inpatient/residential treatment,
outpatient treatment, and Alcoholics Anonymous. None of these 12 independent
samples t-tests was significant at the p <.05 level, indicating that being married
was independent of how extensively help-seekers of either gender participated in
their chosen intervention.
Hypothesis 3: Among help-seekers, unmarried women and married men benefit
more from alcoholism treatment and self-help groups than do married women and
unmarried men, respectively.
This hypothesis proposes a three-way interaction, which presents some analytic
and interpretive challenges. Examining specific types or amounts of intervention
was not possible as this would require more subjects per subgroup than were
available, particularly as the number of married participants was not large even
before dividing them by gender and types of treatment. To simplify and clarify
the results, help-seeking since baseline of all sorts (AA, outpatient treatment,
109
inpatient treatment) was collapsed into a single yes/no variable at each follow-up
and cross-tabulated with abstinence rate at the same wave. These results were
then cross-tabulated with gender and marital status at baseline, as shown in the
lower part of Table 1.
Chi-square analysis (not shown) within each of the groups verified what is
obvious from visual inspection of the table, namely that for all four groups and
both waves, individuals who received help from treatment and/or AA had much
higher abstinence rates than those who did not. Less obvious but nevertheless
evident is a three-way interaction such as that hypothesized. At 1-year follow-up,
the increase in rate of abstinence associated with help-seeking is greater among
married males (9.5% non-help seeking vs 47.4% help-seeking) than among
unmarried males (9.7% non-help seeking vs 34.9% help-seeking). The reverse
pattern was evident among women. At 1-year follow-up, the increase in rate of
abstinence associated with help-seeking is greater among unmarried females
(6.8% non-help seeking vs 45.5% help-seeking) than among married females
(14.3% non-help seeking vs 44.4% help-seeking). Both of these sets of
differences are consistent with the hypothesis that being married increases men’s
and decreases women’s degree of benefit from treatment/self-help groups,
relative to their unmarried counterparts of the same gender.
The 8-year outcomes are less informative and stable because by this point in the
study very few subjects had not sought at least some help. A two-way interaction
not evident at one year emerged, such that married men had better outcomes than
unmarried men across help-seeking status, and the reverse pattern occurred for
women whether they had sought help or not. This, combined with low cell sizes
precluding a direct test for significance, makes it harder to argue for a three-way
interaction being evident at 8-year follow-up. However, the highest 8-year
abstinence rates of all eight gender-by-married status-by help seeking categories
were experienced by help-seeking unmarried women (68.2%) and help-seeking
married men (60.9%), which is consistent with hypothesis three.
Hypothesis 4: The marriages of alcoholic men differ from the marriages of
alcoholic women.
To determine whether quality of marriage might help explain this finding, we
compared married alcoholic men to married alcoholic women on spousal
relationship quality. Married men rated their marital relationship as more
supportive and positive (Mean 31.6, SD 7.8 versus vs. Mean 28.4, SD 8.7 for
married women, t = 1.96, p =.05). The men’s marriages were also of somewhat
shorter duration (Mean 7.8 years SD 8.0 versus Mean 11.5, SD 9.9 for women, t
= 2.05, p = .04). On the other hand, there were no significant differences
between married men and women in number of children (Sample mean = 1.8).
110
Discussion
All of our results must be put in two interpretive contexts. First, this project was
conceived and initiated in the mid-1980s. As such, it did not include
measurement of variables subsequently discovered to be important in
understanding women’s problem drinking, particularly spousal drinking habits,
tranquilizer use, and sexual dysfunction (cf. Graham & Wilsnack 2000;
Wilsnack et al. 1984). Anyone who has conducted long-term research will
identify with our wish that we had a time machine to travel back and add
variables to our baseline inventory. As it is, we simply have to acknowledge this
as a weakness. The second important context is that this study was launched in a
particular geographic context (The San Francisco Bay Area) in a particular
moment in time (the mid-1980s). This raises questions about generalizability, in
part because in the U.S. at least, women appear to be drinking more alcohol more
frequently than they did when our study began (Sidhu & Floyd 2002).
That said, several of our major findings resonate with those found in other
periods and in other locations. The major, intriguing finding of this work is our
replication of a marital status by sex interaction effect first identified in a
different sample studied in a project that began in the 1970s. A similar effect
was reported several years ago in a study of 592 alcoholic inpatients (Schneider
et al. 1995). Replicating any interaction effect is rare in social science, much less
to do so repeatedly. Not only is the stability of the effect sizable, but its nature is
provocative. At baseline, unmarried alcoholic women appear much more
troubled than their married counterparts, but the pattern reverses itself over time.
In contrast, for men, marriage is a positive prognostic sign throughout the
lifespan (or at least the 8 years we studied here and the 10 years in Moos’
original project). Said differently, on average unmarried alcoholic men have
more severe problems than married men throughout long sections of the lifespan.
We tested several explanations for why being unmarried has different
consequences for alcoholic men and women. We found modest evidence that
unmarried women are more likely to enter treatment than are married women.
However, this was not true for AA, and being married was also unrelated to
length of participation in treatment and self-help groups. Thus, treatment and
self-help utilization patterns are not a full explanation of the identified gender
difference.
Despite similar utilization patterns, unmarried women seemed to benefit
somewhat more from treatment/AA than did married women, whereas married
men benefited more than unmarried men. Because over the life course, the
impact of alcoholism treatment is amplified or minimized by more enduring
features of the social context (Moos et al. 1990), it may help to interpret the
findings in that light.
111
Most notably, the married alcoholic men appeared to have more supportive
relationships than did the married alcoholic women, which may have facilitated
the men’s treatment gains. Although the women’s marriages were of lower
quality, they were of longer duration, which may reflect that some negative
features (e.g., harsh criticism, violence) were also of longer-standing, which
could increase likelihood of relapse. Schneider and colleagues (1995) explained
similar findings along classic feminist lines, suggesting that in general, women
are simply more supportive of their husbands than the reverse. Specific to
alcohol problems, a variant of this argument we could not test directly is that
women are more likely to marry heavy drinkers than are men, and to match their
own drinking level to that of their spouse (see Leonard & Mudar 2003). The
difficulty with these arguments for present purposes is explaining why the
unmarried women were doing so poorly at the outset. Did they for example
recently escape abusive marriages, or did they find an unusually good love
relationship after they began recovery? Within the limits of our data, we intend
to explore these questions further as our 16-year follow-up data are gathered.
Those 16-year follow-ups that we have completed as of this writing suggest
strongly that the pattern of unmarried women having particularly positive
outcomes persists at 16 years, which makes understanding the mechanisms
behind this finding all the more important and tantalizing.
A non-competing explanation for our findings is that selection into marriage may
differ by gender. Males may have to demonstrate a baseline level of
socioeconomic competence to be considered “marriageable”, which would imply
that males with severe problems are less likely to become married than are
women with serious problems. This speculation has been supported in studies of
people with schizophrenia, which show that marriage rates among female
subjects are from 2-5 times higher than those for males (Jablensky & Cole 1997).
This would imply that married males, alcoholic or not, tend to be more stable,
socially competent, and have less gross psychopathology than do unmarried
males, which helps them recover from alcohol problems more readily. A related
selection-oriented explanation is that women may be more prone to divorce an
alcoholic husband than are men to divorce an alcoholic wife. Some men may
perceive advantages in heavy drinking by a wife (e.g., greater sexual
accessibility, lower assertiveness) and therefore be disinclined to end the
marriage because of alcohol abuse. In contrast, male alcohol abuse is strongly
associated with common precipitants of divorce, such as physical violence and
other anti-social behavior. In keeping with this explanation, The Lundby
longitudinal study reported that over a 15-year period, the severity of men’s
drinking tended to predict increased social isolation and family disintegration
(Öjesjö 1981).
In summary, we found that being married is a powerful predictor variable of the
course of alcoholism, even though it exerts only a modest influence on treatment
and self-help group participation. Even more interesting, being married has
112
contradictory implications for the prognosis of men versus women. It remains
now for us and others interested in gender and alcohol to assess the generality of
these results, and their implications for improving the formal and informal
response to people with alcohol problems.
113
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116
Epidemiology of Desistence among
Addicted and Non-Addicted Drug Users
Michael Beenstock
1. Introduction
The empirical study of desistence in illicit drug use has followed two main
methodological traditions. In the first, individuals who have stopped using drugs
and individuals who have failed to stop are interviewed in depth in the hope of
discovering the trigger mechanisms responsible for desistence and persistence in
drug use. Examples of this tradition, which emphasize the deeper psychological
and social factors responsible for desistance, include Ludwig (1985), Fiorentino
and Hillhouse (2001) and Cunningham, Koski-Jannes and Toneatto (1999). In
the second tradition, epidemiological data are used in the hope that they will
reveal empirical regularities in the pattern of drug use desistence as well as its
persistence. The former tradition has naturally been espoused by clinicians
involved in the treatment of drug addicts, and is inherently a bottom-up
approach. The latter tradition has been espoused by statisticians, epidemiologists
and even economists, and is inherently a top-down approach. Each approach has
advantages and disadvantages. The bottom-up approach is rich in clinical detail,
but risks missing the wood for the trees. The top-down approach may succeed in
revealing broad tendencies, which may be of interest to policy makers, but which
may be of only limited use to clinicians and practitioners. The two traditions
should be seen as complements rather than substitutes. The present chapter falls
squarely in the second tradition.
I summarize the results from two recent research projects into the process of
illicit drug use desistence1 in Israel. The first is based on general population
survey data, collected by the Israel Anti Drug Authority (IADA), regarding drug
use among adult Jews in Israel. Details of these results have been reported by
Beenstock and Rahav (2003). The second is based on administrative data files
for drug addicts in Israel, who are recipients of benefit from the National
Insurance Institute (NII). Details of these data have been reported by Beenstock
and Haitovsky (2003).
The two projects are quite different in character. In the first respondents are not
necessarily addicts. Indeed, the vast majority of respondents have never used
drugs. Respondents report if and when they started to use drugs, and if they are
1
“Desistence” is a criminological term. Termination and stopping may be less loaded
terms for the same phenomenon.
117
currently using drugs. These IADA data are retrospective because at the time of
the survey respondents recall when they first used drugs etc. The IADA
respondents are not followed-up over time, hence the data are not longitudinal.
However, the IADA survey has been conducted every three years since 1989.
Respondents who reported that they ever-used drugs, but at the time of the
survey had not used drugs during the last 12 months, are deemed by Beenstock
and Rahav to have desisted. Desisters will include both occasional and heavy
users of drugs. Fortunately, the IADA data provide information on drug use
intensity, so we can control for the intensity of use.
The NII data refer to hard-core addicts, who cannot work, and are therefore in
need of financial assistance. The first intake cohort of NII is 1989 and the last is
1998. When they first apply for benefit NII addicts complete a registration
questionnaire, which provides retrospective data on when they started using
drugs etc. NII addicts are required to apply for renewal of their entitlement to
benefit about every two years. If and when they do so, they complete a follow-up
questionnaire, which provides information on what has changed since
registration. By definition all NII addicts use hard drugs on registration.
However, the follow-up data shed light on how their addiction has changed, if at
all. If they report reduced drug use or even zero drug use they may be defined as
desisters. Subsequent follow-up data reveal whether desistence was temporary,
or whether addicts desisted later rather than sooner. Desistence is therefore
inferred from retrospective information in the case of IADA data, and it is
inferred from longitudinal information in the case of NII data.
I use the two data sets to explore different aspects of desistence. Because of their
longitudinal nature, the main advantage of the NII data is that they provide a rare
opportunity to study the dynamics of desistence, and to distinguish short-term
and long-term desistence. The main advantage of the IADA data is that they refer
to drug users who are not necessarily addicts, and the sample is randomly
selected rather than self-selected. Both data sets are used, however, to investigate
a variety of time dependent phenomena in the process of “maturing out” of drug
use. Two key aspects in the literature are singled out in section 2. The first treats
maturing out as an age-dependent phenomenon. The second treats it as a
duration-dependent phenomenon. These two mechanisms are quite different. The
first attaches importance to the life-cycle and growing up. The second is based
on disease theory; drug use is like a disease, which runs its course, so that what
matters is how long a person has been using drugs rather than how old he is.
Section 3 reviews the range of time-dependent phenomena in drug use
desistence. Section 4 summarizes results from the first study (IADA), while
section 5 summarizes results from the second study (NII). Section 6 concludes.
118
2. Maturing Out
The scientific literature on drug use desistence dates back to Winick (1962), who
observed that a large proportion of individuals who in 1955 were listed in FBI
files as narcotic addicts were not so listed in 1960. He concluded that, “…
addiction is a self-limiting process for perhaps two-thirds of addicts”. His graph
of the length of the period of addiction shows that for most addicts the duration
of addiction is less than 10 years. Subsequently, (Winick 1964) he suggested two
related but conceptually different mechanisms to explain what he observed. The
first is maturation; behavior naturally changes over the life-cycle, we grow out of
certain activities, and grow into others as we get older. These changes are closely
associated with age. The second mechanism has to do with duration of addiction.
Addiction, he suggested, may be like a disease that runs its own course, formed
by the experiences and insights accumulated as an addict.
Subsequent research into drug use termination, which has been extensive, has
used a proper longitudinal design, and has been reviewed elsewhere, e.g. by
Granfield and Cloud (1999). Much of this research has sought to identify the
internal and external triggers, which induce individuals to cease their
consumption of drugs. The original question posed by Winick, duration v age
dependence, seems to have fallen by the wayside. Either the difference between
the two mechanisms has been blurred, or one mechanism has been preferred over
the other without the matter being tested. Typically, duration dependence is
ruled out by default in favor of age dependence. For example, Kandel and Raveis
(1989) and Chen and Kandel (1995) focus exclusively upon age as a factor in
drug use termination. So do Labouvie (1996), Fingfeld and Lewis (2002). These
authors did not consider whether their data might also be consistent with
duration dependence.
A minority of authors, including Pierce and Gilpin (1996), Price et al. (2001) and
Schuckit et al. (2001) attach explicit importance to duration of use in the
termination process. However, they do not test for age dependence. An exception
is Levinson (1998) who argues that the success of detoxification programs varies
directly with age and duration of use. Another exception is Anglin et al. (1986)
who directly consider age and duration dependence. They show that both types
of dependence are empirically important on their own but not together. They did
not test which type of dependence is the more empirically relevant of the two.
3. Time Dependence in Desistence
We focus upon the mechanism that drives the process of drug use desistence.
Specifically, we distinguish between age and duration dependent mechanisms.
Age-dependence implies that behavior that was acceptable when younger ceases
119
to be acceptable when older. Hence, as people get older they mature out of their
drug use. Duration-dependence views drug use as a self-limiting phenomenon
that runs its own course, so that the termination mechanism is duration
dependent. The second mechanism implies that people who were younger when
they got into drugs are likely to be younger when they get out of drugs. By
contrast, the first mechanism implies that people who were younger when they
got into drugs are likely to have longer drug careers, because what matters is age
rather than duration of use. These two mechanisms are not mutually exclusive,
since the desistence process may in general be both age as well as duration
dependent. While the issue of age v duration dependence is as old as the
literature on maturing out, the difference between these mechanisms has become
somewhat blurred in the scientific literature.
The two mechanisms are related, and are therefore difficult to disentangle
empirically. If everybody began their drug use at the same age it would be
impossible to disentangle them. However, the fact that people initiate drug use at
different ages enables us to test hypotheses concerning the two mechanisms. A
formal statistical test is proposed for distinguishing between age and duration
dependence in drug use desistence. The methodology allows for both
mechanisms to be at work so that desistence might, in general, be both age as
well as duration dependent. We test the restriction of exclusive age or duration
dependence against this general alternative.
Let A denote the age of a respondent when surveyed in year Y, and let S denote
his age at drug use initiation. Year of birth is therefore B = Y – A and duration
since initiation is D = A – S. For a given birth cohort, the statistical significance
of both D and A in a statistical model for desistence suggests that desistence is
both age and duration dependent. D and A are naturally positively correlated but
they are not perfectly collinear due to the variation of S in the data. Desistence is
positively age-dependent when the coefficient of A is positive, and it is
positively duration-dependent when the coefficient of D is positive. If the
coefficient of B happens to be positive, then more recent birth cohorts desist
more. If, however, the desistence mechanism is entirely age-dependent, then only
A will de statistically significant. If at the other extreme, the desistence
mechanism is entirely duration-dependent, then only D will de statistically
significant.
This schema for identification implicitly assumes that the birth cohort effect (B)
is not a time effect (Y). Only three of the four time dependent phenomena (B, Y,
D and A) are independent. In the previous paragraph the coefficients of A, B,
and D have been “identified” by implicitly assuming that there is no independent
effect of time itself. Alternatively, the coefficients of A, Y and D are “identified”
assuming there is no birth cohort effect.
120
In the NII data there is a further time dimension; the time between registration
and follow-up, which we refer to as the follow-up lag. Normally this lag is 2
years, but its distribution has a long tail because many addicts were late in
attending their follow-up interview. If desistence is more likely to occur over a
longer period of time than a shorter one, we expect desistence to vary directly
with the follow-up lag. However, if desisters return to drugs matters are more
complicated, as discussed in section 5.
4. Retrospective Evidence for Non-Addicts (IADA Data)
The data refer to some 12,500 Jews, aged 20–40 years in Israel observed in
1989, 1992 and 1995. About 8% reported ever-use of cannabis and 1.15%
reported ever-use of hard drugs (cocaine, heroin, methadone and LSD). 58% of
ever-users of cannabis had not used cannabis during the last 12 months, and 47%
of ever-users of hard drugs had not used them during the last 12 months. This
does not mean that the rate of desistence is 58% in the case of cannabis and 47%
in the case of hard drugs, because these percentages take no account of the ages
of the respondents and their duration of drug use. These percentages naturally
vary directly with age and duration of use.
We use survival analysis to investigate the hazard of desistence. The desistence
hazard is the probability of desisting during the next year, conditional upon age,
duration of use and other possible controls. In the IADA data the date of
desistence is unknown; we only know whether or not desistence occurred by
year Y. Had IADA revealed the date of desistence we would have estimated a
failure time model in which time to desistence would have been the key variable
of interest. However, time to desistence is left censored at Y for desisters and it
is right censored at Y for non-desisters. Beenstock and Rahav show that when
the time to failure is both left-censored and right censored as in the present case,
the failure time model becomes a probit model in which the desistence hazard
may be non-monotonic2.
This section summarizes the results reported by Beenstock and Rahav (2003),
who defined desistence as a binary variable (Z) that has a value of unity if the
individual concerned did not use drugs in the last 12 months, but reported having
initiated drugs at age S, and zero otherwise (i.e. he still uses drugs). The natural
way to test hypotheses about the determination of desistence is to estimate
multivariate probit models for Z. A positive coefficient in the probit model
means that the probability of desistence is increasing in the variable, a negative
coefficient implies that it is decreasing. Separate models are estimated for
cannabis desistence and hard drug desistence.
2
In the logit model the hazard function is restricted to be monotonic.
121
The modeling procedure is the “general to the specific” methodology
(Cuthbertson, Hall and Taylor 1991), which is similar to a backward stepwise
procedure. We begin from an unrestricted model in which a range of covariates
to be tested is specified in the model. Apart from demographic variables we
include duration (D) and age (A), which is logically equivalent to using age at
initiation (S) since D = A – S. We also include separate dummy variables for
year of survey because this variable and age are perfectly collinear with year of
birth (B). We successively nest-down from the unrestricted model to a restricted
model, eliminating statistically insignificant variables on the way.
Cannabis Desistence
In all specifications for cannabis desistence the coefficient of age (A) was not
statistically significantly different from zero, implying that the age-dependent
model, is clearly not supported by the cannabis data. By contrast, the coefficient
of duration (D) in Table 1 is 0.046, has a t – statistic of 5.11, and is therefore
very statistically significant. Clearly, what matters in the case of cannabis
desistence is duration of use, not age. The desistence mechanism in the case of
cannabis is exclusively duration dependent.
Table 1 presents the restricted model for cannabis desistence. The model
suggests that the termination probability varies inversely with ever-use of
cannabis (the base case is maximal use). Individuals who used more cannabis
found it more difficult to desist. This is especially true of high and maximal
users. This finding is consistent with the view that cannabis use leads to the
development of a habit, and that the stronger the habit, the more difficult it is to
desist. On the other hand this association may not be causal; it may mean that
people who find it hard to desist tend to consume more.
Table 1 indicates that the probability of desisting varies inversely with the
frequency of pub visits (all the categories of frequency of pub visits have
positive coefficients, compared to those who go to a pub 7 times or more per
month). A related result is the probability of desisting varies directly with the
age at which beer drinking was initiated. The beer – pub culture seems to act as a
social milieu favorable to the use of psychoactive substances, and tends to
prolong the use of cannabis.
122
Table 1. A Probit Model for Cannabis Desistence.
Intercept
Father’s Origin: Israel
N. Africa
Asia
Cannabis use: Low
Intermediate
High
Pub visits: 1 (None)
2
3
4
Duration (D)
Religious observance (intermediate)
Age of beer initiation
Survey 1989
Survey 1992
N
Desisted
-lnL
Coefficient
-2.06
-0.354
-0.332
-0.792
1.641
0.539
0.096
0.777
0.550
0.444
0.204
0.046
0.292
0.027
0.409
0.215
859
500
431
Standard error
0.302
0.123
0.131
0.486
0.141
0.142
0.167
0.179
0.174
0.185
0.22
0.009
0.119
0.014
0.114
0.153
Base case: Father not born in Israel, N. Africa or Asia, maximal ever-use of cannabis,
high or low religious observance, and surveyed in 1995.
The results in Table 1 further suggest that cannabis users, whose fathers were
born in Israel, North Africa and Asia, are less likely to desist, but especially the
latter. This suggests an ethnic dimension to desistence, which does not neatly
conform to classic Sephardic – Ashkenazic cleavages3. Also, individuals with
intermediate levels of religious observance (3 on a 4 – point scale of frequency
of synagogue visits) are more likely to desist, implying that the most and least
religious find it harder to stop.
Given everything else (including age), those surveyed in 1989 were more likely
to desist while those surveyed in the base year, 1995, were least likely to desist.
This finding implies a negative time trend or cohort effect in desistence. Since
age-dependence has been rejected as an explanation for desistence, the survey
year dummies most probably capture time effects rather than birth cohort effects.
If so, desisting has been getting harder over time.
3
Sephardic Jews originate from Asia and N. Africa. Ashkenazic Jews originate from
Europe.
123
Several variables included in the analysis are omitted from Table 1 because they
did not survive the specification procedure and were not statistically significant
given the specification in Table 1. These negative results indicate that,
conditional upon the covariates in Table 1, desistence does not depend upon
gender, marital status, socio-economic status, and education. White and Bates
(1995), whose definition of cannabis use and desistence is similar to ours, found
desistence to be associated with age and gender even when marital status and the
number of children were used as controls. Another variable that does not feature
in Table 1 is the initiation age for cigarette smoking.
The desistence hazard is always increasing, i.e. the probability of desisting given
that desistence has not already occurred increases with duration of use. Indeed,
the same applies to all other cases too. However, the desistence hazard increases
at a diminishing rate, implying that the hazard function is convex, i.e. it is  shaped. The long run probability of desistence, i.e. the probability of desisting
within 20 years of having started is close to unity; implying that nearly
everybody who uses cannabis stops sooner or later.
Hard Drug Desistence
In the probit model for hard drug desistence only two variables survived the
general-to-specific model selection procedure. These are age and minimal everuse of hard drugs. The p-value for duration (D) turned out to be 0.3, which
clearly rejects the duration-dependence model in favor of the life-cycle, or agedependence model. What matters is age rather than duration since initiation. This
means that two otherwise identical drug users face the same probability of
desisting by age 35 despite the fact that one initiated at age 30 and the other at
age 20. This is because desisting is related to age rather than duration of use.
Table 2. Probit Model for “Hard” Drug Desistence.
Intercept
Age
Minimal use
-ln L
-1.792 (0.5560)
0.0578 (0.0183)
0.8595 (0.3164)
63.232
N = 126 of which 65 had desisted. Parameter
standard errors are reported in parentheses.
Table 2, like Table 1, indicates that minimal users of hard drugs are more likely
to have desisted by a given age. However, in contrast to Table 1, there is no
graduated effect on desisting for above minimal use. Such users find it just as
difficult to desist irrespective of the amount of hard drugs consumed. In contrast
124
to the cannabis data, the cell sizes for the more frequent users of hard drugs are
small, hence this effect may be a result of the thinness of the data. More
generally, because hard drug use is a rare event (only 126 cases out of more than
12,500 observations) it is more difficult to make statistical inferences about the
desistence process for hard drugs than it is for cannabis.
We were surprised to find that none of the covariates that feature in Table 1
turned out to be statistically significant in Table 2. Variables, such as gender,
which were not statistically significant in Table 1 continue to be insignificant in
Table 2. However, variables, such as ethnic origin, which were significant in
Table 1 cease to be significant in Table 2. This suggests that there is less
observed heterogeneity in the desistence process for hard drugs than there is in
the desistence process for cannabis. It also suggests that ethnicity and
socialization, which were found to affect cannabis desistence, are not important
in the case of hard drug desistence. Nor is there a cohort or time effect in hard
drug desistence. The hazard of desisting increases with age. As in the case of
cannabis, the hazard function is convex. Here too the long-term rate of
desistence turns out to be very high; nearly everyone who starts using hard drugs
desists sooner or later.
The desistence processes for cannabis and hard drugs are very different, both in
terms of their time dependence and the covariates that determine them. Note that
when duration (D) is added to the model in Table 2 its coefficient is not
significantly different from zero, and the estimated coefficient on age (A)
remains virtually unchanged. Note also that when age is added to the model in
Table 1 its coefficient is not statistically significant and the estimated coefficient
on duration remains virtually unchanged.
5. Longitudinal Evidence for Addicts (NII Data)
Data
This section reports new results obtained from the data used by Beenstock and
Haitovsky (2003) for about 7300 drug addicts in receipt of benefit from Israel’s
National Insurance Institute during the period 1989-19974. It should be stressed
that because the NII data are taken from administrative files, the sample is not
necessarily representative of the population of drug addicts in Israel. The sample
does not represent drug addicts who did not apply for NII benefit. Presumably,
the latter were better off or more sensitive to becoming welfare recipients.
4
The benefit was introduced in 1987 and still exists. In 1989 the data began to be
computerized. Unfortunately they ceased to be computerized in 1997.
125
The provision of NII benefit is not conditional upon treatment or rehabilitation.
An independent Diagnosis Center determines whether applicants for benefit are
addicted to drugs. Indeed, a minority of applicants turns out to be ineligible. On
registration at the Diagnosis Center addicts report their current frequency of drug
use by type of drug, age at first use, treatment histories, criminal histories etc.
They are interviewed for a second time (first follow-up) some two years later
when, and if, they wish to renew their entitlement to benefit. However, some
addicts apply sooner than this and many apply later. The Diagnosis Center
operates a liberal policy in renewing entitlement. It does not immediately
terminate the entitlement of reformed addicts. Nevertheless, there is an obvious
problem of moral hazard and incentive compatibility; addicts have an economic
incentive to continue their addiction in order to remain entitled to benefit.
Slightly less than half the addicts who registered applied to renew their
entitlement to benefit. There are about 3600 addicts who were interviewed both
on registration and at first follow-up. For these addicts we have information on
changes in their drug use and other behavior that occurred between the
registration interview and the first follow-up interview. These data enable us to
calculate the proportion of addicts who ceased using drugs sometime between
registering and the first follow-up some two years later. Desistence is defined in
terms of positive drug use on registration and zero use on follow-up. Reversion
is defined in terms of zero use on first follow-up and positive use on second
follow-up.
About 30% of the addicts who presented for the first follow-up interview,
presented for a third time (second follow-up) some two years after the first
follow-up. For these addicts we may calculate the proportion that ceased using
drugs between registration and first follow-up, the proportion that ceased
between the first and second follow-ups, and the proportion that reverted to
drugs between the first and second follow-ups. The total period covered for
addicts with two follow-ups is approximately 4 years. About 45% of the addicts
who presented for a second follow-up also presented for a third follow-up, and
about 30% of the latter presented for a fourth follow-up.
These longitudinal data provide a rich, and possibly unique, opportunity to study
the dynamics of addictive behavior. Beenstock and Haitovsky (2003) used these
data to investigate the effects of treatment on drug consumption. They found no
statistical difference between addicts who had been in treatment (by type and
number of treatments) and addicts who had not undergone treatment. Here I use
these data to shed light on the desistence process in drug use by addicts.
Unlike the IADA data the NII data are heavily self-selected both on registration
and follow-up. Addicts who choose to apply for NII benefit are self-selected.
Unfortunately, we have no information on addicts who did not apply for NII
benefit, hence we cannot say much about the selection process in registration.
126
Most probably the NII addicts are, as mentioned, negatively self-selected
because they typically have no other source of income. Secondly, addicts are
self-selected on follow-up. We have no information on the addicts who did not
reapply for entitlement to benefit. Perhaps they did not reapply because they
were no longer addicted, or had been received into some rehabilitation
community. Or perhaps they had been imprisoned or had died of an overdose. As
in all longitudinal data sets the causes of sample attrition are unknown, and may
induce attrition bias. Moreover, the degree of attrition naturally increases with
the length of follow-up5.
Desistence and Reversion
The 2-year desistence rates for various drug categories are reported in Table 3.
This table refers to 3206 addicts who had at least one follow-up. All of these
addicts use some or all of cocaine, heroin and methadone6. Note that addicts use
different combinations of drugs. Of these addicts 3115 also used cocaine or
heroin (i.e. 91 used methadone) and 2498 used cannabis in addition to hard
drugs. The groups featured in Table 3 naturally overlap.
Not surprisingly, the desistence rate is greatest for cannabis and smallest for
users of at least one of the hard drugs (cocaine, heroin and methadone, CHM).
However, the desistence rates for hard drugs may also seem surprisingly high.
About 7% reported that they stopped using CHM. It should be recalled that the
NII database refers to addicts and excludes non-addicted users of drugs.
Table 3. Two-Year Desistence Rates among Addicts.
Cannabis
Cocaine/Heroin
Cocaine/Heroin/Methadone
5
6
Number of Drug Users at
Intake
2498
3115
3206
Proportion Stopped
(S01)
0.407
0.176
0.070
Jones (1989) and Labeaga (1999) suggest the use of a double-hurdle model. In the
present context the first hurdle would refer to registration and the second to attrition.
Otherwise they would not have been accepted as addicts by the Diagnostic Center.
127
Table 4 uses longitudinal information on about 1600 addicts who presented for
first and second follow-ups. It reports the probability of desisting during the
roughly 2 year period between registration and first follow-up (S01), the
probability of desisting during the roughly 2 year period between the first and
second follow-up (S12), the probability of reverting to drugs between the first and
second follow-up (R12), and the cumulative probability of desisting by the second
follow-up (S02 = S01 + S12(1 – S01) – R12S01).
Table 4. Desistence and Reversion Rates (2 Follow-ups).
Cannabis
Cocaine/Heroin
Cocaine/Heroin/Methadone
N at Intake
1159
1504
1552
S01
0.439
0.170
0.063
S12
0.403
0.171
0.060
S02
0.417
0.192
0.064
R12
0.566
0.710
0.867
Notes: S01 denotes the probability of desistence between registration and first follow-up.
S12 denotes the probability of desisting between the first and second follow-ups. S02
denotes the probability of desisting between registration and the second-follow-up. R12
denotes the probability of returning to drugs between the first and second follow-ups.
Table 4 shows that 6.3% stopped using CHM between intake and the first
follow-up, and that another 6% stopped using CHM between the first and second
follow-ups. However, as many as 86.7% of the addicts who had stopped by the
first follow-up subsequently reverted to drugs between the first and second
follow-ups. The latter is responsible for the relatively low rate of cumulative
desistence of 6.4%. These results show that desistence is not a one-way street.
Indeed, a high proportion of desisters revert to drugs. The reversion rate is
lowest for cannabis and highest for CHM. Table 4 is consistent with Table 3 in
the ranking of desistence rates for S01. However, it should be recalled that the
addicts in Table 3 are not the same as in Table 4, because not all of the former
had a second follow-up. Nevertheless, the estimates of S01 in Tables 3 and 4 turn
out to be quite similar.
Table 5 and 6 extend the analysis in Table 4 to third and fourth follow-ups
respectively. The number of addicts naturally declines with the number of
follow-ups. There are only 170 addicts who consumed CHM on registration, and
who had first, second, third and fourth follow-ups. Since follow-up interviews
take place about every two years, these addicts were followed-up over a period
of roughly 8 years. Table 5 shows that the cumulative probability of desisting for
CHM rises to 6.1% from 4.4%. This happens despite the high probability of
reversion, which is 0.921 between the first and second follow-ups and 0.896
between the third and fourth follow-ups. As in Table 4 the desistence rates are
highest for cannabis and lowest for CHM, and the reversion rates are lowest for
cannabis and highest for CHM.
128
Table 5. Desistence and Reversion Rates (3 Follow-ups).
Cannabis
Cocaine/Heroin
Cocaine/Heroin/Methadone
N
414
551
573
S01
0.403
0.149
0.044
S12
0.405
0.166
0.049
S23
0.406
0.169
0.059
S02
0.394
0.183
0.051
S03
0.440
0.200
0.061
R12
0.622
0.719
0.921
R23
0.509
0.663
0.896
Notes: S01 denotes the probability of desistence between registration and first follow-up.
S12 denotes the probability of desistence between the first and second follow-ups. S23
denotes the probability of desistence between the second and third follow-ups. S02
denotes the probability of desistence between registration and the second-follow-up. S03
denotes the probability of desistence between registration and the third follow-up. R12
denotes the probability of returning to drugs between the first and second follow-ups. R23
denotes the probability of returning to drugs between the second and third follow-ups.
Table 6 takes the analysis one follow-up further, but at the expense of a lower
sample size. The cumulative desistence rate for CHM rises from 2.9% to 8.2%.
This happens despite the very high reversion rates, thanks to the increase in the
desistence hazard from 0.029 to 0.075. The desistence hazard seems to indicate
positive duration dependence, while the reversion hazard indicates negative
duration dependence.
Table 6. Desistence and Reversion Rates (4 Follow-ups).
Cannabis
Cocaine/
Heroin
Cocaine/
Heroin/
Methadone
N
S01
S12
S23
S34
S02
S03
S04
R12
R23
R34
126 0.310 0.287 0.368 0.312 0.310 0.365 0.317 0.641 0.641 0.674
163 0.129 0.126 0.128 0.129 0.135 0.147 0.141 0.809 0.727 0.792
170 0.029 0.024 0.060 0.075 0.023 0.065 0.082 1.000 0.748 0.818
Notes: S01 denotes the probability of desistence between registration and first follow-up.
S12 denotes the probability of desistence between the first and second follow-ups. S23
denotes the probability of desistence between the second and third follow-ups. S34
denotes the probability of desistence between the third and fourth follow-ups. S02 denotes
the probability of desistence between registration and the second-follow-up. S03 denotes
the probability of desistence between registration and the third follow-up. S04 denotes the
probability of desistence between registration and the fourth follow up. R12 denotes the
probability of returning to drugs between the first and second follow-ups. R23 denotes the
probability of returning to drugs between the second and third follow-ups. R34 denotes the
probability of returning to drugs between the third and fourth follow-ups.
129
Modelling Desistence among NII Addicts
This subsection returns to the issue of duration v age dependence in desistence
by addicts. The data in Table 3 are used to investigate the correlates of
desistence between registration and first follow-up. The advantage of focusing
upon the first follow-up is that it permits a relatively large sample size, in the
order of 3000 addicts. Had longer-term follow-up data been used the sample size
would have been severely reduced. The obvious disadvantage is that it does not
distinguish between short and long-term desistence. Indeed, a more thorough
investigation would focus upon both desistence and reversion at different stages
of follow-up
In addition to age, duration and cohort effects there is an additional time
dependent phenomenon in the NII data that did not arise in the IADA data. The
time lapse between registration and follow-up is approximately two years.
Beenstock and Haitovsky (2003) report that the time lag between registration
and first follow-up in fact varies between 18 months and 4 years with a mode of
about 2 years. The longer is the follow-up lag the greater should be the
probability of desisting between registration and first follow-up. The follow-up
lag is entered therefore as an extra regressor in addition to those used in section
4. Here too the general-to-specific methodology has been used to determine the
specification of the model, which is estimated as a logit model7.
Table 7. Logit Models for Desistence (1 Follow-up).
Registration Year
Age
Duration
Follow-up lag
Pseudo R2
Observations
Cannabis
-0.0349 (0.030)
-0.0159 (0.007)
-0.0049 (0.004)
-0.0092 (0.003)
0.0524
2564
Cocaine/Heroin
-0.1489 (0.031)
-0.0095 (0.007)
0.0029 (0.004)
-0.0055 (0.003)
0.0385
3167
Cocaine/Heroin/Methadone
-0.3863 (0.042)
-0.0121 (0.009)
0.0138 (0.006)
-0.0112 (0.005)
0.1039
3257
Parameter standard errors are reported in parentheses. Positive coefficient means that the
probability of stopping varies directly with the variable concerned. Controls include
family status, gender, ethnicity and origin dummies.
Table 7 reports the estimated coefficients for time related variables in logit
models for stopping. The variable, “registration year”, captures a cohort effect.
The later the year of registration the younger is the birth cohort given age. A
negative coefficient for this variable implies that the probability of desisting is
smaller for more recent cohorts. Alternatively, it means that there is an adverse
7
As mentioned in footnote 3 the only difference between the logit and probit model
concerns the shape of the desistence hazard funtion.
130
time trend in the desistence process; given everything else more recent birth
cohorts find it harder to stop. This is the result for CHM and cannabis, i.e. more
recent cohorts find it more difficult to desist. However, in the case of cocaine
and heroin the result is not statistically significant.
The coefficient on Age is negative in all three models and is statistically
significant in the cases of cannabis and CHM. This implies that older addicts (at
the time of registration) were less likely to desist. Hence the desistence process
for NII addicts appears to be negatively age-dependent. The desistence process
in the case of CHM is statistically significant and positively duration-dependent.
Nor does it appear to be duration dependent, at conventional levels of statistical
significance. Finally, Table 7 indicates that the probability of desistence is
statistically significantly related to the follow-up lag between registration and
first follow-up interview. The longer the lag the less likely it is that addicts will
desist, especially in the cases of cannabis and CHM.
Since, as Tables 4-6 indicate, desistence is a reversible process, there is no
inherent reason why the probability of desistence should vary directly with the
follow-up lag. However, it is unreasonable that it should vary inversely with the
follow-up lag, as suggested in Table 7. Most probably, addicts who take more
time in getting round to attending the follow-up interview are harder cases, who
find it more difficult to desist. The negative effect of the follow-up lag in Table 7
is presumably picking up this selection effect.
Sample attrition may bias the parameter estimates reported in Table 7. It will do
so if the residuals of the models in Table 7 are correlated with the unknown
factors determining attrition. If this correlation is zero, however, attrition bias
will be zero. As mentioned, the NII addicts are a self-selected sample. Indeed,
the sample is truncated because nothing at all is known about addicts who did
not apply for NII benefit. Attrition is a less severe problem than truncation,
because the data reveal information about those who dropped out of the sample.
If the residuals in the models reported in Table 7 are correlated with the
unknown factors determining addicts’ decisions to apply for NII benefit, the
parameter estimates reported in Table 7 will be biased. If, however, this
correlation is zero sample selection bias will be zero. Since I do not take account
of sample selectivity here8 the conclusions drawn from Table 7 are necessarily
tentative.
8
I have addressed this issue elsewhere. See Beenstock and Rahav (2002).
131
6. Discussion
Epidemiological data for Israel have been used to shed light on the desistence
process in illicit drug use. One data set (IADA) refers to users of illicit drugs
who are not necessarily addicted. The second (NII) refers to addicts who cannot
work, and are in need of social security benefit. These two groups are very
different, and there is no reason why the desistence process for the two groups
should be identical, or even similar. The rate of desistence in the first group is
very high. The rate of desistence in the second group is, not surprisingly, much
smaller.
We find high rates of “spontaneous” or unassisted desistence in the IADA data
for cannabis and, even more so, for ‘hard’ drugs. This finding for Israel adds to
the growing international body of evidence on the widespread nature of
spontaneous desistence. In the short term the rate of desistence is about 40% in
the case of cannabis and about 30% in the case of hard drugs. However, in the
longer term these rates climb steadily towards 80% and beyond for non-addicted
users.
Addicts typically first used drugs a long time ago. It might be thought that
because time had failed to heal their problem up to the time of registration, it
would have no role to play subsequently. The NII data indicate that this is not the
case. About 3% to 6% of addicts have ceased using hard drugs (including
methadone) within two years of registration, and this proportion rises to about
8% after about 8 years. However, many addicts who had stopped subsequently
revert to drugs. About 87% of addicts who had stopped by the first follow-up
had reverted to drugs by the second follow-up.
A statistical methodology for testing rival hypotheses of the desistence process
was proposed. Our findings suggest that there are two distinct mechanisms; one
is related to age, and the other is related to duration of drug use. These are
separate phenomena. The former implies that the desistence probability is greater
simply because people are older, probably involving some effects of personal
maturation, and the assumption of various social roles. The latter implies that
desistence is more likely among younger individuals, provided they initiated
sooner. In the case of cannabis desistence for non-addicted users, the latter
model was statistically superior, implying that maturing out is not a question of
age but of duration of use. In the case of hard drug desistence the effect of age
seems to be dominant.
In the case of addicts matters are quite different and more complicated. There is
little clear evidence of either age dependence or duration dependence. If
anything, age-dependence is negative, i.e. it is more difficult for older addicts to
mature out. On the other hand, our results show that with the passage of time
132
addicts are more likely to desist. This may sound paradoxical, but it is not. At the
first follow-up addicts are some two years older than on registration and have
been using drugs for two years longer. There is therefore no way of separately
identifying the effects of age and duration subsequent to registration. So time
matters, but the mechanism cannot be clearly identified for addicts. For nonaddicts, however, the mechanism can be clearly identified. This stems from the
fact that the IADA sample is not truncated; it includes all drug users, regardless
of whether or not they happened to have desisted. By contrast the NII data are
truncated; addicts who desisted prior to registration are excluded from the data.
Age dependence suggests that the life-cycle and maturity are important. Duration
dependence suggests that drug use has its own built-in clock, as in the case of a
disease, which runs its natural course. Our results suggest that for non-addicts
cannabis use has its own internal time clock, which regardless of age at initiation
runs its course and then stops. This is not the case for hard drugs, where the
disease theory does not apply. Instead, more mature or older people shed their
habit regardless of its duration. We do not speculate why this happens. Nor do
we speculate why the desistence processes are completely polarized.
The desistence processes for cannabis and hard drugs differ in other aspects too.
In the case of cannabis, desistence rates vary across ethnic groups, depend upon
socialization, and exhibit negative cohort effects. By contrast, hard drug
desistence does not depend upon any of these phenomena. This suggests that
cannabis desistence is more responsive to external forces and environmental
influences than hard drug desistence. It seems that the internal clock that drives
cannabis desistence is sped-up or slowed-down by external influences, whereas
the life-cycle processes that drive hard drug desistence are impervious to such
influences. This difference between cannabis and hard drugs could be due to
differences between the two types of users rather than differences between the
two types of drugs. Hard drug users may be more impervious to their
environment and background than cannabis users.
Had the desistence process for hard drugs been duration-dependent rather than
age-dependent matters would have been considerably more serious. It would
have meant that hard drug use would have persisted for much longer than it did,
because people generally initiate hard drugs after they initiate cannabis. It also
means that the longer hard drug initiation can be delayed, the shorter will be the
duration of hard drug use. By contrast, delaying age at cannabis initiation will
not shorten the duration of its use. This suggests that drug prevention policy
should be aimed at delaying hard drug initiation for as long as possible because
it will shorten hard drug careers. Since cannabis careers cannot be shortened
there is no point in trying to delay cannabis initiation.
Apart from their epidemiological interest, our findings are relevant to the design
of detoxification programs and related policies. If drug users cease their habit
133
spontaneously, there is a risk of over estimating the success of detoxification
programs, since some of the treatment group would have terminated their use
even in the absence of treatment. Indeed, this criticism has been voiced by
Manski et al. (2001) regarding the evidence on the apparent effectiveness of drug
treatment programs.
Beenstock and Rahav (2004) distinguish between immunity and susceptibility in
the initiation of drug use. They hypothesize the existence of an immune
population, which would never use drugs in the first place, and a susceptible
population, for which it is a matter of time until they initiate drug use. At the
other end of the drug use cycle the same dichotomy seems appropriate. There is
most probably a susceptible population for whom it is a matter of time before
they desist, and an immune population, which will never desist. For the immunes
drugs are a one-way street; there is entry but no exit. These two populations have
not been distinguished here. However, future work might usefully do so.
If drug use is by and large a passing habit, public concern into drug use
prevention, which has been dominated by Gateway Theory, needs to be balanced
by the view that the vast majority of drug users return through those same
gateways to drug-clean existences. This in no way belittles the intense suffering
of the several thousand addicts in Israel who failed to make the return trip. But
even in their case there is hope. Some 3% to 7% desist within two years, and
despite the fact that many revert to drugs, this proportion grows to about 8%
after 8 years.
134
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136
Sweden’s “War on Drugs” in the Light of
Addicts’ Experiences
Jan Blomqvist
Mind-altering substances have been used throughout human history. However,
the specific substances that have been preferred and socially accepted, or feared,
condemned and subjected to bans have varied with time and place. Likewise,
there have been varying ways of reacting to and dealing with those whose
substance use, or behaviour when under the influence, has been deemed to be
deviant. In fact, the extent to which the use of a certain drug is likely to put the
user in serious straits or evolve into an addiction, may be just as dependent on
these reactions as on the pharmacological properties of the drug in question (cf.
Room 1985; Blomqvist 1998a). At the same time, the way in which the
environment reacts towards problem users is likely to have a strong impact on
these users’ options for coming to terms with their problems (e.g. Klingemann et
al. 2001). Moreover, it has been shown that reliance on problem users’ own
understanding of their predicament is conducive to a successful outcome of
interventions (e.g. Hänninen & Koski-Jännes 1999; Hubble et al. 1999). Thus,
one reasonable way of evaluating a certain society’s drug policy might be to
examine it in the light of present and former problem users’ own perceptions
about their addiction and path out. This chapter gives an overview of the
development of the Swedish version of the “war on drugs” and presents a
summary of addicts’ and ex-addicts’ experiences of drug use and recovery as
they appear in a recent study. On this basis the chapter proceeds to highlight
some dilemmas in Sweden’s present way of dealing with narcotic drugs and in
its response to individual problem users in particular.
The Governing Image of Narcotic Drugs and Drug
Addiction in Sweden
Sweden is one of the countries that has historically paid most attention to, and
spent most resources on, countering the use and misuse of psychoactive
substances (Klingemann et al. 1992). At the same time, there have been and still
remain wide differences between the “governing images” of alcohol and narcotic
drugs respectively, as well as between the ways in which official alcohol policy
and drug policy have developed. According to Hübner (2001) alcohol and
drinking were historically institutionalised as social problems in a process of
open debate and compromise between articulated opposing interests. This
formative process developed essentially “from below”, and has over time
139
engaged large parts of the population, most of whom have been able to relate to
the debate through personal experiences. By and large, the “Swedish model” of
handling alcohol problems represents a “middle way” (Johansson 1995) that has
adapted to shifting social, political and economic realities, and that has been in
line with changing popular majority views (Blomqvist 1998b). In summary, this
model has century-long relied on a governing image of alcohol as a legitimate,
albeit potentially harmful product, and the main thrust of society’s interventions,
throughout periods of shifting specific policies, has been towards the
minimisation of such harm (cf. Hübner 2001).
The social construction in Sweden of the use of narcotic drugs as a serious social
problem has a rather different history. Far from representing a “middle way” in
drug policy, Sweden rather belongs to a small group of countries where the end
of creating a “drug-free society” has justified not only enormous costs, but also
far-reaching curtailments of the individual’s civic rights (Barker 1998). This first
section of the chapter gives a brief account of the historical development of this
policy and its main underlying assumptions
Drug Use and Policy in Sweden – Some Historical Notes
As has been shown by Olsson (1994), the use of morphine and cocaine, and to a
lesser extent cannabis, for medical purposes was widespread in Sweden as early
as the 19th and the first part of the 20th century. There was also an appreciable
consumption of the same substances as ingredients of various “patent drugs” that
were sold openly as remedies for a great number of everyday ailments (ibid.).
During the 1940s and 1950s, along with the rapid growth of the pharmaceuticals
industry, central stimulants became popular as a means of performance
enhancement and, with time, as remedies for overweight problems. It has been
estimated that in the early 1940s, about three per cent of the Swedish population
were to some extent users of central stimulants (Goldberg 1968). Nonetheless, in
contrast to what had been the case with beverage alcohol, the drug issue did not
raise much concern. On the contrary, the medical profession’s evaluation of
central stimulants in particular was for long almost unanimously favourable –
something that has contributed to the atypical pattern of drug misuse in Sweden
where amphetamine, not opiates, is the main “problem drug” (Olsson 1994;
Boekhout van Solinge 1997). As Hübner (2001) puts it, as long as the medical
profession essentially controlled the substances, which are today collected under
the heading of “narcotics”, they were handled as both legal and legitimate.
The first discussions on drug use as a major social problem can be traced to the
late 1950s, when the “social locus” of the use of central stimulants started to
shift from intellectual and cultural circles and well integrated citizens to more
marginalised groups (Olsson 1994). In response to this, and to the growing habit
140
in these groups of dissolving the tablets and injecting them intravenously, a
number of the most popular substances were classified as narcotic drugs. This
led to the emergence of a black market for central stimulants, which in turn
contributed to the realisation in 1964 of the Narcotics Decree. This decree,
which stated fines or a maximum of two years’ imprisonment for the
manufacture, sale and possession of narcotic drugs, represented a significant new
step in drug legislation and can be seen as the starting-point for contemporary
Swedish drug policy (Olsson 1994). Four years later, the government issued a
10-item programme to combat the drug problem, and Parliament adopted a new
Narcotic Drugs Act that raised the maximum penalty for major drug offences to
four years’ imprisonment1 (cf. SOU 1967:27; 1967: 41). The 10-item programme
identified three primary lines of action, namely legal control, preventive
measures and treatment; three “pillars” to which the official rhetoric has since
clung. Nevertheless from the 1970s onwards the emphasis in drug policy has
gradually shifted from what Lindgren (1993) terms a “care and treatment
strategy” towards a “control and sanction strategy”. A watershed in this
development was the adoption by Parliament in 1978 of a “drug-free society” as
the ultimate goal of Swedish drug policy. This has remained the principal clause
through shifting political majorities, and has been used to legitimate increasingly
repressive measures towards the individual drug user (ibid.; Tham 1999). Thus,
in 1983 facilitating a drug deal was made a criminal offence, in 1985 a maximum
penalty of six months’ imprisonment was introduced for possession for personal
use, and in 1988 personal use in itself became punishable by fines. Eventually, in
1993, the maximum penalty for personal use was raised to six months’
imprisonment, thereby adding to the already extensive rights of the police in
fighting drugs, the right to use coerced urine and blood tests on the suspicion of
drug use, whether past or present (cf. Boekhout van Solinge 1997).
Assessments of the impact of these regulations on the incidence of drug use and
addiction have varied. Although the interpretation of official statistics has caused
some debate (Goldberg 1997; Olsson et al. 2001), there seems to be fairly broad
consensus that recreational as well as problematic use of narcotic-classified
drugs reached a peak in the late 1970s, but decreased substantially during the
following decade (e.g., CAN 1993; Olsson et al. 2001). Two nationwide surveys
did identify about 15,000 “heavy drug abusers”2 in 1979 and about 19,000 in
1992 (Olsson et al. 2001), but on the basis of the age distribution in the two
surveys and other available information3 it may be rather safely deduced that the
annual number of new “heavy addicts” did in fact decrease during most of the
1980s (ibid.). Whereas the official line has been that these figures prove the
1
2
3
Further raised to six years in 1969 and to ten years in 1972.
Defined, with some variation over the years, as any intravenous use and/or daily or
almost daily use of narcotics-classified substances during the past four weeks.
E.g. data on recreational use and drug-related mortality, and data from customs and
police on the availability of narcotic drugs.
141
effectiveness of Swedish drug policy, critics have claimed that the decrease in
consumption largely preceded the tougher sanctions and had other reasons. In
addition, many have maintained that an increasingly repressive drug policy has
generated as much harm as it has prevented, among other things by threatening
openness and democracy and by fostering distrust towards society in the young
generation (von Hofer et al. 1998; Tham 1998; Hilte 1998).
During the past fifteen years, the basic prerequisites for Swedish drug policy
have changed in important respects. Rapid and deep-going geopolitical changes,
not least in Eastern Europe, have led to an increasing inflow of both traditional
and “new” substances (EMCDDA 2003a). At the same time, new influences and
changing sentiments in the wake of ongoing globalisation have meant that the
traditionally strong barriers against even experimenting with drugs have started
to erode, not least in many youth groups (EMCDDA 2003b). Finally, Sweden’s
accession to the EU has made border control and the prevention of illegal import
tangibly more difficult (Rikspolisstyrelsen och Tullverket 2003). On the
structural level, all this has coincided with what Oscarsson (2001) describes as a
transition from an inclusive and cooperative society towards a differentiating
“competitive society” in which utilities such as housing, jobs and education are
no longer defined as basic civic rights, but as something that the individual has
to “deserve” or compete for. Along with these changes, the incidence of
recreational drug use has climbed back close to the figures recorded in the 1970s
(CAN 1997; 2001), and the number of “heavy drug abusers” has risen to about
26,000 in 1998 (Olsson et al. 2001)4. However, in contrast to what has been the
case with alcohol policy (cf. Abrahamson 1999), Swedish drug policy has
remained rather unaffected by these changes. Thus the new Drugs Commission,
appointed in 1998 to evaluate prevailing policy, maintains that increasing drugrelated harm can largely be attributed to negligence in the enforcement of this
policy, not to deficiencies in the policy itself. Despite the exacting title of the
Commission’s main report, The Choice of Road. The Challenge in Drug Policy
(SOU 2000:126), the core message is that all three parts of the traditional
strategy need to be strengthened in the continued pursuit of the “drug-free
society”. The means applied to this end, thus far, have included the appointment
of a national Drug Co-ordinator and the launching of a nationwide campaign,
Mobilisation Against Drugs (Government Proposition 2001/02:91). In a critical
comment Bergmark (2001) contends that the Commission’s directives have left
room only for conclusions that lie “between the already given and the
impossible” (p.314). As a consequence, the appellation of a “choice of road” has
become no more than a rhetorical symbol – a means of handling the growing
tensions between the ordained strategy of continuity and increasing evidence that
this strategy has not worked (ibid.).
4
From national surveys, it can be calculated that the annual incidence of “heavy drug
abuse” was on average 800 from 1979 to 1992 (cf. O. Olsson et al.1993), and about
1,900 from 1991 to 1998 (cf. Olsson et al. 2001).
142
The Reigning “doxa” and Why It Has Prevailed
Using a term borrowed from Bourdieu (1977), Bergmark and Oscarsson (1988)
have characterised Swedish drug policy as a “doxic” field. By the concept of
“doxa”, they refer to a set of undisputed and allegedly indisputable themes which
provide the unreflected basis for any public debate on, and public actions
targeting, the drug problem. One such theme is the conviction that narcotic drugs
present a serious or “high profile” problem. Another is the view of narcotic
drugs as inherently dangerous (with the corollary that all use is equal to “misuse”
or addiction). A third and a fourth theme are the depiction of the drug misuser as
a powerless victim of the drug’s pharmacological properties, and the notion that
long-term and intense treatment is necessary in order to save him or her from the
perils of the drug. According to the authors, the “doxic” character of these
themes effectively inhibits any moderation concerning the seriousness of the
problem and the necessary resources to eliminate it. Thus, for example, it allows
for including ever new substances under the rubric of “narcotics”, based on a
discovery of their alleged dependence-generating properties, and it excludes the
interpretation of drug use as an intentional activity as well as the idea that people
might stop using drugs on their own (ibid.). Theoretically, the “doxa” draws on
the assumption that narcotic drugs are capable of “short-cutting” the brain’s
pleasure system, thereby obliterating the user’s ability to execute his/her own
free will (e.g., Bejerot 1972; 1980). In addition, drug use is assumed to have an
epidemic character, meaning that every drug user can “contaminate” a number of
other susceptible persons (cf. Bejerot 1969; 1975). As a consequence, restricting
or eliminating the availability of narcotic drugs should be the main goal of
national drug policy, and sanctions should first and foremost be directed towards
reducing the demand for narcotic drugs, i.e. towards the individual consumer.
There have been various, partly complementary ways of accounting for the
perseverance of this singularly Swedish version of the “war on drugs”. Boekhout
van Solinge (1997) maintains that one potentially important factor has been
Sweden’s traditional “temperance culture”, which is claimed to have provided a
receptive ground for the demands for swift and ruthless action against the “new
danger” that were put forth by a small, but insistent and vociferous opinion in the
late 1960s (ibid.). A leading part in this crusade for a new, more repressive
policy is ascribed to the medical doctor and debator Nils Bejerot (cf. above),
whose ideas soon proved to have strong popular and media appeal. In addition,
they were picked up by various lay organisations such as the National
Association for a Drug-Free Society, Parents Against Drug Abuse, and Hassela
Solidarity. According to Boekhout van Solinge (1997), these and other lobby
groups for tougher restrictions have continued to exert a strong influence on
Swedish drug policy till the present day, not least through gaining important
posts in policy-making and influence-exerting bodies.
143
Christie and Bruun (1985), in a seminal analysis, describe Swedish (or Nordic)
drug policy as a symbolic war aimed at preserving the illusions of safety,
national unity and rational social progress at a time when deep-going structural,
economic and politico-ideological changes have created disintegration and
widespread distrust of traditional authorities. In this war, narcotic drugs stand
out, for several reasons, as “the ideal enemy”. One such reason is that the
problem, thus defined, directly concerns only a rather small minority of mostly
socially marginalised people. Another is that this enemy is vague enough to
make a thorough scrutiny of the alleged seriousness of the problem impossible,
and can thus, without much objection, be depicted as evil, inhuman and alien.
Since this makes the final defeat of the alleged enemy impossible, the “war” may
go on forever, and serve as a scapegoat for more awkward political issues that
cannot be attacked without challenging powerful circles (ibid.).
In a summary evaluation, Hübner (2001) contends that drug use and addiction in
Sweden, in contrast to the case with alcohol problems, were historically defined
and institutionalised as serious social problems “from above”, in a dialogue
between a rather limited number of influential lobbyists, government officials,
and the media. According to Hübner the strong popular support for an
increasingly repressive policy can be attributed to the fact that relatively few are
able relate to this issue through personal experiences, and that views opposing
the reigning official doctrine have been virtually non-existent, particularly in the
media. Rather, the public debate on the drug problem has been characterised by
“a spiral of silence”5, which has repressed even modest objections to the reigning
“doxa”, in the face of the threat of being defined as a “drug liberal” and being
excluded from the debate (ibid.).
Reflections of the “doxa” in the Treatment Field
One way of stating the core difference between alcohol and drug policy in
Sweden is to say that drinking is basically seen as a legitimate activity, whereas
drug use is seen as a sign of moral and social deviance (cf. Hübner 2001). This
difference is also reflected in the way that problem users have been approached
in the treatment field at large.
The treatment of drinking problems in Sweden dates back to the late 19th century.
During the first half-century this was largely a disciplinary excerise, targeting a
rather small group of social outcasts (Fredriksson 1991; Blomqvist 1998b). From
the 1960s the emphasis has shifted towards professional voluntary treatment, and
the content has become more diversified and more therapy-oriented, the main
orientation changing with time from psycho-dynamic concepts through social5
The expression is borrowed from Noelle-Neumann (1995).
144
psychological models towards 12-step ideas and cognitive-behavioural methods
(e.g., Oscarsson 2001). In quantitative terms, the treatment of alcohol problems
reached its peak in the mid-1970s, and has declined tangibly with the recession
of the early 1990s. The latter has also meant a transition from residential towards
open care, and a growing reliance on voluntary and self-help organisations
(Blomqvist 1998b).
The way that society deals with individual drug misusers has developed rather
differently. As discussed earlier, drug problems were seen as a purely medical
matter until the 1950s, and therefore dealt with by the medical profession. It was
not until the 1960s that specialised treatment for drug misusers started to emerge
outside the medical sector. Initially, these initiatives borrowed much of their
form as well as their content from contemporary alcohol misuse treatment.
However, as the “control and sanction strategy” gained influence, a tougher
approach to dealing with individual drug misusers soon emerged in the treatment
field as well. Many enterprises started to criticise the therapeutic orientation of
alcohol misuse treatment, and to lean rather on ideas from e.g. the hierarchical
American Daytop and Phoenix House movements. Another initiative that gained
strong influence in the early 1980s was the domestic “Hassela Pedagogic” for
young misusers, relying on re-education, “socialist fosterage”, adult staff
members as role models and authorities, and on coercion (cf. Bergmark &
Oscarsson 1990; Fridell 1996). It is also worth noticing that one of the explicit
motives behind the new coercive legislation, which was rapidly instigated in
1982 and which ran counter to the principle of voluntarism that permeated the
new Social Services Act of the same year, was the perceived need to force drug
misusers into treatment. The same is true of the revision of the coercive care
legislation in 1989, which broadened the requisites for compulsion and raised the
maximum duration of involuntary treatment from two to six months. By and
large, whereas the approach to problematic drinkers has over time become more
“therapy oriented”, and more diversified with regard to both professional
ideologies and methods (Abrahamson 1989), the approach to drug misusers has
developed in a more unitary way, directed at control and socialisation (Bergmark
& Oscarsson 1988), relying on “regulating” and “instructing” activities (Hilte
1990)6, and aiming to break down the client’s “junkie identity” and to build up a
new identity as a norm-abiding and socially respected citizen (Svensson 1996).
In quantitative terms, drug misuse treatment reached its highest level in the late
1980s, following the detection of HIV/AIDS and the subsequent government
initiative, “Offensive Drug Abuse Care”, which led to a rapid and massive
expansion of residential care. However, with the economic recession around
1990, this investment more or less ceased, making many of the new treatment
6
Referring to Bernstein (1976), Hilte (1990) distinguishes between four types of
”socialisation contexts”, namely ”fantasy-inducing”, ”interpersonal”, ”instructing” and
”regulating” contexts.
145
homes extremely short-lived (Bergmark & Oscarsson 1993). Mostly for
economic reasons, the past decade has seen a partial “implosion” of drug misuse
treatment into alcohol misuse treatment (Bergmark 1998). However, there are
clear indications that the decrease in treatment referrals during the first part of
the 1990s has essentially concerned alcohol misusers, whereas the number of
admitted drug misusers has remained rather constant (SoS 2001). There are also
rather clear indications that the two fields continue to show different ideological
and methodological orientations. Thus, for example, a reanalysis of recent data
from the National Board of Health and Welfare (SoS 2000) shows that
contemporary alcohol misuse treatment is typically outpatient and inclined
towards 12-step and cognitive/behavioural methods, whereas drug misuse
treatment is to a much greater extent residential, relying for instance on socialpedagogical methods and social skills training (cf. Blomqvist 2002a).
Paths into and out of Drug Addiction – Addicts’ Own
Experiences
How, then, do the assumptions underlying the Swedish “doxa” compare with the
“lay theories” of those concerned? This section summarises what 75 former or
active problem users have to say about their drug experiences and about what it
takes to “become clean”. The data used originate from a recent study aimed at
attaining a better understanding of the processes of change in successful
solutions to drug addiction problems, as well as of the main forces behind these
processes (Blomqvist 2002a&b). The study sample comprised 48 stable remitters
from severe addiction to amphetamine and/or heroin, 23 with and 25 without the
help of treatment7. In addition 27 persons with ongoing drug problems, 14 of
whom were previously untreated and 13 of whom had received treatment, were
interviewed8. Partly due to the strict inclusion criteria, all respondents had
previous or present drug problems similar to those in common treatment
populations as regards severity, duration and negative consequences.
Methodologically, the study used a combined strategy. On the one hand detailed
recordings were made, year by year, of the development of the subjects’ drug
use, the severity of their drug problem, and drug-related negative consequences,
as well as the occurrence of significant life events in seven vital areas. In
addition, standardised inventories were used to assess the subjects’ own
attributions of factors important in motivating and maintaining the resolution. On
the other hand, in a effort to obtain a more unbiased view of the subjects’ own
understanding, all of them were also asked to give a spontaneous
autobiographical account of their lives and their drug experiences (cf. Alasuutari
7
These respondents were all solicited by media advertisements.
8
Most of the non-resolved subjects were recruited via social services or treatment
facilities.
146
1986; Klingemann 1991; 1992). Even if the respondents did not constitute a
random sample of problem drug users in Sweden, there are other circumstances
that speak for the relevance of their experiences in the present context. One is
that while being largely comparable to treated populations as concerns the
severity and duration of their drug problems, these users represented clearly
different positions in terms of treatment experiences and long-term outcome.
Another is that the life course perspective adopted in the study, and the way in
which it combined quantitative and qualitative methods, may be claimed to have
generated in-depth and essentially trustworthy descriptions of the addiction
experience and path out.
Becoming a Drug Addict
A first hint of what the study has to say about what it takes to develop an
addiction to amphetamine or heroin can be derived from data on the respondents’
social and family background. For example, even though 50 per cent or more of
the respondents came from split families, had parents with alcohol or drug
problems, and/or displayed early signs of psycho-social discomfort, more than
one-third of them grew up in “normal” and what they described as happy
families. In other words, although weak social resources and various types of
individual strain, for instance, are likely to make people more susceptible to later
drug problems, the results indicate that these are not necessary conditions for
being snared in an addictive life-style. The fact that the age at onset of drug use
varied between 12 and 29 years raises further doubt about the notion that there is
one single route to addiction. It may be noted that a family history of substance
use problems was somewhat less common among later remitters than among
respondents with prevailing problems, and that respondents who never sought
treatment had a somewhat later onset of drug use than those who did. The later
self-changers stand out as the group with the greatest overall social and family
resources.
As concerns the respondents’ own attributions of the reasons for starting to use
narcotic drugs, the later remitters in particular gave rather elaborate and complex
accounts, no doubt partly due to the fact that re-assessing their own life history
had been part of the solution. A categorisation of the reasons mentioned most
often showed that more than half of the men and one-third of the women solely
or partly referred to “peer pressure”:
Since I was into music, well, the whole culture was permeated by cannabis and
flower power and using drugs, so it wasn’t actually anything strange. Everyone
did it. Even your pals’ parents smoked the occasional joint, just to show that they
were hip, and with a tie around their forehead (untreated remitter; male).
147
Another commonly endorsed reason was using drugs as a means of “social
recognition” or as an admission ticket to more advanced circles that were
perceived to be “cool” or exciting:
During those years you are extremely susceptible and you want to be “in” and to
be tough and you do things other people do, to be liked….And in the beginning I
really thought that I was popular, that they liked me as a person (untreated
remitter; female).
This type of reason was mentioned by one-third of both male and female
respondents. In addition, many respondents claimed that their initial drug use
had at least to some extent been an active search for a remedy for, or refuge
from, depression, anguish, self-contempt or psychological “emptiness”. Almost
half of the women, but less than one-fifth of the men described their initial drug
use as some form of “self-medication”:
I went to school and was bullied, and I went home and was humiliated. And it
just kept on like this, and I crept into myself, more and more….And then when I
turned 14, everything changed. We moved to X, and there they were doing
Preludin, and there I took Preludin and there I was born. That was my salvation.
If I hadn’t used drugs, I would have gone up in smoke, I would have just
vanished (untreated remitter; female).
Almost as many respondents, mostly men, further described their initial drug use
as part of a general “revolt” against parents, teachers and other adult authorities:
Above all I think it was a revolution against the parents, I mean that happens at
that age. And I came from the upper classes, so I suppose I had more to protest
against….But I must say that another part of that liberation was a social and
political consciousness, that prevails, even today (treated remitter; male).
In addition, quite a few of the women said their older partners had introduced
them to drugs:
And then I meet what I think is real love. We meet at work, and it was just so
romantic. And he has left his wife and children, and he moves in with me. And
that is how I happened to start using amphetamine (untreated remitter, female).
Finally, five respondents reported that they were first introduced to drugs while
in hospital or youth care. Overall, “self-medication” and “recognition” were
more commonly endorsed reasons among women than among men, and later
self-changers were more inclined than other respondents to refer to “peer
pressure”. Taken together, these data may be claimed to belie “contagion theory”
as a single explanation, and to clearly indicate that there are many different paths
to drug use and addiction.
148
Living as a Drug Addict
As already mentioned, the respondents as a group were generally comparable to
clinical samples with regard to the severity and duration of their drug problems.
In hard figures this means, for example that the mean duration of drug use was
16.2 years, that almost one-third had used three or more different drugs, and that
about nine out of ten admitted to intravenous use. Further, although more than
half of all respondents had in a life-time perspective used both heroin and
amphetamines, more than two-thirds stated that amphetamines had been their
preferred drug, whereas about one-third had mainly used heroin. However, even
though these figures are largely in line with the traditional pattern of “heavy”
drug misuse in Sweden, it should be noted that heroin as the main drug was less
common among future self-changers than in the other groups. Further, the treated
groups scored somewhat higher on overall severity9 and negative consequences.
As for the development from recreational or experimental use to severe misuse, a
few respondents did indeed claim that they had become addicted almost
instantaneously
And when I ran into amphetamine, then everything was, like, done. Like falling
in love. I knew at once that nothing would be able to get me away. Because this
was the most powerful thing I had met (treated remitter; female).
At the same time, almost as many explicitly described their addiction as a
deliberate choice:
I got tired of being a mother and at the same time doing drugs just during the
weekends. So I made up my mind to become a full-time addict. I made a choice
there. I know that I thought it over carefully. It was a choice (untreated remitter;
female).
Generally, however, the respondents described a process in which using drugs at
first was a rather pleasurable and positive activity, or at least fulfilled its
function as an effective remedy for, or refuge from, the strains of life:
There are many good things with drugs as well. Because they can certainly make
you happy. And of course that is the trap, that is the great danger. If it were as
terrible as the anti-drug prophets claim, no-one would ever start using them
(untreated remitter; male).
And the drugs gave me all this. I didn’t see any negative aspects until I fell ill,
but I rather liked living in this world. I felt that I was in charge of my own life.
That was what it was about (untreated remitter; female).
The sense of freedom and the social cohesion in the peer group of drug users,
and the stimulating and disinhibiting effects of the drug – not least sexually –
9
According to a brief version of Drug Abuse Screening Test (Skinner 1982).
149
were commonly endorsed positive aspects. It was only with time that most
respondents realised they had been caught up in an addiction – a way of life in
which most of their thoughts, feelings and actions had come to centre around the
drug. In fact, one respondent maintained that her drug use did not evolve into an
addiction until after 17 years, and the average duration from onset to the first
insight that drug use had become problematic was 4.0 years.
The respondents’ overall circumstances during their drug misuse also seem to
have differed widely, depending on such factors as family background, gender
and socio-economic status. Thus, more than one-third were employed during
most of their addiction, almost half lived with children, and more than two-thirds
had a stable housing situation. At the same time, more than seven out of ten were
involved in selling drugs, almost as many in other forms of criminal activity, and
12 per cent in prostitution. A good third had also spent time in prison. Generally,
non-resolved subjects had been more immersed in a criminal life-style than
resolved subjects. As for the dynamics of the “addiction circle”, the narratives
provide a rather complex picture of interacting forces. References to the drug per
se are rather scarce, and mainly limited to a few mentions of the anticipation of
the horrors of heroin abstinence as an effective barrier to quitting. Instead, most
respondents hint at some form of social-psychological process in talking about
their addiction in terms of having been caught up in a destructive life-style rather
than having been simply “hooked” by the drug.
In a way, it was an effective self-medication. But at the same time, because of
the things you do in that world, you need ever more drugs to escape from having
to deal with the real world and your own feelings (untreated remitter; female).
I think that everyone discovers, sooner or later, that you spend twenty-four hours
a day hunting, to be able to pay debts, to fix new drugs and so on. And it’s like a
vicious circle because you need more and more drugs to get the energy to get
through with this (treated remitter; female).
All in all, about one-third of the respondents, mostly men, describe themselves
as having been immersed, at least temporarily, in what may be called a “junkie”
life-style (cf. Stimson 1973). At the same time, quite a few of the women
describe themselves as “loners” (ibid.) or depict their addiction mainly as an
integral part of their all-encompassing and passionate relation to a man who also
used drugs. However, the majority, and the later self-remitters in particular,
describe what may be termed a “double life”, characterised by continuous efforts
to “keep up the facade” in front of neighbours, relatives, and social services, in
spite of the narrator’s drug use and participation indealing and petty crime. This
type of description was about as common among women as among men, but the
reasons for wanting to conceal one’s involvement with drugs differed by gender.
Thus, whereas women more often talked about their fear of being questioned as
mothers, and deprived of their children if exposed as drug misusers, men more
often talked about the need to hide their predicament from employers or various
150
authorities. It is also worth noting that half of the respondents, twice as many
women as men, reported having interrupted their drug use on one or more
occasions, sometimes for periods of a year or more. Among women the most
cited reason for taking such a “pause” was pregnancy or childcare. Other reasons
given were changes in the drug market or altered living circumstances. To sum
up, the narratives may be claimed to give an eloquent illustration of Svensson’s
(1996) thesis that drug addicts’ lives do not necessarily follow a unitary and
predictable “regressive” course, but rather exhibit “a kaleidoscopic character”,
entailing a number of seemingly conflicting commitments and being open to
different interpretations10.
Leaving the Addiction Behind
Quitting Drugs
As we have seen, more than half of the respondents had long since left their drug
problems behind, either with or without the help of treatment. The average time
elapsed since finding a solution was 9.7 years, with no significant difference
between the treated and the untreated groups. However, a detailed recording of
the subjects’ drug use and consequences as well as of the occurrence of negative
and positive life events during a period covering four years before and two years
after the resolution or the past treatment experience, points to other differences.
A series of variance analyses reveals that help-seeking, whether or not this had
led to recovery, had generally been preceded by increasing drug use and
increasing negative consequences, as well as increasing negative events in
several vital life areas, and few rays of hope in the overall life context.
Respondents who continued to use drugs after treatment, were not on average
more severely addicted than respondents who quit their drug misuse after
treatment, but they had been more often in trouble with the law, and had
experienced even fewer positive events. Self-changers, on the other hand,
exhibited a severe but relatively stable misuse pattern during the years preceding
the resolution, and had in some cases even tapered down their drug use before
quitting altogether. Moreover, in addition to experiencing powerful negative
stress, most of them also reported at least some significant positive events in
vital areas during the last year before the resolution. Thus, whereas help-seeking
commonly seems to have occurred in a situation where the drug use, as well as
10
”It is a life with many dramatic elements, a life with different rules, norms and
traditions, but it is also a life in the ordinary society. This means that drug addicts
sometimes, in periods of intense use, are close to the cultural stereotype, but also that
they at times are extremely normal, eating hot dogs, chatting about football,
dreaming about a house of their own, letting themselves be entertained by TV, and
reading newspapers, just like us” (Svensson 1996, 338).
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the strains of living as a drug addict, had reached some kind of peak, self-change
seems rather to have been motivated by a combination of negative and positive
incentives.
As for the respondents’ own explanations as to what had made them quit, it may
be noted that self-changers more often mentioned “inner” reasons for their
emerging wishes to change, and more often quoted situational change and
positive “key events” as important incentives. Treated remitters, on the other
hand, typically described their decision to seek help as the result of having
exhausted most of their personal and social resources, and often related their
initial resolution to a specific turning-point or a “rock bottom” experience.
Overall, women reported more intra-psychic and long-term motives for recovery,
whereas men more often mentioned work and financial reasons, and pressure or
advice from other people. Notably, half of the female self-changers attributed
their decision to quit, partly or entirely, to becoming pregnant or realising their
responsibility for the children they already had. Among female treated remitters,
the hope to regain custody of children taken into care by the social services was
a common reason for seeking help. Among men, meeting a new partner was the
most quoted single motive for change, and only two men made some reference to
their children in this context. Finally, it may be noted that whereas the most
frequently reported barrier towards seeking help among male self-changers was
having believed in their own capacity, female self-changers more often referred
to the fear of being exposed, questioned as a mother and, perhaps, subjected to
some form of coercion. In sum, these results corroborate that the odds for selfchange regarding drug problems, as well as the outcome of drug misuse
treatment, are heavily dependent on individual human and social resources
(Granfield & Cloud 1999), as well as environmental influences that evolve over
time (Tucker et al. 1994; 1995). They are also in accord with the notion that
professional or formally organised treatment, although often playing an
important and even crucial role, is neither a necessary nor a sufficient condition
for overcoming an addiction.
Maintaining the Resolution
A common experience among drug addicts is that the real challenge is not
quitting, but staying drug-free (cf. Pearson 1987). The respondents of the study
discussed here constitute no exception. Thus, in most cases the whole process
from quitting to a true sense and conviction that the addiction was history, lasted
several years, and was shaped by a variety of interacting internal and external
influences. The great majority mention the role of internal changes (e.g.
increasing will-power or self-control, taking on new responsibilities or spiritual
involvement) as well as support from significant others (partner, other family
members or friends) as important reasons for their having been able to maintain
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the resolution. About half of the respondents further make references to other
habit changes (diet, smoking, physical exercise, etc.), changed life conditions
(work, residential and financial changes) and/or social life changes (making new
friends, engaging in new leisure activities, wanting to preserve a new social
status). Some of the treated remitters further report that treatment was a
maintaining rather than a motivating factor (cf. Tucker et al. 1995). Except for
the role of treatment, the attributions of what had helped the respondents stay
drug-free differed less between treated and untreated remitters than their
inferences about what was important in the motivational process. However, it is
worth noticing that more than half of the treated remitters, as compared to onethird of the self-changers, worked at the time of the interview in the health and
welfare sector. Moreover, a quarter of the former actually worked in the
substance misuse treatment field11. As concerns gender differences, it may be
noted that men more often mentioned the role of a significant other (in most
cases the new spouse) and improvements with regard to job or finances, whereas
women more often mentioned having acquired a new social role and gained
other people’s respect. Indeed, most of the men, to whom a new partner often
played a role in initial recovery, reported living with a new family at the time of
the interview. In contrast, most of the women, who often had experienced
physical and psychological abuse by their addicted partners, had chosen to be
single after the resolution, although quite a few lived with their children.
Overall, women also more often reported having struggled with feelings of guilt
and shame after quitting. At the same time, they had more often taken up and
completed higher studies after the resolution.
In summary, these results further underline the role of environmental factors and
other people’s support in lasting solutions to drug problems (cf. Granfield &
Cloud 1999). More specifically, they also hint that the odds for leaving the
addiction behind are better for people who have not exhausted their personal and
social resources than for those who have (ibid.). Finally, a comparison with
treated and untreated remitters from alcohol problems indicates that drug addicts
have a more difficult path out, requiring stronger incentives to start
contemplating change, as well as more profound changes in the overall life
context to maintain the resolution (cf. Blomqvist 1999b; 2002b).
Rewriting One’s History
The data presented thus far may be claimed to show not only that the ways in
which one may “get hooked” by narcotic drugs are manifold, but that there are as
many ways to “leave one’s lover” (cf. Klingemann et al. 2001). This conclusion is
further corroborated by a narrative analysis of the recovered respondents’
11
This may partly be due to solicitation bias, partly to the fact that this is one of the
careers that is most readily available to former drug abusers (cf. Klingemann 1997).
153
spontaneous life stories. In short, the choice to supplement data from standardised
inventories with such an analysis was based on Davies’ (1997) reminder that all
people do not necessarily share the same “variable profile”, and on Bruner’s
(1986) discussion of the paradigmatic and narrative approaches as two
complementary ways of ordering human experience: the one aimed at abstraction
and generalisation, the other explicitly interested in subjects’ interpretations of
their own world. The analysis started out from the idea of narrators as “theorists of
their own lives”, drawing on various culturally prevailing popular beliefs,
convictions and theories. Drawing on previous work by Andersson and Hilte
(1993) and Hänninen & Koski-Jännes (1999), an attempt was made to detect
fundamentally different ways of accounting for the addiction experience and the
path out12. As a result, four “story types” were discerned, reflecting different basic
explanations of the addiction, and different attributions of what was the “key” to
recovery.
In short, the typical maturation story depicted a childhood characterised by
personal or social isolation and lack of positive feedback, which resulted in
feelings of alienation and low self-esteem. Initial drug use was described as a
means of obtaining access to and being accepted by coveted social circles, and of
avoiding or postponing the shouldering of adult responsibilities. Being a drug
addict, according to this story, meant adopting a submissive role in relation to a
dominant and drug-using partner and/or to the rules of the “drug world”. The
recovery process typically began when something happened that made the
protagonist realise that s/he wanted something else out of life and had the
capabilities to shape her/his own future. Over time, the process involved breaking
loose from oppressive relationships and/or environmental restraints and starting to
build up a new personal and social identity, at first in the form of a rather lonely
and isolated struggle, at later stages as a valued member of a new social network.
This type of story, leaning on ideas from developmental psychology and the notion
of hidden capacities, was told almost exclusively by self-changers, and more often
by women than by men.
The willpower story typically conceives of initial drug use and entering the drugusing subculture as acts of free will. The drug experience is described as much in
positive as in negative terms, and being part of the “drug world” as a way of
gaining influence or a means of “easy money”. The turning-point in this type of
12
In short, the procedure meant that subjects’ accounts were first categorised according to
the basic explanations of addictions that they reflected and the views on the key to
recovery that they expressed. By combining these dimensions, four basic categories,
reflecting four different conceptions of addiction and recovery, were obtained.
Thereafter, a composite story of each type was constructed, using material from several
original accounts. Finally, each individual account was compared with the “type stories”
and classified as belonging to one of these categories or as an interlaced story; i.e. a
combination of two story types (cf. Gergen 1997). See Hänninen & Koski-Jännes (1999)
and Blomqvist (2002a).
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narrative occurred when the protagonist realised that the price for leading this kind
of a life was becoming too high, and/or that s/he no longer was in full control of
the situation. What was required to resolve these problems was self-determination
and strategic action (moving to a new place, finding new social networks, etc.),
and the long-term solution involved finding new arenas on which to give vent to
the protagonist’s competence and energy (a new family, a new job, new leisure
activities, etc.). This type of story, drawing on the ancient “hero saga” and/or the
concept of “Homo Economicus”, is told by both self-changers and treated
respondents, but is most common among the men in the former group.
The liberation story typically starts with a description a traumatic childhood where
the protagonist was unloved and unseen, and where any expression of negative
emotions was banned. Addiction is described as a vicious circle of anguish,
depression and attempts at self-medication by drugs and other addictive
behaviours. Recovery was typically achieved through a cathartic process in which
the narrator came into contact with his/her true feelings, understood his/her own
motives, and dared to face up with reality. This type of story, which may be said to
be modelled on a classical psychotherapy discourse, is told by more than one-third
of the women – in both the untreated and treated groups – as compared with less
than one quarter of the men.
The conversion story, finally, may be described as being modelled on the typical
AA narrative and/or on the cultural stereotype for religious conversion. In this type
of story addiction is attributed to the protagonist’s “nature” and/or the “power” of
the drug and often depicted as a love relation. The solution is described as being
preceded by a long history of denial and increasing problems, until the narrator
realised that he/she had to choose between destruction or seeking help. Life after
the resolution is characterised by gratitude, humbleness and commitment to assist
one’s fellow sufferers. This type of narrative is endorsed by both women and men
in the treated group, but is rare in the self-change group.
On a general level, these results are concordant with the conclusion that treated
respondents had been more deeply immersed in the “drug world” than the selfchangers, and had to a larger degree exhausted their personal and social
resources prior to seeking help. They are also in line with the interpretation that
women relied more often on their own “inner strength” and had a longer path
out, whereas men were more dependent on external influences and partner
support, and more inclined to “seize the opportunity”. More importantly, the
narrative analysis may be claimed to support the notion of exit from drug
addiction as an active process, where people make use of the available “cultural
tool-box” (Bruner 1990), actively adapting and transforming prevailing theories
or beliefs to fit with their own experiences (Andersson & Hilte 1993; Hänninen
& Koski-Jännes 1999).
155
The Role of Treatment
Besides exploring the long-term processes of change, an important objective of
the study was to gain a better understanding of the specific role of various
professional or formally organised interventions in various stages of the recovery
process. To this end the two treated, resolved and non-resolved groups were
compared with regard to the development of their drug use and consequences, as
well as the occurrence of significant, positive and negative life events, during the
years prior to and following their last treatment experience. In addition, the
respondents were asked for a narrative account of this experience, and to rank a
number of potentially crucial treatment elements according to their overall
significance and whether they had had a positive or a negative influence.
Whereas for the resolved group the inclusion criteria guaranteed that they had
quit their drug use permanently during or soon after treatment, the firstmentioned analyses showed that to the non-resolved group treatment had not
meant much more than a temporary hiatus in drug use. Furthermore, and more
importantly, whereas to the latter group treatment had had no significant impact
on other life areas, the overall life context of the resolved group had started to
improve in vital areas already while in treatment, a development that continued
after discharge. A reasonable interpretation is that these changes were as much
the prerequisite for as they were the consequence of coming off drugs
permanently. As for the role of treatment in the long-term change process, it
should first be noted that the treatment experiences of the resolved and nonresolved groups did not differ on average with regard to setting, type of
programme, theoretical ground or professional ideology. However, from the
respondents’ narratives and their ranking of various treatment elements, a
number of factors could be discerned that seem to have been common to
successful treatment experiences and to have distinguished these from treatment
that did not work. Among these factors were having been “seen” as a person and
met with respect, having felt that their own ideas and wishes were taken
seriously, and having developed a close and trustful relationship with an
individual helper. Further, the respondents in the resolved group mentioned far
more often that they had received help in dealing with social, financial and other
problems in their overall life situation, that they had been subjected to some
emotionally shaking experience, and that they had taken part in some form of
specific therapy that they could name. In most respects, these differences
between successful and less successful treatment experiences paralleled those
found among former and active problem drinkers (Blomqvist, 1999a&b). By and
large, these results indicate that treatment success depends, to a large extent, on
a number of “common factors” that are not specific to various treatment
ideologies or techniques (cf. Frank & Frank 1991; Blomqvist 1996; Hubble et al.
1999). Thereby, they further underline that effective help to substance misusers
156
is best conceived of as a means of evoking, facilitating, accelerating and/or
strengthening their own efforts to change (cf. Moos 1994; Blomqvist 1996).
Addiction in the Life Course Perspective: the “doxa” vs. the
Addicts’ View
Although the data reviewed were not primarily collected as a “test” of Swedish
drug policy, and although caveats must be made regarding overall
representativity, it is clear that what the interviewed drug addicts and ex-addicts
have told about their experiences point at some dilemmas regarding Sweden’s
present way of dealing with drug problems.
According to the reigning “doxa”, the substances subsumed under the legal
definition of “narcotic drugs” will, irrespective of their varying chemical
properties, rapidly and almost inevitably give rise to a psychological dependence
in the individual user, making him or her a powerless slave under their addiction.
Further, the prevailing public discourse depicts living as a drug addict as
entering an alien and frightening world “which is screened off from the rest of
the society, which is permeated by criminality, prostitution, violence, illness and
death, and which is extremely difficult to get out from” (Kristiansen 1999, 9).
Thus, to break the vicious circle, determined interventions on behalf of society
are warranted, including long-term residential treatment, into which it may be
necessary to coerce people who do not realise what is best for them. Finally,
given the allegedly strong dependence-generating properties of all narcotic drugs
and the contagiousness of drug use, far-reaching controlling, disturbing and
punitive interventions on the part of the authorities are seen as legitimate.
Without in any way denying or diminishing the pain and suffering that drug
addicted persons may cause themselves, those closest to them, and others in their
environment, it must be acknowledged that what the respondents have told about
their experiences is in many ways at odds with the notion of drug misuse as an
easily delineated, inexorably progressive and largely predictable pathological
condition, which is contained in the prevailing “doxa”. As for the entry into drug
addiction, the data certainly indicate that “peer pressure” is a common reason for
starting to use use drugs, a fact that may be interpreted as support for “contagion
theory”. However, some respondents rather describe their addiction as a
deliberate choice, quite a few depict it as the effect of a voluntary, albeit
misdirected attempt at self-medication of various psychological ailments, and
some claim to have become addicted while in custody of the social services
authorities, for instance. Moreover, most respondents give rather complex and
modulated motivations both for starting drug use and for having been caught up
in the addiction circle. Overall, the study results strongly indicate that there are
many ways in which one may come to centre one’s life around an addictive
157
habit, and that the specific path varies widely, among other things, with gender,
socio-economic background, and the historical period during which one made
one’s acquaintance with the drug.
The lapse of time from initial use to full-blown addiction also varied, both
between study groups and between individuals in the same group. As for the
character of the addiction circle, the narratives depict a changeable process that
is driven by a complex web of personal, psychological motives and external,
social and structural forces, and frequently interrupted for longer or shorter
periods for personal reasons or by altered external conditions. There is also great
variation – both between individuals and over time for the same individual – in
the descriptions of what it has meant to live as a drug addict. Indeed, some of the
narrators recount how they have been more or less immersed in the “drug world”
with its deviating norms, rituals and rules, supporting themselves by dealing,
other forms of crime and prostitution. However, most respondents – even if they
too have experienced powerful negative consequences in the form of violence,
psychological oppression, deception, physical and psychological distress,
feelings of anguish, guilt and inferiority – seem to have led some form of
“double life”, with at least some bonds to the surrounding “normal society”. For
instance, many of the women actually functioned as mothers during the whole or
most of their addiction, a number retained at least some ties with the labour
market, and quite a few tried to keep up at least some close relations with nonaddicted friends or relatives.
Finally, the path out of the addiction, whether assisted or unassisted, is
commonly described as a protracted process, the specific character of which
seems to have been strongly influenced by the narrator’s personal values and
social resources, other people’s reactions, and a number of sometimes
unpredictable naturally occurring events. Figure 1 attempts to summarise the
“internal logic” of the addiction process and the path out, as well as the major
driving forces in these courses.
158
Figure 1. Entry into and exit from drug addiction. “Inner logic” and main driving
forces.
LIFE EVENTS
(Negative consequences, mundane
or dramatic “turning-points”,
positive incentives)
INDIVIDUAL PREREQUISITES
(Values, capacities, experiences,
personal and social resources)
“Functional”
drug use
Using drugs
“central activity”
New social and/or
personal identity
Gains from
drug-free life
Increasing medical, psychological and social problems
Crisis/insights/
wishes to change
Handling initial
problems (“resisting”)
Hope/decisions/
efforts to change
STRUCTURAL FACTORS
(Distribution of resources, drug
policy, popular beliefs, social
policy)
RELATIONS
(Partner, family, friends,
professional and informal
networks)
Rather than supporting the prevailing “doxa”, more than anything this
description fits in with the notion of drug addiction as a “central activity” in the
addict’s way of life (Fingarette 1988; Blomqvist 1998a), or as an adaptive albeit
destructive reaction to the strains of life (e.g. Peele 1985; Drew 1986). As for the
path out, this may best be pictured as a “salutogenic process” (Antonovsky
1979), that is as the result of each individual’s way of making use of various
“resistance resources” – whether indigenous, naturally existing or provided in
the form of treatment – in his or her striving to make their world intelligible,
manageable, and meaningful (cf. Hedin & Månsson 1998; Blomqvist 1999a;
2002a).
Some Implications for Practice
The Need to Place “Treatment” in Context
To help clarify some implications of the reviewed data for individual problemhandling, it may be useful to refer to the discussion by Brickman and colleagues
(1982) of models of helping and coping. The authors start out from the assertion
that moral attributions actually involve two questions, the issue of blame and the
issue of control. The first question is about the extent to which an individual is
159
considered to be responsible for causing his/her problem. The second is about
the extent to which he/she is considered to be responsible for and capable of
solving the same problem. Based on the answers, four different approaches to
personal and social problems can be formulated. Under the assumptions of the
“moral approach”, people are held responsible for both creating and solving the
problem, which means that help essentially takes the form of punishments and
rewards. Under the assumptions of the “medical approach”, on the other hand,
problems are seen as having been caused by forces beyond the subject’s own
control, and as curable only by professional experts. By and large, these two
models correspond to the classical “badness-illness” dichotomy (cf. Mäkelä
1980). To this common figure of thought, however, the authors add the
“enlightenment or spiritual approach”, according to which people are deemed
responsible for having caused their problems, but are at the same time seen as
incapable of solving them. As a consequence, the subject’s best hope for a
solution lies in submitting to a higher moral authority that can help him or her
master their destructive impulses. Finally, according to the “compensatory
approach” people are seen as subjected to various handicaps or obstacles,
imposed on them by the situation or by nature, but as basically responsible for
and capable of managing their own lives. Accordingly, they may be entitled to
certain help, given on their own terms, and aimed at empowering them to do this
on the same conditions as other citizens.
In another context (Blomqvist 1998b), I have concluded that the handling of
drinking problems in Sweden has developed during the past century by and large
from the moral to the medical, and to some extent the spiritual approach. The
handling of drug problems, for its part, may rather be claimed to have developed
from a medical approach (even in the strictest sense of this term) to what stands
out as a hybrid between the moral, medical and spiritual approaches (Blomqvist
2002a). On the one hand, drug use, and intravenous use in particular, is
conceived as “the incarnation of the most abominable deviation we can imagine”
(Olsson 1994, 198). On the other hand, the misuser is depicted as a powerless
victim, in need of long-term specialised treatment – or possibly spiritual
“conversion” – to be able to rid him/herself from the spell of the drug.
A common feature of the moral, spiritual and medical approaches is that they all
aim at remedying, by exhortations and punishment, by expert treatment or by
conversion, some – alleged or real – moral, physiological or psychological –
inner defect (Blomqvist 1998b). Closely in line with this idea, the treatment of
drug – and alcohol – problems in Sweden (and indeed elsewhere) has
traditionally been conceived as a situation where a professional therapist (or
some other “authority”) applies expert knowledge to more or less ignorant
clients or patients (cf. Orford 1986; Cameron 1995). Most typically, this has
been in the format of time-limited, albeit long-term, programmes in an in-patient
setting (Lindström 1986; Blomqvist 1991). The manifest goal,in drug misuse
treatment in particular, has been a total and lasting cure achieved in one
160
treatment occasion (Lindström 1993). In addition, most programmes seem to
have been designed with a view to clients who are seeking help for the first time
(Blomqvist 1991) and who from the outset have a strong motivattion for change
(Prochaska et al. 1992). Still, coercion is perceived as a viable and justifiable
means of urging drug addicts in particular into treatment. The reasonableness
and effectiveness of such a format in helping people to change their addictive
habits have often been questioned (e.g. Mäkelä 1980; Mulford 1988; Blomqvist
1991). However, neither this critique nor the generally meagre overall outcome
of traditional treatment (e.g. Lindström 1992; Bergmark & Oscarsson 1993)
seem thus far to have had very much impact on the organisation and content of
society’s efforts to persuade substance misusers to quit using. It is true that there
has been an increasingly loud call for “evidence-based methods” in social work
and substance misuse care in Sweden (e.g. SBU 2001). It is also true that the
new “Mobilisation Against Narcotics” campaign, even if it essentially clings to
the “control and sanction strategy”, emphasises the need for more and better
treatment (Action Plan 2002). However, the resources allotted to this end are
relatively scarce, there is no specification of what the intended improvements
would contain in more concrete terms, and there is, overall, little to signal a
readiness to reassess the traditional notion of drug misuse treatment in a more
thorough sense (Blomqvist 2002a).
Turning to the interviewed ex-addicts’ own experiences, it is easy to see that
much of what they have recounted stands in rather stark contrast to the
assumptions of any of these models, as well as with the traditional “doxic”
notions of what it takes to move away from one’s addiction. For one thing the
study, in accordance with similar research in other settings (cf. Klingemann et al.
2001), has shown that even severe drug misusers may under certain
circumstances find a lasting solution to their predicament without professional
treatment or other formally organised interventions. Although this finding
provides no arguments for cutting the overall resources for helping substance
misusers13, it clearly belies the notion of long-term expert treatment as a
necessary and basically sufficient condition for full and enduring recovery.
Further, the study results support previous findings which indicate that factors
such as clients’ expectancies (e.g., Blomqvist 1996), a warm and confiding
“therapeutic relationship” (e.g., Frank & Frank 1991) and adapting what is done
in treatment to each client’s specific constellation of human and social capital
(Granfield & Cloud 1999), may be as decisive for a beneficial outcome as, for
13
Potential selection bias prevents any conclusion as concerns the prevalence of such
solutions. Taking into account Moos’s (1994) reminder that the distinction between
”treatment” and ”life context” is rather arbitrary, it is quite possible that many of the
self-changers would have found a quicker and less strainful path out, had they been
offered professional help of a kind that they had found relevant (Blomqvist 2002a). At
the same time, it is not unlikely that self-change from drug misuse is more prevalent in
countries that are less ”treatment-inclined” and/or have not taken as strong a stance
against all drug use as Sweden (cf. Klingemann 1992; Blomqvist 2002b).
161
instance, the programme’s professional ideology or the specific methods or
techniques it endorses. Finally, the study indicates that there are many different
paths out of severe drug problems, that moving away from the addiction is
typically a long-term process, and that different sets of interacting psychological
and social factors are crucial in different stages of this process (cf. Prochaska et
al. 1992). All in all, these findings support the notion that formal treatment is at
best only one part of the complex web of internal and external influences that
may eventually lead a drug addict to an enduring solution (cf. Edwards 1989;
Humphreys et al. 1997).
Consequently, it seems doubtful whether allocating more resources to, and
introducing new treatment techniques into, the traditional drug misuse care
system will be enough to achieve the goal of significantly increasing the number
of addicts who will permanently leave their addiction. Certainly, there are no
reasons to question per se the ambition to strengthen society’s overall capacity to
help substance misusers, to dismiss what can be learned from scholarly outcome
research, or to refrain from using the best “tools” available in assisting people to
change their life-styles. However, as the study referred to here has shown, there
is more to a lasting solution to an addiction problem than being subjected to
time-limited “treatment”, including even the best of treatment techniques. Thus,
to really improve the overall outcome of the drug misuse care system, the notion
of treatment must be placed in context in a more fundamental sense.
In short, the findings and arguments presented above speak for arranging
society’s assistance to alcohol and drug misusers according to the “compensatory
approach” (Brickman et al. 1982). Unlike the three other approaches, this
approach conceives of help-recipients’ troubles essentially as life-style problems
that are strongly influenced by contextual, environmental factors, and sees the
individual as basically capable and responsible, and as striving to make his or
her life endurable and valuable as best s/he can. However, in spite of its close
affinity with the traditional Swedish social welfare ideal, the compensatory
approach has – for reasons that have been discussed elsewhere (Blomqvist
1998a; 2002a) – as yet been largely absent from the country’s alcohol and drug
misuse care system. Without going into the details, some crucial aspects of a
transition from the moral/spiritual/medical or “expert” model to the
compensatory approach can be delineated. Among these are that it is vital “to
start where the client is” (Blomqvist 1996), that the helper needs to acknowledge
each individual’s own views and expectations (Hubble et al. 1999), that what is
done has to build on his or her personal and social resources (Granfield & Cloud
1999), and that the helper needs to identify, support and interact with various
“healing forces” in the natural environment (Lindström 1992). Further, since
motivation to change is perishable goods, help must be easily available and
provided in an unthreatening and unstigmatising setting. Finally, it needs to be
recognised that the client may subjectively have perfectly “good reasons” for his
162
or her drug use, and that improvement in vital life areas may in some cases be an
acceptable and viable goal. Of these claims, the last two are probably the ones
that are hardest to reconcile with the prevailing “doxa”, tending to regard
anything but zero tolerance as a serious threat to the vision of a “drug-free
society”, and to misconstrue “harm reduction” as “drug liberalism”.
Drug Problems and Larger Social Realities
As already indicated, the core message of Sweden’s new campaign against
narcotic drugs is that the traditional “control and sanction strategy” has proven
its effectiveness, and that increasing drug problems and drug-related harm during
the past decade should be attributed to deficiencies in the enforcement of this
policy. Others opposed to this view have interpreted Sweden’s “war on drugs” as
mainly a symbolic activity, without much relevance for actual developments
with regard to the prevalence of severe drug misuse or the total sum of drugrelated harm (e.g. Christie & Bruun 1985; Tham 1995). Lenke and Olsson (1996)
maintain that Sweden’s comparatively low prevalence of drug problems until
rather recently, has been due less to specific drug policy measures than to the
country’s “protected” geo-political location and a strong welfare policy, which
has guaranteed low unemployment and a high degree of social integration.
According to such a perspective, the proper way to handle today’s situation,
when the conditions have changed for the worse in both these respects, is hardly
more controlling and repressive measures based on a traditional paternalistic
perspective. Rather, what is needed is a policy that takes into account the
personal experiences of those concerned and tries to adapt to today’s social and
economic realities (Olsson 1999).
The data reviewed in this article provide no solid ground for deliberations over
the potential effectiveness of traditional Swedish drug policy in preventing
people from starting to use or experimenting with narcotic drugs. What they do
indicate however, is that a true strengthening of the “third pillar” of Swedish
drug policy, i.e. getting more addicts to quit, would also require a basic shift of
perspective. For example, the accounts of the interviewed ex-addicts have clearly
shown that an enduring solution, whether with or without the assistance of
professional helpers, has entailed much more than simply to stop using. Gaining
hopes for the future and finding credible alternatives to a life centred around the
drug have in most cases been crucial aspects of the motivation for trying to alter
one’s life-style. Similarly, maintaining the resolution has not only required
finding a rewarding life-situation in terms of proper housing, decent jobs and
satisfying social activities. It has also required support from the environment and
finding an option to build up a new social role as a responsible and valued
citizen. Further, it is rather obvious that the strain it has taken to move out of
one’s addiction, as well as the amount of formally organised support that has
163
been necessary, has been strongly related to each respondent’s total amount of
“rehabilitation capital” (cf. Granfield & Cloud 1999). Indeed, the respondents
who, in spite of extensive treatment experiences, have not been able to quit have
differed from the “remitters” less in terms of the severity and duration of their
addiction than in terms of personal and social resources. In addition, the study
results indicate that there are strong barriers to seeking help, due to the stigma
attached to coming out as a drug addict, and the perceived risk of being exposed
and questioned in one’s capacity of a parent, a neighbour or an employee.
Moreover, they hint, at least indirectly, that the prevailing “doxa” may
jeopardise the environment’s inclination to put faith in and support the
recovering drug addict, as well as his or her trust in their own capacity, thereby
functioning to a degree as a self-fulfilling prophecy (cf. Klingemann 1992;
Blomqvist 2000). These results may be claimed to support the interpretation that
the increase in the number of “heavy drug misusers” during the past decade has
been the result not primarily of weakening legal control, or even an alleged
reduction in the number of treatment options, but rather of the social and
structural changes undergone by Swedish society, making it increasingly
difficult to establish a dignified and rewarding life as an ex–drug misuser (cf.
Lander et al. 2002; Oscarsson 2000; 200114). Thereby, they also point to the need
to acknowledge the extent to which phenomena such as addiction or dependence
are tied to the structural matrix of late modern society, and embedded in the
misusers’ social and cultural context.
A more detailed discussion of what such a shift from a largely control and
treatment oriented view towards a wider, socio-cultural and structural
perspective would entail, or which new strategies it might generate, falls beyond
the scope of this chapter. Indeed, several authors have claimed that addiction is
actually “a basic condition” of the late modern or market economy society (e.g.,
Alexander 2000). Svensson (1996) maintains that drug addicts’ tendency to
prevail in their misery, in the face of obvious negative consequences, can to a
great part be attributed to the fact that living as a drug addict provides a – largely
illusory – solution to many of the “dilemmas of modernity” delineated by Berger
(1977)15. Giddens (e.g. 1991; 1994) discusses repetition, i.e. addiction, as a
panacea for handling existential agony in a society where, in the wake of the
14
Oscarsson (2001) claims that the conviction of many practitioners that treatment
resources have been dramatically cut may be partly illusory, reflecting rather their
frustration over the lack of viable alternatives for former drug misusers after
treatment.
15
In short, being part of the ”drug world” means living in the present, in a context where
the drug is cult, surrounded by routines and rituals for financing, acquiring and
consuming the psychoactive substance (Svensson 1996). Thereby, living as a drug
addict can be seen as a way of trying to handle the secularisation of the modern
society, as well as its inevitable ”future-directedness”, its alienation of the individual
from the traditional community, and the compulsory freedom of choice (cf. Berger
1977).
164
collapse of tradition, the individual self has become a “reflexive project” that
must be continuously constructed and re-constructed without guidance from any
given constellation of social institutions. Notions such as these may make any
attempts to solve the addiction problem within the limits of the prevailing order
seem rather futile. However, as the saying goes, it might not be necessary to
regard “the best” as the enemy of “the second best”. For instance, Giddens has
pointed out that precisely the “boundlessness” that characterises late modern
society, entailing loss of meaning and the dissolution of traditional social
institutions, may also create room for new institutional arrangements and new
forms of social integration. Following this train of thought, Granfield and Cloud
(1999) have pointed to local popular mobilisation, aimed at increasing the local
community’s aggregate amount of “social capital”, as a more constructive and
productive way of countering addiction and other social problems, than expert
treatment, initiated by various authorities and targeting this or that specific
“problem group”. Similar ideas on how to deal with alcohol problems on the
local level have been described earlier by Mulford (1979; 1988).
As for the Swedish drug situation, Lander et al. (2002), in their plea for a more
realistic drug policy, put faith in the hope that the Swedish welfare state model
will prove not to have exhausted its potential in this field; i.e. that stronger social
policy measures will again be able to counter social and ethnic segregation,
widespread unemployment and housing problems, thus creating alternatives to
choosing a life as a drug addict. Possibly, and considering the obvious
significance of widespread “grassroot commitment” in achieving such goals,
these hopes main gain some support from Rothstein’s (1994) claim that the way
in which public institutions are organised will influence civic values (cf.
Blomqvist 1998b). If nothing else, one might argue that if making the
alternatives visible is a necessary condition of change, this should be valid not
only for drug addicts’ efforts to alter their life-style, but also for society’s
attempts to assist them in doing so. Whatever the odds for such a shift of focus,
there is much to indicate that a real “choice of road” in Swedish drug policy
would entail not only paying attention to perceived “risk factors”, but also, and
to a much greater degree than presently, to the structural, social and
psychological “resistance resources” that may help people cope with their lives,
without taking refuge through chemical means. After all, in trying to prevent
certain behaviours that are deemed unacceptable, it would make more sense to
target the conditions that produce and maintain these behaviours than to just
control, punish or try to reform those who exhibit them. To paraphrase Granfield
and Cloud (1999): there may not be much point in trying to get people to “say
no” to drugs, unless we can show them something more attractive and more
fulfilling to “say yes” to.
165
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Reshaping Drinkers’ Identities?
Douglas Cameron
We all know that if you look at general population data people’s drinking
patterns change over time. Generally, the story is this. Young men drink to high
session intake infrequently. As they get older, they drink more frequently less
and as they get older still, they drink less, less frequently. But there is lots of
diversity. There will be people who drink a lot and give up, people who drink in
much the same manner throughout their drinking careers, people whose drinking
gradually increases as they get older. Thus a series of papers by Marcia Russell
and her colleagues from the USA (e.g. Russell et al. 1998) was particularly
illuminating, for it examined that diversity. What she did was looked in great
detail at the drinking careers of very large numbers of folk – thousands – aged
between 50 and 80 at the time of interview. She did it by getting them to create
lifetime diaries retrospectively: when they went to school, changed school, left
school, got their first job, went to college, did military service, got into
relationships, got married, divorced, changed jobs etc. She then put these events
onto a huge diary, added in years and asked people what their “typical drinking”
was like every month, with all sorts of detailed questions like “did you drink on
Fridays at that time. If so, how many Fridays per month?”
Her aggregate data showed the usual picture: young men drank lots per month
and the amount dropped off over time. Contrarily, young women started drinking
later and drank less but their consumption remained relatively stable. Because
she had such detailed diaries, Russell could look at changes in drinking pattern
on a month by month basis. The pattern was of people in their late teenage
showing many changes in their drinking behaviour followed by a reducing
number of changes as they get older. To put it another way, people learn how to
drink, what to drink, when to drink, and having learned they settle down and get
on with it. That is the effect you get if you aggregate all the data. But if what you
do is a cluster analysis of these various patterns, you get five groups, as you
always seem to with cluster analyses. They are worth describing in more detail:
Group 1 is much the biggest group. People in this group start drinking in mid
teenage, their drinking reaches a peak at 21 then gradually subsides over time.
The proportion of women in that group is higher than in any other.
Group 2 are later onset drinkers. They don’t have an early peak and by the age of
35 their drinking matches the predominant group, Group 1.
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Group 3 are very late onset drinkers. They don’t start till their mid 30’s but by
50, they are drinking the same as the other two still drinking groups.
Interestingly, this group contains more African Americans than any other group.
Group 4: These are early onset drinkers who peak in late teenage and have given
up altogether by the age of 30. I suspect that this trajectory is the same as one
gets with illicit drug use.
Group 5 are early starters, heaviest drinkers of all in their 20’s and early 30’s but
then they give up, and from their 40’s onwards, they are abstinent.
The first caveat is that these are American data, and I have no reason to believe
that the trajectories would be the same in Britain, or in Italy or in Sweden.
Indeed, it would be surprising if they were. For instance I suspect that Group 2,
predominantly young white males who do not start till the age of 20, are an
American phenomenon. But that is not the point. The point is that in any
drinking culture drinking careers are far from homogeneous.
Somewhere embedded in the middle of these trajectories some people are getting
designated as having alcohol problems. So I want to report a “factitious” case
history, actually more of a story than a case history. Ron McKechnie and I have
used this account elsewhere (McKechnie & Cameron 2000).
Mark is aged 39, married with two children, a boy aged 13 and a girl aged 10.
He works in London as a partner in a firm of chartered accountants and lives 50
miles north of London in a small town. His wife, Judy, used to be the office
manager in Mark’s firm. The couple have lived together for 16 years, and moved
to their current home 8 years ago so that the children could go to a “better”
school than the ones that were near their London flat. Judy also wanted to move
nearer her parents. She has been a full-time housewife since the children were
born but has helped out in the local playgroup, which is operated by the church
of which she is a member but not a particularly regular attender. To the
consternation of his in-laws, Mark never goes to church.
Both Judy and Mark are drinkers. They used to have wine with dinner most
evenings but Judy has tried to restrict their drinking together to weekends,
holidays and special occasions. She has done this because she is concerned about
Mark’s drinking.
Mark has been a regular drinker since his mid-teens. He started to play rugby
for the school and continued playing for a local club after that. He and “the lads”
were in the habit of having a few “jars” after training and after the match on
Saturday, He drank heavily when he and his mates went to watch the England
team play their international matches at Twickenham, (London) and he always
went to Dublin for the weekend every other year when England were playing
there. He told Judy tales of the drunken sprees that took place in Dublin. Mark
gave up playing rugby in his late twenties following a knee injury, and left the
rugby club when he and the family moved out of London. Now he goes to the
local pub to watch rugby matches on the big TV screen there. Even so, the ritual
trip to Dublin is still seen as “a must” and he still gets excited when he talks to
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Judy about it. Judy has worried about sexual infidelity in Dublin, and has toyed
with the idea that he has a “regular woman” there. Mark denies this.
Mark accepts that he drinks more than Judy does, but does not believe it is a
problem. He is in the habit of having a few drinks on the commuter train on the
way back home from work and says he has earned it after a hard day’s work. He
has to leave early in the morning, and, as much of the work of the accountancy
firm involves bankruptcy and liquidation work: dealing with stressed clients and
having to make ruthless decisions, he uses drink to “wind down”. After a meal at
home in the evening, he will sometimes go to the local pub for the last half-hour
which in reality means that he is often not home until midnight. Sometimes Judy
will go with him, although that means leaving the children unattended. Whether
Judy goes depends upon how drunk she perceives Mark to be when he makes the
suggestion. She will go if she wishes to have a little time with Mark and feels he
will be reasonable company. She will not go if she feels he has already had too
much to drink and will not be attending to her. Mark has occasional hangovers
but mostly he is able to “get his head on” sufficiently, to go to work, although he
has told Judy of occasions when he had to meet clients and was clearly the worse
for wear.
This year, Judy tried to stop Mark from going to Dublin. It coincided with a
function to mark her father’s retirement from work in the local council planning
department. Mark went to Dublin, and during her father’s retirement party Judy,
according to her, “inexplicably” burst into tears. She told her mother about her
problems with Mark. Her mother said that she would not have mentioned it
herself, but that she also had been worried for some time. She said that she had
found an article in a woman’s magazine about alcoholism and it had a
questionnaire in it. She thought on the basis of the questionnaire that Mark was
an alcoholic. Judy got the article from her mother next morning and could not
but agree with her. She decided she would have to take it up with Mark when he
came back from his weekend in Dublin. Mark duly arrived home, still somewhat
intoxicated, and wanted to tell Judy about how England had “trounced” Ireland.
He gave the kids little Leprechaun glove puppets, He gave Judy a bottle or Irish
Whiskey which he knew she liked. Judy burst into tears again. The kids were
hurriedly asked to sit in front of the television while “Mum and Dad talk”. Judy
told Mark about the article, the questionnaire, her mum’s view and that she
thought he should get help. Mark said that he thought she was talking rubbish,
that he didn’t drink even as much as the mates with whom he had spent the
weekend, and that his mother in law had never liked him because he was not a
Churchgoer. He terminated the conversation by asking Judy if she wanted to go
out for a drink. She refused so he went to the pub by himself. When he got home,
Judy was in bed. He crept in beside her and next morning left the house at the
usual time to get the train to work. When he came home that evening, neither he
nor Judy mentioned what had happened the night before……
There is nothing special about that story. It is mostly about the kind of painful
domestic problems that can arise in a relationship where one person is unhappy
with another. In Mark and Judy’s case, the focus of Judy’s unhappiness is on
Mark’s drinking. The process of creating Mark’s drinking problem can be seen
as occurring at three levels, at the intimate interpersonal, at the level of the
person’s social matrix and at the level of society as a whole. Each of these levels
has an impact on the process of problem creation and identification, and interacts
with the other levels (Figure 1).
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Figure 1. Leves of Alcohol Problem Designation.
Referral from
Inner circles
Drink
Driving
Health Problems
+ Reinforcing drinking style and
drunkenness
Workplace
Identification
Intimate Conflict:
Needs met and
unmet, Absence
of identity
- Validating problem
Publicly
status
Visible
Domestic Disputes
Drunk and disorderly
Let us start by looking at Level 1, the intimate interpersonal. There are clearly
conflicts going on here. There are issues of what behaviour is acceptable, about
Judy’s needs being unmet, about Mark’s autonomy, about who Mark is, about
his identity. So, I want to look at the process of identity formation.
There are two dimensions to identity formation, the public and the private and
the individual and the collective. Figure 2 is an adaption by Anja Koski-Jannes
(2002) of the work of Rom Harre. Identity formation begins in the top right hand
corner of this figure, by appropriation of various identity materials from others:
values, role models, ways of talking, ways of behaving. These are then tried out
in private, modified as necessary and become part of one’s private identity. At
some point, the individual will try this persona out in public: that is publication.
And the cycle is completed by public acceptance of these publicised expressions
of personal identity. This process goes on all the time. A lot of appropriation
occurs from one’s family of origin, but also from schooling, from school friends,
from characters on the television. To quote Koski-Jannes:
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In other words, by the presentation of self in public, a person create a social
identity, whereas one’s personal identity is the product of appropriations and
transformations of culturally defined identity resources. Finding a place for
oneself in the world thus involves both of these projects. A person must
establish a social identity that secures him or her an honourable position among
fellow human beings. Yet one also needs to find and maintain a personal identity
in the sense of biographical uniqueness.
Figure 2. Harre's Conceptual Framework of Identity Formation.
D
Public
1
4
Public
-ation
R Individual
PERSONAL
SOCIAL
Conventionalis
-ation
Collective
3
Transform
-ation
Appropri
-ation
2
Private
R=Realization
D=Display
So, back to “Mark” and “Judy”. We know most about his social identity: Male,
married, father, accountant, commuter, ex-rugby player, now supporter, regular
drinker, and so on. We know much less of his personal identity. It has to be so. It
is personal. But there are glimpses: ruthless in the workplace, still one of the
boys, oppressed by in-laws and by churchgoers, still willing to maintain his
independence regardless of Judy’s disapproval. Despite all the domestic
trappings, still “Mark the Lad”.
And Judy: wife and mother, daughter, more or less lapsed churchgoer, ex office
manager, occasional drinker. We have much less clue about her personal
identity. But we know that she is unhappy with the way her life is going. And we
know there is a mismatch between her drinking and Mark’s, and she has chosen
177
that as a “battleground” in her relationship with Mark. I make no judgement
about the rightness or wrongness of her position, or for that matter, Mark’s.
What happened next in our little story was that Mark and Judy’s problems leaked
to Level 2. Here, in the immediate social matrix, there are conflicting sets of
beliefs. Mark’s mates view him as one of the boys, and validate his attitudes,
behaviour and use of alcohol. Judy’s mum validates her view that Mark’s use of
alcohol is problematic. Now if Mark accepts that view, it will have severe
consequences. He will have to give up a bit, or perhaps a lot, of his personal
identity. So what he did was immediately recruited the purported views of his
“mates” to maintain the status quo, and then he tried unsuccessfully to recruit
Judy into that process too, by asking her if she wanted to go down to the pub.
What is important is that it was not the fact that Mark was drinking that caused
Judy to designate him as a problem drinker. He could have drunk probably just
as much as he did in Dublin at his father-in-law’s retirement party. It was that he
deemed the Dublin drinking session as more important to him than a similar one
at his father-in-law’s function. If Mark had not gone to Dublin, he would have
waved goodbye to “Mark the Lad” in favour of Mark, the husband, and the
dutiful son-in-law. The purpose of the drinking in Dublin was very different
from the purpose of the drinking he would have done had he stayed home.
The story stops there. We do not know what happened next. However in this
next story we know exactly what happened next.
Ajit, who is of Indian extraction, is now aged 44. He is married with three
children, girls aged 18 and 6 and a boy aged 16. His wife is aged 37. He runs a
small textile company in Leicester. His history is turbulent. He was born in
Uganda but left there in 1972 at the age of 10 when his parents left. Like many
people of Indian extraction who lived in Uganda, Ajit’s family was persecuted
under the regime of Idi Amin. His father co-owned with his brother a textile mill
in Uganda and the family was wealthy, having a large “colonial style” house with
servants. Ajit’s uncle, of whom he was very fond, was killed by a band of
Amin’s henchmen and Ajit remembers going with his father to look for him, only
to find his mutilated body by the dirt trackside. So, Ajit’s father rounded up his
family and left Uganda in great haste, coming to Leicester where he had a
nephew, Jiva. Life in Leicester was hard. Ajit’s father could only get a job as a
process worker in a tyre factory and his mother got work in a local textile factory
where Jiva also worked. The family of six lived in a small terraced house in a
run-down area of inner city Leicester.
Ajit’s elder brother, Vinod, three years his elder, was very clever. He adapted
very quickly to Britain, did well at school and went to the local Polytechnic, now
de Montfort University, to study law. He married a white girl whom he met at
University. This led to terrible fights within the family and Ajit’s parents refused
to go to the wedding. Ajit went and he says his father never forgave him. Vinod
moved away from Leicester and now lives in London. Ajit, on the other hand,
had a parentally arranged marriage to a young woman from Gujerat in India
whom he only met when she came to Britain for the wedding. Ajit’s older sister,
a nurse, is married to a local doctor, and lives in a well-to-do part of Leicester
178
but his younger sister has learning difficulties and continues to live with her
mother in their original terraced house.
After leaving school, Ajit started working in the textile factory where his mother
worked. His cousin, Jiva, by then had been promoted to a supervisor role and
took Ajit under his wing. He also introduced Ajit to Lager. Although Ajit’s
father drank, he did so only on Saturday afternoon with a number of male
friends. They would visit each other’s houses, drink whisky and play cards,
gambling unspecified but possibly quite large amounts of money. None of the
female members of Ajit’s family drink at all, and Ajit’s mother and later his wife
believe that people who drink are “weak”. But that was all to come. One day at
the age of 17 Ajit went with Jiva to a local Indian drinking club. His cousin was
obviously well known there, and Ajit was made very welcome. He drank two
pints of Lager and enjoyed it, feeling really adult. He enjoyed the feeling of
liberation induced by the alcohol. He “joined” the club and visited regularly after
that, mostly with Jiva, but sometimes by himself. Neither of his parents
commented on Ajit’s drinking but when he came home very intoxicated one day,
he told his mother that he was ill and went straight to bed. In the future his
mother was to say to him, “Not ill again!” on many occasions. Ajit was, by the
time of his marriage, drinking four or five pints of 5% lager at least three times
per week.
His wife, Rani, knew nothing of this drinking and was shocked when she
discovered it. Ajit told her that it was what men did in England. She was trying
to adjust to marriage, to the move from Gujerat and being away from her family,
to the language, so she just got on with it. But she did not like it. Nor did she like
it that Ajit no longer went to the Mandir (Hindu Temple).
Then she got pregnant. Her first pregnancy was not easy. She vomited a lot and
had difficulty doing the housework and preparing meals. But she got through the
pregnancy and enjoyed being a mum. She got pregnant again and had a son. The
second pregnancy was easier but soon after her son started at school things really
went wrong. Ajit’s father died and Ajit really did not cope. He started bullying
Rani, claiming he was now the head of the family and that she had to do as she
was told. The demands were petty, about what she should cook, about how she
dressed, about how she was spending money and about how she disciplined the
children. And he was drinking more and more. He went to the club every night
of the week and often would not arrive home until after midnight. Rani actually
preferred him to come in late because at least she could pretend to be asleep. She
went to discuss her difficulties with her mother in law but that was not helpful:
all she got was her mother in law extolling Ajit’s virtues, “a good son, unlike
Vinod”.
Ajit told Rani that he and Jiva were going to leave their jobs and set up their own
business. Rani did not know whether they had actually been sacked. Jiva and Ajit
certainly left their jobs and spent more and more time in the drinking clubs.
There was little sign of their own business starting up. Rani did not know what to
do, so she went to the Mandir and poured her heart out to one of the priests
there. He suggested that the best thing to do was to try and get Ajit to attend the
temple again. Rani tried to persuade Ajit to go back, saying that there was a
celebration meal on offer. Ajit did turn up, but he was grossly intoxicated and
fell about, making an exhibition of himself. He and Rani were asked to leave.
Rani was in tears. When they got home, Ajit went out and did not come home
that night.
179
The next day was even worse. Rani had hardly slept at all. She got the kids off to
school without telling them that their father was missing. They were well used to
their father sleeping in until late morning. Rani went to her mother in law’s but
Ajit was not there. Her mother in law accused her of not looking after him
properly and of bringing shame onto the family. Rani phoned Ajit’s elder sister.
Ajit was not there. She phoned Vinod at his office but he did not return her call.
And when the older kids came home from school, they were upset and told her
that they had been teased at school and told that their father was a “drunk”
(darudiyo). Rani felt utterly alone. Her family was in India; there was no support
from her in-laws. She did not know what to do.
Then Ajit came home. He was shaking and cold. He had no overcoat and his
clothes were soaking. He said that he had been walking around the city streets all
night. Despite what had happened over the past 24 hours, Rani was pleased to
see him. She ran a bath for him and prepared him a meal and at his request she
joined him at the table, which she had not done for many months. They did not
say much to each other but Ajit said this, “I have brought shame (Beizzart) onto
the family and have made a decision. Either we have to move away from
Leicester or I have to give up drinking. So I have decided to give up drinking.”
That was seven years ago. Ajit has been abstinent since. For the first month, he
went to the Mandir every day. He still goes regularly. Then he devoted himself
to setting up his own business. He had received a small amount of money on his
father’s death because Vinod had been excluded from the will and with what was
left after he and Jiva had drunk a good deal of it, he rented a small industrial unit
in Leicester and furnished it with second hand industrial sewing machines. He
employed his mother, his sister, Rani when she had the time and Jiva. It has been
very hard work but the business is still there although it is very seasonal. It
depends on small orders from major suppliers of chain stores. Ajit’s firm gets the
job of rapidly manufacturing small runs of particularly popular items such as
football shirts and summer tee shirts when the main runs are sold out. He now
employs 12 people full time and when in receipt of a particularly big order for
him, he employs other women who have sewing machines at home on a
piecework basis.
Jiva is still a heavy drinker and an unreliable employee. When he works he
works well but he is frequently absent and he often smells of whisky. He always
denies that he has been drinking. But, says Ajit, he is a member of the family and
he needs to be looked after. The folk in the factory seem to regard him as a
somewhat wayward pet, but they will say nothing against him: at least not in
Ajit’s earshot.
This is another “factitious” story created from a number of the stories we
collected in a study we did of natural recovery from alcohol problems in our
biggest ethnic minority population in Leicester (Cameron et al. 2002). Again it
illustrates the same principles outlined above. Ajit as a young man attempted to
forge a new public identity for himself, emulating Jiva that was at complete
variance to that expected of him by his mother and wife. Unlike Judy, Rani never
drinks and that was her expectation of Ajit, and that was reinforced by the
Mandir and by the extended family and much of the community. When Ajit
decided to become abstinent he was readily picked up by and supported by the
community again. There was a religiously based supportive network for him, a
natural “community reinforcement system” to which he responded. In a sense
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Ajit’s options were more clear cut than Mark’s. There was no negotiating about
acceptable or unacceptable drinking. It was all unacceptable. It is hardly a
surprise that in our ethnic minority sample of 20 all-male natural recoverers, 19
opted for abstinence. Their trajectory approximates to Marcia Russell’s Type 5.
From the point where Mark’s story ceases, he has a number of options. He could
stop drinking altogether. He could simply go on behaving much as he had been.
Or he could gently, slowly, modify his drinking behaviour. Overall he could
drink less. He could, perhaps, go to the pub less often. He could take up more
wine drinking with Judy at home. He could even give up going to Dublin every
other year. If he took that third course of action he would remain broadly within
the parameter’s of Russell’s Group 1 but be behaving more like one of the white
indigenous Leicestershire so-called spontaneous remitters. As the table from our
paper (Cameron et al. 2002) demonstrates, they are rather different from their
ethnic minority counterparts. They opt for abstinence less even though at the
height of their problems they were more “dependent”. They already drink at
home more and being stably housed and feeling better psychologically are more
important maintainers of change.
Table 1. Ethnic Minority and Indigenous Caucasian Natural Recoverers
Compared.
Sex
Location of problematic
drinking?
Previous intervention
Units (8. Ogm alcohol) / day
Mean SADQ
Severity of problem (1-10)
Interference with life (1-19)
Accept “addict” status?
Transition process
Post-resolution status
Contrasting maintaining
factors
Common maintaining factors
Ethnic (n=20)
100% male
75% pub
25% friends’ home
25%
8-96
20.1
5.3
8.8
100% no
60% “just stopped”
40% final binge
30% substitute
95% abstinent
5% controlled
Religion, Family,
Social
Caucasian (n=12)
75% male
33% pub
50% own home
58%
16-96
37.2
9.1
7.8
83.3% no
100% “just stopped”
0% final binge
66% substitute
75% abstinent
25% controlled
Accommodation, Psychological
Physical health
Self-esteem
Coping
Work
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Both these vignettes are restricted to the inner two circles of Figure 1. There is,
however, a third level, and that is where we so-called professionals come in. And
what we tend to do is to validate problem status, with our questionnaires, our
safe limits, with our finger wagging about long-term health consequences of
heavy drinking. And if our drinking places us in conflict with other social
institutions, such as the law or the workplace, that feeds back into the inner
circles. But that is not what I wish to pursue. Let us assume that Mark said to
Judy “It’s a fair cop, you are right, I’m an alcoholic”, or some such term. What
would happen then?
He might have been told to stop, or to cut down following a brief intervention.
He might have gone for day or residential treatment, he might have gone to AA.
Whatever the intervention, he would have been required to pick up some
modifying features to his identity from the top right hand corner of Figure 2, and
he would have had to appropriate them. And in the process, his personal identity
would have to change. We’re talking big stuff here: “I’m not a normal drinker,
I’m an overindulgent drinker, I’m a hazardous drinker, I’m alcohol dependent,
I’m an alcoholic” or whatever. The idea of the treatment would ostensibly be to
mend his ways, and I accept that I am using a moral value laden term. And if the
treatment was “successful”, he would become a different person. And if he was
refractory, he could always go back to his “Level 2 mates” who would revalidate
and reinforce his old identity.
Ajit, in a sense, has it easier. He did not need to incorporate an “addict” or
“problem drinker” status into his identity. He just needed to become a nondrinker and continue to live out his life among the substantial number of never
drinkers in his community, people for whom alcohol use was irrelevant to their
identity projects.
What I want to do is to pick up one particular line from Koski-Jannes: “Yet one
also needs to find and maintain a personal identity in the sense of biographical
uniqueness”. It’s the word biographical that is notable. It is this notion that we
are all, as we stagger through life, accumulating in our heads some kind of story
of ourselves. We are reporting on ourselves to ourselves. And, in the light of new
insights or experiences, we are rubbing out some explanations of our stories and
replacing them with other explanations.
We all do that. And I think the job of the psychotherapist can be seen as helping
people with their personal biographies. But more relevant here is Alcoholics
Anonymous (AA). I think that what AA does is shapes people’s biographies in a
very powerful and consistent way. Attendance at AA meetings is a way of
helping people to rewrite their personal biographies. You tell your story as you
see it and very subtly, the story gets reshaped and reframed until you accept that
it was not the biography as you first reported it. What you have to accept is that
some of your reasons for drinking were “excuses”, that the core problem was not
182
work stress, or domestic disharmony. The drinking caused the stress and
disharmony. You were an alcoholic and powerless over alcohol; that was the
core problem. What AA does is both gives adherees a new identity and rewrites
their biographies. But part of the new identity is that there are only two ways
forward. Either you become abstinent or you remain a determined drinker. You
have the option of AA or DD. That is also how it works in Ajit’s world: Ajit
opted for abstinence, his cousin Jiva opted for Drinking Determinedly.
But in cultures where drinking is the norm, it is not like that. Somewhere in the
middle of Russell’s multiple trajectories are people with alcohol problems, and
there are all sorts of routes from one way of using alcohol to another. For
instance at the age of forty, say, you can stop drinking altogether; you can
escalate your drinking; you can tether it back somewhat. Or you can continue to
be as you were. Mark’s options are much more diverse than Ajit’s. Let us call
them respectively AA (Abstinent Alcoholic), BB (Bigger boozer), CC
(Controlled connoisseur) and DD (Determined drinker). And I am sure there are
many more such options.
The trouble is that there is no systematised biographical training for other
trajectories out of problems. There are lots of bits and pieces in the top right
hand corner of Figure 2, for instance in Britain there is The Campaign for Real
Ale, CAMRA, and various wine circles. But such organisations are concerned
with shaping up beverage choice mostly. What they are not particularly
concerned about is behaviour when intoxicated. Nor are they particularly
concerned with personal identities.
It strikes me that if we are going to make a success of alternatives to abstinence
in drinking cultures, then we need organised supportive networks advocating
BB, CC and KK, whatever. At the moment our drinkers in distress do not have
other places to go and be.
183
References
Cameron, D.; Manik, G.; Bird, R. & Sinorwalia, A. (2002): What may we be learning
from so-called spontaneous remission in ethnic minorities? Addiction Research, 10: 175–
182.
Koski-Jannes, A. (2002): Social and Personal Identity Projects in the Recovery from
Addictive Behaviours. Addiction Research and Theory, 10: 183–202.
McKechnie, R. J. & Cameron, D. (2000): Drinking at Cross Purposes. In: Plant, M. &
Cameron, D. (Eds.): The Alcohol Report. London: Free Association Books.
Russell, M.; Peirce, R. S.; Vana, J. E.; Nochajski, T. H.; Carosella, A. M.; Muti, P.;
Freudenheim, J. & Trevisan, M. (1998): “Relations among alcohol consumption measures
derived from the Cognitive Lifetime Drinking History.” Drug and Alcohol Review, 17:
377-387.
184
A Life Course Perspective on
Exiting Addiction:
The Relevance of Recovery Capital in
Treatment
William Cloud & Robert Granfield
Introduction
Over the past several years, research on the life course has examined the
pathways associated with social deviance, status mobility, and educational
attainment. The life course perspective seeks to uncover the dynamics of life
span trajectories as well as the transitions that occur within any given trajectory.
An important dimension of this perspective has been the recognition that
continuity and change are mediated by a “dynamic process whereby the
interlocking nature of trajectories and transitions generates turning points in the
life course” (Laub & Sampson 1993). For some, turning points can be abrupt,
radical turnarounds that separate the past from the future (Elder 1985). For
others, and perhaps most, turning points are part of a process occurring over time
(Clausen 1990; McAdam 1989).
The life course perspective suggests that trajectories and transitions are bounded
by broader social environments and social relationships. For instance, a good
deal of research has found that trajectories into and out of criminal behavior are
affected by the degree of social capital available to an individual. As Laub and
Sampson (1993) assert, adults will be inhibited from committing crime to the
extent that, over time, they accumulate social capital in their work and family
lives, regardless of delinquent background. These researchers recognize that the
accumulation of social capital can lead to normative systems as well as assorted
resources that serve as pathways to change. This paper adopts a life course
perspective, and particularly the focus on social capital, to examine the process
of natural recovery and explores the implications that natural recovery has for
treatment providers.
Method
The results reported in this paper are derived from interviews with 46 individuals
who overcame their addiction to alcohol and drugs without treatment (Granfield
& Cloud 1999; 2001). The majority of the individuals in the study had completed
185
high school. Most had graduated from college and several respondents held
advanced degrees. Most were employed in professional occupations, including
law, engineering, and health care, held managerial positions, or operated their
own businesses. With the exception of two individuals, all respondents were
white. At the time of the study all resided in a large western city in the United
States. Three-fifths of the sample was male (28) and two-fifths was female (18).
Three criteria for untreated recovery were used during the screening interviews
to select our final pool of respondents. First, respondents had to have been
previously drug or alcohol dependent for a period of at least one continuous
year. To meet this requirement the person had to have experienced extended
periods of daily use, frequent cravings resulting from use, and serious negative
life consequences resulting from use. On average, respondents reported being
addicted for nearly 11 years. Second, to be eligible for the study, persons had to
have resolved their dependencies for a period of at least one continuous year.
The mean period of time since addiction reported by respondents was 6.5 years.
Finally, individuals could not have received treatment for their substance
dependencies, including participation in 12-step groups. Some exceptions,
however, were made when a few prospective participants stated that contact with
treatment or 12-step groups had been very minimal and that such contact had not
contributed to their successful cessation. While our screening interviews
supported these claims, we were aware that there could have been residual
beneficial effects from even minimal exposure to treatment – effects these
respondents could have been unaware of at that time. Overall, however, about 90
percent of our participants fit into the category of never having experienced such
contact at all.
Interviews with respondents were 2-4 hours in length and were conducted as
guided conversations allowing individuals to freely discuss the issues that were
being raised by the interviewers. The interview process was intentionally
informal so as to help the respondents feel comfortable and open about sharing
their experiences. While the interviewers used an interview schedule to guide
them through the interviews, the process itself was more open-ended, less
structured. The topics covered during these interviews included: respondents’
use and misuse of substances, addictive behaviors (positive and negative aspects
of the experience), strategies used to overcome heavy drug use, reasons for
avoiding treatment, perception of self in relation to previous substance misuse,
and general benefits associated with overcoming addiction. In most cases,
respondents were very willing to discuss the intimate details of their lives,
requiring little additional prompting from the interviewers to encourage their
responses.
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Experiencing Strain
Initial concerns about substance use were typically triggered by the assorted
problems respondents were experiencing. These concerns, or first doubts as
Ebaugh (1988) calls them, produced significant tensions and strains in our
respondents. Strain occurred on a variety of different levels and was usually
followed by the desire to take some kind of action to reduce tension.
Alienation and feelings of social disconnection were typical forms of strain
identified by respondents. A 33 year-old paralegal whose husband was dealing
large quantities of cocaine explained the personal strain she eventually came to
experience:
My life was deteriorating quickly. I was not creative. I wasn’t happy. I wasn’t
producing what I was capable of…. I was lonely. I was sad. I had a little one and
another on the way. I think during the whole drug scene I just wasn’t able to do
and be who I was to the level of satisfaction that I would want to perform at.
This respondent’s sense of self as an effective and creative human being had
collapsed, thereby initiating the process of identity transformation that she would
eventually experience.
Many respondents experienced strain when intimates and friends raised the
specter of concern about their abuse. Consistent with Ebaugh’s (1988) findings,
significant others, friends, and parents had a great impact on triggering doubts
about substance misuse. For instance, a 27 year-old woman who had been an
active cocaine “free-baser” for more than four years explained that: “my parents
couldn’t trust me. They didn’t like me. My friends were the same way. They
were seeing a different person.” Several respondents commented that their
friends confronted them and told them they were using alcohol and drugs in
excess, and that they were ruining their lives.
Many female respondents complained of domestic violence. In addition to the
fear and brutality associated with living with violent men, many of these women
expressed general fears of male drug users. As one respondent explained:
I remember a guy coming over at 2:30 in the morning. Terri, my husband, wasn’t
there and I was home by myself and I was scared. This guy really scared me. He
walked right into the house and I had a hard time getting him out of the house. I
was really afraid that he was going to hurt me or rob me or rape me.
Given the hierarchical and often violent nature of gender relations that
frequently exist within heavy drug using circles, such fears are well justified.
For other respondents, the strain from excessive use of substances was related to
more dramatic occurrences. Some ran afoul of the law, being arrested for DUIs
187
or for participation in criminal activities. Others recounted having experienced
serious financial difficulties that forced them to sell their possessions in order to
purchase drugs. Respondents also experienced difficulty in locating and holding
jobs and, thus, experienced great financial strain. As one respondent reported, “I
was in debt for thousands of dollars and there was a lot of financial pressure. My
landlord put me out of business because I hadn’t paid rent for a year.”
Finally, several study participants complained of experiencing negative health
consequences as a result of their extensive use of substances. Many complained
of ill effects associated with substance use, such as nose sores and abscesses
from extensive cocaine use, chronic insomnia, withdrawal symptoms, digestive
tract problems, infections from needles, and a general sense of being chronically
sick. One respondent, a 25 year-old woman who had been addicted to heroin for
five years, complained that her health problems interfered with her career in
fashion modeling. As she explained, “I was getting sick all the time at work and I
had to eventually stop working…. It fucked up my teeth, it fucked up my skin,
and I just looked like shit.” Another reported that she lost a great deal of weight
and developed a painful ulcer that eventually required surgery.
These multiple degradations served to promote in our respondents a reappraisal
of their commitment to substance use. Frustrated aspirations, traumatic life
experiences, feelings of alienation, and a general existential angst frequently
acted as catalysts to powerful conversion experiences that radically re-structured
and re-organized our respondents’ identities and meaning systems.
Turning Points
In most cases, respondents experienced a turning point that sharply and
dramatically disrupted their lives to the extent that they recognized that they
were no longer “themselves.” As Lofland and Stark (1988, 138) write, turning
points occur at the “moment when old lines of action were complete, had failed
or been disrupted, or were about to be so, and when they faced the opportunity
(or necessity), and possibly the burden, of doing something different with their
lives.” Such turning points represent “cultural dislocations” in which current
ways of living become increasingly unworkable (Strauss 1958).
Our respondents identified a variety of distinct turning points. Frequently, they
were related to experiences involving other people, particularly intimates. For
instance, one respondent explained that his resolve to stop using occurred when
his father passed away. As he described his turning point:
My father was an alcoholic. He would come home from work and would drink
several quarts of beer and watch TV and go to bed. He finally died from a tumor
that doctors said came from his heavy alcohol use. I decided to quit that day.
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The death of loved ones often can produce a rupture in the manner in which
individuals compose their lives. At such moments, individuals are often ripe for
personal transformations. Referring to the power of death to increase awareness
of the need for personal change, another respondent explained:
The biggest reason I decided to quit using was that I lost my brother at 41 in
1989. He died on the same day my father died, exactly 20 years prior. They both
drank themselves to death. I had become keenly aware a few years earlier that
my father died from alcohol. It came to the surface because I saw my brother
doing the same things. Eventually, my brother died. When I first got the news I
thought he’d put a bullet in his head. Actually, he died from pancreatitis. To me
that was the final straw. That was enough loss. I told myself that I would put all
my drinking behind me and I did.
As this respondent exemplifies, the proverbial “straw that broke the camel’s
back” was not only the loss of loved ones, but the recognition that he could
experience a similar fate if he persisted in his heavy use of alcohol. The ability to
identify with others, particularly those who had experienced pain and suffering,
facilitated reaching a turning point. This identification with a “generalized other”
fractured this respondent’s working consensus of substance use by leading him
to a profound awareness of his connection to a larger world outside his own
immediate experience (Mead 1934).
In some cases a turning point was facilitated by responsibilities to children. The
innocence of children and the need to nurture them provided a powerful
motivation to terminate addictions. This was particularly the case among our
female respondents. Several of these women stated that the turning point in their
addiction careers revolved around either giving birth, or experiencing some
egregious incident involving their children. Turning points also occurred through
“bottom-hitting” events that were far outside the realm of normalcy that it
produced a profound awareness of a significant problem. Such events signaled
that an individual had transcended the boundaries of controllable drug use.
Several indicated that they came to realize that they were not themselves and
that, as one respondent commented, “this wasn’t me.”
Cessation Strategies
The strategies that our respondents used to initiate their cessation of addiction
cluster into three general areas: engaging in alternative activities, relying upon
relationships with family and friends, and avoiding drugs, drug users and the
social cues associated with use. Of the 46 respondents interviewed, 29 reported
that engaging in alternative practices served to initiate cessation, while 28 and 23
respectively cited the importance of personal relationships and the avoidance of
drugs. These strategies are further delineated below.
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Alternative Activities
In most cases, respondents experienced a conversion to a new way of life and a
new epistemology of meaning. Respondents indicated that they became intensely
involved in alternative pursuits that engulfed them and gave them new personal
meaning. These new pursuits led to a dramatic re-alignment of their relationship
to the world that was now incompatible with heavy alcohol and drug use.
Frequently, these pursuits were religious in nature. For instance, one respondent,
a 36 year-old graduate student who had been an IV cocaine user for five years,
discovered a sense of meaning and purpose through his participation in Buddhist
rituals:
I had to redo my life. I had to recreate who I was. You have to have something
inside of you that says, “I need to be something different.” I got involved in
Buddhist religion through a friend and it changed my life. I felt that if I had some
kind of spiritual faith, that would help, and it did. Through Buddhism I really
discovered a respect for myself and found that I had the power to overcome
obstacles.
Another respondent, who described herself as having become a “personal growth
freak” explained that not only did she become actively involved in her church,
but had “mystical experiences that led to a spiritual transformation.”
While religious conversion was the most common cessation strategy employed,
it was not the only type of conversion that respondents reported. Their
absorption of non-religious ideologies and their involvement in secular
organizations were no less a conversion experience. Most of the non-religious
conversions revolved around an intense immersion into institutionalized roles
associated with education, work, and community life. For instance, a health care
worker, who years earlier had dropped out of school and sold cocaine to support
her 8-year addiction, described how important returning to school was for her:
I started school immediately after I stopped using. This was a difficult time for
me. I started a program at Metro State College and I started learning about
things. I learned about why my body went through those changes and the mental
part of it. I think I used schooling a lot as my recovery. I just threw myself into
it. Metro is real conducive to personal inner growth because you take these great
classes and you start to apply them to your life.
This respondent exchanged her former status of being a drug addict into a new
conventional role as an addiction counselor.
Other respondents immersed themselves in a variety of different activities. One
woman with a long history of alcohol problems became actively involved in a
women’s group and participated in various feminist events. Another woman
immersed herself in civic activities by taking up community service and
volunteer work. Whatever activity respondents used – religion, education,
190
community, politics, work, or physical wellbeing – it typically became the focal
point of their lives and was fervently performed. Such fervent involvement in
alternative activities suggests that these pursuits act not merely as substitutes and
replacements for addiction, but rather, represent avenues to new meanings and
epistemologies through which an individual can compose a self that is
incompatible with excessive alcohol and drug use.
Relationships
Active involvement in these alternative pursuits allowed some respondents to
enact significant relationships with non-drug users and to avoid others who were
connected to the drug scene, thereby making their conversion to a conventional
life easier. For instance, many highlighted the importance of residual
relationships as well as newly enacted ones in accomplishing their personal
transformations. In such cases, most respondents had not yet “burned their
bridges” and were able to rely upon the support of family and friends. One
respondent explained how an old college friend helped him get over his
addiction to crack:
My best friend from college made a surprise visit. I hadn’t seen him in years. He
walked in and I was all cracked out. It’s like he walked into the twilight zone or
something. He couldn’t believe it. He smoked dope in college but he never had
seen anything like this. When I saw him, I knew that my life was really screwed
up and I needed to do something about it. He stayed with me for the next two
weeks and helped me through it.
Several others claimed to have had good friends that stuck by them during their
efforts at personal transformation. One 26 year-old businesswoman who used
cocaine daily for two years explained that, “I had some very dear friends that
were very supportive and they helped me take a look internally as far as pulling
up my own willpower and making the decision to quit. I owe them a lot.”
Another reported that she, “couldn’t have made it without [her] friends.”
Others found support in their families to help them overcome their addictions.
As one respondent explained, “my wife and my children were the most helpful in
making the decision to quit. I was able to draw upon their strength.” Similarly,
one woman, who reported being abusive to her husband during her addiction,
spoke about receiving support from him when she decided to change her life. As
she explained, “I’m getting a new identity and I’m identifying who I am and
John, my husband, despite all we’ve been through, is right behind me. I look to
John for support and he gives it to me.” In another case, meeting and eventually
marrying a woman turned one respondent’s life around: “When I met my wife
Patty, I made the decision to quit drinking. Meeting her helped a lot. It changed
my life.” Another respondent, a young woman with an extensive heroin
addiction discussed how her husband stood by her:
191
I think the main reason I’m clean today is because of my husband. One day we
had a fight and he was ready to leave. He had had enough. I thought, well I’ll
just leave but I couldn’t because I was chained to my drug dealer. My husband
didn’t end up leaving but everything was packed. We even fought about which
dog we would take. I knew he felt sorry for me and he totally understood. He had
done some heroin too and had a brother die from it. My husband had been clean
for quite a while now. I knew any day that he would leave and that if I didn’t
fucking stop I was going to loose him and I didn’t want to loose him. I knew that
I finally had a really good person and I should do everything I could to quit.
The existence of such relationships made it less necessary for these individuals
to seek out treatment communities such as those found within 12-step groups.
Such groups may be considerably attractive when a person’s natural
communities break down. For many of our respondents, the conversion to a nonsubstance-dependent lifestyle was, in part, facilitated by the strong relationships
that they were able to salvage out of their years of addiction.
Avoidance
Not only did these individuals establish or re-establish connections with family
and friends, they also severed their connections, either literally or symbolically,
with the substance-using world. Many discontinued relationships that they
believed contributed to their desires to use. For women, this often meant
terminating relationships with men who were not only alcohol and drug
dependent, but frequently violent as well. One woman explained how, after
deciding to quit using cocaine and speed, she left her husband:
The last time I got high was June 23, 1987. This was the last time. It was also the
time I decided to leave my husband for good. I had left my husband once before
but this time I knew I had to get out. We started to tweak on coke and he gets his
gun and started to shoot the house up. I had to fight him over his rifle because he
thought that the house was surrounded. I threw him out for good a week later. I
was dealing for him and I knew that that was the only way to get away from the
whole scene.
Unlike men, most of these women were connected to the drug world primarily
through their intimate relationships. As is typical of drug use among women, the
female respondents were introduced to drugs by men to whom they attributed
their eventual addiction (Rosenbaum 1981). This is not unusual given that
women drug users frequently are enmeshed in a web of asymmetrical power
relations (Murphy & Rosenbaum 1997). For many of the female respondents,
empowering themselves to overcome the gender subjugation they experienced
within these relationships was a prerequisite to their independence from a
lifestyle of excessive use.
Severing one’s connection with drugs and alcohol also meant avoiding other
users. Although respondents who were alcohol dependent reported changing
192
their friends, it was more typical among the illicit drug users to avoid contact
with other drug users. This is mostly due to the fact that networks and
connections are more important for acquiring illicit drugs than for acquiring
alcohol. Avoiding friends who used drugs as well as areas where drugs were
commonly available served to remove respondents from the drug scene within
which they had been ensconced.
Breaking one’s tie to the drug scene sometimes meant a physical relocation. An
effort to terminate drug use by leaving an area is frequently referred to by those
in the drug rehabilitation field as the “geographic cure.” Such “geographic
cures” have been shown to be effective strategies among drug dependent persons
for removing themselves from a network of drug users (Biernacki 1986).
Rewards
The final stage in the personal transformation was a realization of the rewards
associated with their new, non-addicted statuses. Not unlike religious converts
who value the perceived changes in their lives that have occurred through their
conversions, these respondents viewed their cessation of addiction as beneficial.
Perceiving the benefits associated with a personal transformation appears to be
critical for self-change to persist. As with religious converts, drug and alcohol
dependent individuals must learn to perceive and value the benefits associated
with non-dependency. This is often problematic since the rewards associated
with the experience of using substances are many and include benefits that range
from the tangible, such as sexual excitement, increased energy and selfconfidence, and relaxation (Waldorf et al. 1991; Zinberg 1984), to the less
tangible such as gaining respect, demonstrating cultural resistance, and
experiencing community (Bourgois 1995).
Our respondents attributed a number of rewards and benefits to their newlyformed, non-addicted statuses. Many respondents witnessed improvements in
their family and kinship relations. One respondent was thankful for the reprieve
he received from his family. As he explained, he feels he’s been given a new
lease on life.
What benefits are there to quitting? Well I have 2 healthy beautiful children who
know the truth about their parents and their relationship and their use of drugs
and alcohol. They are empowered to express their feelings about how they feel.
I’m able to express who I am to my family, I have a passion for my life with
them…. I’m even the PTA president at my kid’s school.
Relationships with spouses were also seen as having improved. This is
particularly important to respondents who felt that they had violated the trust of
their significant others. In other cases, respondents claimed to have experienced
improvements in their relations with siblings and parents. “I have my family
193
back” one respondent exclaimed in an elated voice; “My parents are very proud
of me and my brothers and sisters have a lot of respect for me. It just feels
great.”
In addition to renewed relations with family members and friends, respondents
saw improvements in their levels of attachment to and involvement in society.
One businesswoman saw a number of benefits inherent in her transformation,
particularly in the arena of civic engagements: “I’m now very active. I’m singing
in two choruses. I’m on the Board of Directors of a non-profit agency. And I
volunteer down at a local public broadcasting station.” Other respondents found
pleasure in a wide variety of other activities. As one respondent commented, “I
write poetry, I journal, I listen to music, go to films, talk walks with friends, just
call friends and say I’m down…. I enjoy getting into conversations with people
now.”
For the most part, study participants reported just feeling better. One respondent
referred to having returned to her “former self.” As she explained, “I’m happier
now. I’m not high strung. I’m back to the person that I remember. I’m relaxed
and more easygoing.” Several believed that their self-esteem had increased while
others reported that their financial status had improved. Still others were
reflective about becoming more honest and trustworthy. Overall, they attributed
dramatic improvements in their lives as a result of their cessation of substance
dependence. Whether they re-established connections with family and friends,
became more active in their communities, or experienced greater satisfaction in
their work, all found their personal transformation affirming and deeply
rewarding.
Recovery Capital
As we have demonstrated, natural recovery from addiction among those in our
study did not occur solely as a result of their own psychological will to change.
Rather, much of the impetus and motivation to change was associated with
conditioning factors in their social environments that supported their desired
change. The process of self-resolution, as illustrated by our respondents, rarely
occurs in isolation. Instead, personal transformation is a social product that is
greatly influenced by the situational social context in which an individual is
located. The social relations that surrounded and enveloped those in this study
facilitated their recovery from addiction. Their motivations, cessation strategies,
opportunities to change, and their ultimate success at recovery were largely a
product of their social interactions with others and the related social capital
derived from these relationships. While an examination of the strategies used by
these self-remitters can be instructive to practitioners, so too can an exploration
194
of the key social and personal characteristics they shared that facilitated selfchange
The participants in this study were well-educated and employed, from stable
middle-class backgrounds, and with no obvious mental health problems. While
the interviews clearly demonstrated that they had been drug and/or alcohol
dependent they were not the stereotypic “street addict” or “skid row alcoholic,”
nor had any of them been incarcerated for lengthy periods of time. Beyond illicit
drug-related offenses, most had not engaged in the sort of street crime,
prostitution, or violence commonly associated with the world of drug addiction.
The majority had held steady jobs prior to their problematic substance use and
many remained employed during these periods, even though they had
experienced a host of problems.
These contextual conditions are critically important in understanding the use,
dependency, and self-recovery of those in this study. Such conditions can be
seen as resources or forms of capital that increase ones capacity to recover. We
refer to this collection of capital as recovery capital (Granfield & Cloud 1999;
Cloud & Granfield 2001). Recovery capital is a term that is compatible with the
ideas of social scientists (Bourdieu & Wacquant 1992; Coleman 1990; Hagan &
McCarthy 1997; Putnam 1993; Teachman et al. 1997) who have examined the
functions of certain types of resources within specific social structures. Recovery
capital is embodied in actual as well as virtual resources and includes a range of
conditions in which one exists, as well as situations in which one will find him
or herself in the future. It encompasses attitudes and beliefs that one has towards
the past, present, and the future. It includes ones mental status and other personal
characteristics that can be used as resources to resolve substance dependency.
We see recovery capital as the convergence of resources that fall within four
major classes that have been examined in the literature: social capital, physical
capital, human capital, and cultural capital. Coleman and others have referred to
such resources as assets that can be used to facilitate desired actions.
Social capital is perhaps the most potent type of resource that was available to
our respondents (Granfield & Cloud 2001). Social capital represents the
resources that are developed through the structure and reciprocal functions of
social relationships. It can be drawn upon to facilitate actions that are taken in
one’s own interest (Coleman 1990). For example, social capital can take the
form of favors owed to you, access to particular situations, emotional support,
normative expectations held of you by others that foster change, preferential
treatment of you by others, trust in you by others, to name a few. Persons
attempting to overcome substance dependencies would be drawing on their
social capital if they responded to the confidence in them and expectations held
of them by others that they would, in fact, overcome such problems. Similarly, if
one’s substance use or recovery effort had resulted in unemployment, one’s
195
social capital might be used to expedite access to other employment options
through strong or even weak social ties.
Physical capital, often seen as economic or financial capital, refers to income,
property, investments, and other tangible assets that can be easily converted to
money. Whether persons overcoming substance dependency problems remit on
their own or undergo formal treatment, they retain distinct advantages if they
have access to physical capital. Physical capital allows the substance dependent
person options and flexibility. If a decision is made to pursue a course of
recovery without formal treatment, access to physical capital can better position
the person to do so because he or she can employ a variety of recovery strategies,
including those identified by our respondents and discussed above. For example,
if he or she feels a strong need to extract him or herself from drug-using family
members, friends, or other networks, access to physical capital will increase such
opportunities.
Human capital can be conceptualized as knowledge, skills, abilities, education,
health, and other individual qualities that can be relied upon to negotiate daily
life, problem-solve, or otherwise attain goals (Coleman 1990). As was the case
for most of our respondents, having a college degree, vocational skills, or
acquired knowledge and abilities that can be drawn upon to help negotiate
personal difficulties are examples of human capital. In the context of this
discussion, human capital can be viewed as all of the personal characteristics of
a person that can be used as resources to combat his or her substance
dependency problem. In our view, access to human capital by those in our study
who were illicit drug users kept them employable and prevented them from
becoming overly immersed in the drug subculture and related street crime. It
provided them with the essential resources to negotiate conventional life while
simultaneously participating, to varying degrees, in the life of the drug world.
Finally, cultural capital embodies familiarity with cultural norms and the ability
to act in one’s interest within those norms. Cultural capital also includes values,
beliefs, dispositions, preferences, behavioral patterns, and other personal
qualities that emanate from membership within a particular culture. Cultural
capital suggests an understanding and acceptance of conventional pro-social
norms and values of a particular culture, along with a belief that such norms and
values are equitable and desirable. In typical modern industrial societies, cultural
capital could include honoring obligations to family and friends, a desire to be
self-sufficient, a belief that reaching life goals is possible, and that postponing
gratification will lead to a greater good, for example. Cultural capital promotes
feelings of being a part of a society rather than alienated from it. Persons with
high levels of cultural capital would be expected to be better able to re-integrate
into conventional life after separation from it because they “buy into” that way
of life. Conversely, those who feel alienated from the culture of which they are a
196
part would likely have fewer incentives to “join in” and perhaps limited ability to
so if they chose to.
We realize that the demarcations between these categories of capital can be
blurry and that others theorists might conceptualize these forms of resources
quite differently. However, regardless of the conceptual scheme one applies, the
major point in this discussion is that there are a variety of different types of
social and personal resources that persons possess that can be extremely
instrumental in overcoming substance dependency.
We caution the reader that mere possession of high levels of recovery capital
will not necessarily result in cessation of substance dependency. There are, of
course, many well-connected, wealthy individuals who continue to struggle with
alcohol and/or other drug problems for many years. The point is that when
persons with large amounts of recovery capital make a decision to quit, the
probability of success will generally be higher than the probability of quitting for
someone with low levels of recovery capital.
Recovery Capital and Treatment Providers
This discussion of recovery capital suggests that treatment providers should pay
close attention to the social environmental contexts in which their substance
dependent clients are embedded. It implies a hypothesis that would predict that
the more social and personal resources these clients have the greater their
capacity and chances of overcoming substance dependency might be.
Unfortunately, it also reminds us that such resources are differentially distributed
across distinct groups within any society and that substance dependent persons
with little recovery capital represent huge challenges for treatment providers.
One major way to improve treatment placement planning is for practitioners to
be able to draw the distinctions between their clients who have and do not have
access to these personal and social resources. Such client information could be
particularly useful for providing practitioners the kind of data that would help
them make more efficient use of shrinking treatment resources.
Simply calling the attention of treatment providers and substance dependent
clients to the important role that recovery capital can play in a successful
recovery effort is, in itself, extremely important. Frequently, substance abuse
assessments lead to such intense focus on clients’ predispositions for drug
dependence, extent of substance use, and difficulties related to use that the assets
to which persons have access that can bolster recovery efforts receive little
attention (Cloud & Granfield 2001). Conversely, when such assets are few, it is
essential for the client to be aware of the range of barriers and challenges ahead
197
as treatment proceeds and concludes. In doing so, more targeted and more
effective aftercare strategies can be planned.
An important advantage of collecting such data for ethnic minorities and others
from disadvantaged circumstances would be to the ability to identify the absence
of these resources; thus, documenting a need to take action to help create them
(Murphy & Rosenbaum 1997). For example, far too often African Americans
who reside in urban centers return from treatment to networks of friends in their
social environments that overwhelm their best intentions to stay clean (Brown &
Alterman 1992; Lewis et al. 2002). The lack of success at terminating substance
abuse problems among disadvantaged populations and the frustration of
treatment professionals that serve them are well-known throughout the substance
abuse treatment community. In a recent study of inner-city African American
crack cocaine users, one of the authors of this paper was surprised when several
study participants reported that they did not have any non-using friends; they
reported that all of their friends used crack cocaine and other drugs. When asked
about employment prospects, many reported that they had dropped out of school
and had no marketable job skills. Others in that study reported that their criminal
records prevented them from obtaining satisfactory employment. The most
disturbing conclusion to come from this study was that for these African
Americans (males and females alike), simply returning to their neighborhoods
after treatment was perceived as a major risk for resumed use. Therefore, it could
be reasoned that the groups who might realize substantial benefit from an
examination of recovery capital are inner-city ethnic minorities, other
disadvantaged groups, and treatment providers who work with members of these
groups. Through careful attention to these clients’ recovery capital, practitioners
would identify the major personal and social assets and deficits that could
significantly increase or decrease their probabilities of experiencing successful
clinical outcomes. Hence, assessments that include examinations of clients’
recovery capital could hold value for different groups in different ways.
Below are some of the potential advantages for collecting such data from those
with high versus low levels of recovery capital.
198
Persons Possessing High Levels of
Recovery Capital
Persons Possessing Low Levels of
Recovery Capital
Can draw upon these assets to help with a
recovery effort. (For example, a client may
need to relocate, change jobs or careers,
retool, or terminate or distance him or
herself from a substance using relationship
with a partner or spouse.)
May benefit from less intrusive, less
costly, and less stigmatizing types of
treatment.
Tangible barriers to recovery can be
identified, barriers such as lack of
education and marketable job skills, lack
of reliable transportation, and lack of
pleasant living arrangements.
Drawing on these assets can create a
greater sense of self-efficacy, a quality that
can be drawn upon to solve other types of
life problems.
Likely to have broader access to non-using
friends and other stable networks that can
be used for support and recreation.
Likely to have the ability to implement
aftercare plans once formal treatment
concludes.
Likely to have much to loose if use
continues at same destructive level because
of their relative higher stake in
conventional life, e.g., family, good paying
job, home, professional prestige, etc. (Such
perceived high stakes can be strong
motivating factors for taking action and
staying the course.)
Intangible barriers can be identified (For
example, when “getting high” is a highly
valued quality in the client’s natural
environment, such a condition could be
identified).
Relatively abstract but critical obstacles to
successful recovery can be identified, such
as little stake in conventional life or major
emotional rewards for remaining within the
drug-using subculture.
Identifying recovery capital deficits can be
used to justify more resources extended to
persons who likely have the worst
prognosis for successful recovery.
Identifying these deficits can also be used
to influence public policy and managed
care guidelines so that these guideline are
more driven by client needs than is
currently the case.
For targeting and developing strategies for
addressing highly intractable deficit
situations.
For identifying aberrant values (e.g.,
“street values”) that are incongruent with
recovery efforts and that could present
significant challenges.
Conclusion
Analysis of the qualitative data collected for this study reveals that the process of
natural recovery involves four distinct stages. Individuals experienced assorted
strain associated with their addictive use of substances, experienced turning
199
points and significant disruptions during their addictive careers that initiated a
felt need to change, undertook numerous cessation strategies, and were able to
find benefits in abstaining from use of substances. Respondents indicated that
overcoming addictive problems without treatment typically involve a process of
becoming immersed in personal relationships and social activities that are
rewarding and satisfying. What this analysis also demonstrates is that recovery
from addiction without treatment occurs when individuals’ relationships to
family, work, and other aspects of their environment improve. These
respondents’ recovery narratives demonstrate that the power that individuals
have over intoxicants, even the addictive use of these substances, is greater than
the power these substances have over individuals. Not unlike those who go
through addiction treatment, the individuals interviewed for this study
experienced a conversion to conventional social life that allowed them to live
with the world as opposed to against and above it. They all developed a renewed
stake in conventional life and in their social relationships. In a very real sense,
they converted to the spirit of collective life found within their meaningful
investments in social relationships and existing social institutions.
The natural recovery from addiction among these respondents did not occur
solely as a result of their own psychological will to change. Rather, much of the
impetus and motivation to change was associated with conditioning factors in
their social environments that supported their desired change. The process of
self-resolution, as illustrated by these respondents, rarely occurs in isolation.
Instead, personal transformation is a social product that is greatly influenced by
the situational social context in which an individual is located. The social
relations that surrounded and enveloped these respondents facilitated their
natural recovery from addiction. Their motivations, cessation strategies,
opportunities to change, and their ultimate success at recovery were largely a
product of their social interactions with others and the related social capital
derived from these relationships.
Understanding the social dimension of the transition out of addiction has
considerable utility for treatment professionals. Conceptualizing the transition
out of addiction in terms of recovery capital can help sensitize treatment
professionals to the broader life course dimensions of recovery. While a
systematic method for identifying substance dependent clients’ levels of
recovery capital remains undeveloped at this point, the authors of this paper are
currently engaged in efforts to create and evaluate the psychometric properties of
a recovery capital assessment instrument. We hope to share the results of this
effort in the near future.
200
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How Appetites Become Less Excessive:
Illustrations from the Clinic and the
Community
Jim Orford1
Background
The process of exiting addiction, recovering from dependence, or leaving off
excessive appetitive behaviour, is intriguing and mysterious. Some people are
spectacularly successful whilst others are tragically unsuccessful. The
playwright Eugene O’Neill successfully overcame a drinking problem in his late
thirties and from thereon, apart from two or three lapses, remained sober until
his death at the age of 65 (Goodwin 1988), and the Arsenal and England
footballer Tony Adams is a recent example of someone who has written about
his successful struggle against alcohol addiction (Adams 1999). By contrast, the
writer Malcolm Lowry (author of the heavily autobiographical Under the
Volcano) never stopped drinking until his death at the age of 48 from accidental
inhalation of vomit when drunk (Goodwin 1988), and the British comedian Peter
Cook died at the age of 57 from a gastrointestinal haemorrhage resulting from
sever liver damage, after drinking excessively for years (Thompson 1997). It is
not clear why some exit and others do not.
One thing is clear; people can exit addiction without the aid of expert treatment.
That is true not only in the case of addiction to tobacco smoking but also, more
surprisingly perhaps, in the case of alcohol dependence (e.g. Sobell et al. 1991)
and, more surprisingly still, in the case of heroin addiction (e.g. Biernacki 1986).
Not only is there now abundant evidence for such ‘unaided recovery’, but it also
appears to be the case that the search for a ‘best’ treatment has not succeeded,
and that a strong case can be made for concluding that all credible treatments are
effective to a more or less equal degree. That appears to the case even when
expert treatments differ markedly in intensity (e.g. treatment versus advice:
Orford & Edwards 1977) or when treatments have utterly different theoretical
rationales (e.g. 12-step facilitation versus cognitive-behavioural: Project
MATCH 1997), or even whether treatment focuses on the object of the addiction
or not (e.g. interpersonal versus cognitive-behavioural therapy for excessive
eating: Agras 1993). Nor can we hold out much hope for the idea of client1
In collaboration with the UK Alcohol Treatment Trial and Birmingham Untreated
Heavy Drinkers Research Teams
203
treatment matching which was “severely challenged” by the findings of Project
MATCH (1997, p. 1690). Lindström (1991) nicely summarised the ‘best
treatment’ and client-treatment matching hypotheses, contrasting them with the
idea that treatment worked through non-specific processes, or the alternative idea
that apparent treatment effectiveness could entirely be attributed to natural
healing processes (see Table 1).
Table 1. Assumptions regarding the treatment of alcohol problems (Taken from
Lindström, 1991, 847).
Is treatment
effective?
Do therapies
vary in efficacy?
Is there a superior
therapy?
The technique hypothesis
Yes
Yes
Yes
The matching hypothesis
Yes
Yes
No
The non-specific hypothesis
Yes
No
-
The natural healing hypothesis
No
-
-
What might those non-specific or natural exit processes be? Many students of
exit processes in the addictions have concluded that the central process is a
cognitive one which is variously labelled, ‘resolving’, ‘decision making’,
‘strategic’ or the like (e.g. Armor et al. 1978; Sobell et al. 1993). It is argued
that some higher mental process is necessary to override the ingrained, habitual,
at least partly automatic nature of addictive behaviour (e.g. Hunt & Matarazzo
1973). The present author’s construction of addiction as ‘excessive appetite’
(Orford 2001a, b) fits with the idea of change as decision making. According to
that view the individual faces a choice between behavioural options, but the
decision to be made is a particularly difficult one because good intentions are
opposed by an attachment to the addictive object which may have grown to
considerable strength. Exit changes are therefore best construed as difficult life
decisions. The transtheoretical model of change (e.g. DiClemente & Prochaska
1982), which has become a leading model of change in the addictions, also has a
strong cognitive element (stages such as precontemplation and contemplation;
and processes such as self-liberation and self-re-evaluation) but also includes
behavioural elements (stages such as action and maintenance; processes such as
counterconditioning and stimulus control).
An advantage of such cognitive or cognitive-behavioural models of change is
that they offer us a unified way of thinking about change which might equally
204
apply to different forms of addiction which otherwise might be thought of very
differently (e.g. tobacco smoking and heroin use) and which might apply equally
to processes occurring in the clinic and the community (i.e. whether or not
change is aided by expert help). Such models have been criticised, however, for
omitting what are thought by some to be essential elements. From the
perspective of the excessive appetites model, I have argued (Orford 2001a, b)
that these difficult life decisions are made in a social and cultural context, and
that purely cognitive or cognitive-behavioural models therefore omit at least
three vast domains of human experience that cannot be ignored: the social, the
spiritual, and the moral. Nearly thirty years ago, Bacon (1973) saw the
importance of the social when he wrote, “The recovery personnel of prime
significance are the associates, the significant others… not the specialists during
formal ‘treatment periods’ ” (p. 25). Drew (1990) observed, “We have produced
a psycho-bio-social model of drug dependence that excludes the essence of
human existence – options, freedom to choose and the centrality of value
systems” (p. 208). Miller (1998) has written of the neglect of the spiritual
component in the theory and practice of addictive behaviour change despite its
clear presence in the philosophy of Alcoholics Anonymous and other 12-step
programmes. Gusfield (1962) went so far as to suggest that giving up addiction
was a process of “moral passage out of deviance”. Much more recently McIntosh
and McKeganey (2002), having interviewed people who had successfully given
up illicit drug use (most but not all had received some formal treatment),
concluded that the management of personal identity was central to the change
process: “It appears from our study that at the heart of most successful decisions
to exit drug misuse is the recognition by individuals that their identities have
been seriously damaged by their addiction and the lifestyle that accompanies it”
(p. 152).
The present paper aims to explore exit processes further, using material from two
complementary studies in which the author and colleagues have been recently
engaged. Both involved comparatively unstructured interviews with individuals,
some of whom had recently experienced a marked reduction in alcohol
consumption which had previously been very heavy or excessive. One study
draws on interviews conducted two years after participants joined a cohort of
untreated very heavy drinkers (the community study). The second draws on
interviews with clients of alcohol problems treatment services twelve months
after entering treatment (the clinic study). The particular focus of the present
paper is the interplay of naturally occurring and professionally aided processes.
205
The data
The Community Study
The present paper draws on data from the second wave of a cohort study of
untreated heavy drinkers. At the first wave in 1997, 500 heavy drinkers (men
drinking 50 or more standard units of alcohol most weeks, women 35 units or
more) living or working in the West Midlands metropolitan county of England
took part in a two-hour interview, part of which was comparatively unstructured
but focused on one of a number of sub-topics of interest (Dalton & Orford 2001).
Eighty-one per cent were re-interviewed in 1999 using a similar procedure. For
30 consecutively interviewed participants the less structured but focused part of
the second interview was devoted to exploring whether change had occurred
since the first interview, and if so to what change was thought to be attributable.
Seven of the 30 reported substantial reductions in drinking which had lasted for
at least several months, and it is on the accounts of those seven that the present
paper draws. The data consist of detailed post-interview reports prepared by
interviewers within a few hours of the interview taking place. Interviewers were
trained to write reports that included all the points made by the interviewee,
including exact interviewee quotations where they were useful to clarify or
illustrate a point2.
The Clinic Study
These data are taken from 12-month follow-up interviews conducted with
participants in the United Kingdom Alcohol Treatment Trial (the UKATT
Research Team 2001). The latter is a multi-centre alcohol problems treatment
trial involving approximately 750 clients of a number of specialist treatment
services in England and Wales. Two treatments were compared: Motivational
Enhancement Therapy (MET) based on the assumption that successful change is
essentially cognitive; and Social Behaviour and Network Therapy (SBNT) based
on the assumption that change is essentially social in nature, requiring social
support from others (UKATT Research Team 2004). The research interview at
12-months follow-up included a less structured section, approximately 20
2
Although audio tape recordings of these interviews were made for purposes of quality
control, audit, and more detailed later study, our research group has developed a
method that includes training interviewers to take detailed notes during an interview
and to write full reports shortly afterwards. We find this to be an economical method
of carrying out qualitative analysis. When interviewers write reports they are in effect
beginning the process of data reduction and analysis. Checks on this process suggest
that very little is lost in this process provided the analysis is one that focuses on the
content of what is said (e.g. the grounded theory approach) as opposed to the form of
what is said (e.g. discourse analysis or conversational analysis).
206
minutes in duration, which focused on the participant’s perception of change in
drinking and, where change had occurred, the factors to which change was
attributed. The present paper draws on seven interviews carried out in the middle
of the trial series at one of the trial centres (the West Midlands). These were
consecutively conducted interviews with the exception that those involving
participants who reported no change in their drinking (approximately one third)
were excluded. Data are again based on post-interview reports written by
interviewers.
Findings
Community Study
The seven interview reports from the community study that were examined in
detail for the present paper suggested a process of change that was usually multifaceted. Although reference was made to mental processes, including the making
of decisions, change was often attributed to changes in life circumstances
(particularly changes in relationships, friendship networks, and employment) or
to life events (particularly those related to illness and health). Even though the
sample was part of a cohort of originally untreated heavy drinkers, and only a
small minority of the cohort had actively sought advice or treatment (9%) or had
received direct professional advice to reduce from their general medical
practitioners (18%) between the first and re-interviews, it was the case that some
professional intervention was mentioned in all but one of the seven reports
(although it was usually little emphasised). The following is a good example (in
all the quotations that follow, some details have been omitted and others changed
in order to protect anonymity):
P [participant] developed pains in her chest around September 1997 [21 months
previously] and had to have several tests as an inpatient in hospital. She became
very concerned about these pains and although the tests were not conclusive she
was advised to reduce her drinking and smoking. She felt that if she had carried
on with her previous habits that “I am not going to last very long”, and as her
first granddaughter was born around the same time she felt that she had to make
changes in her life if she wanted to see her granddaughter grow up. She has
subsequently reduced her consumption considerably. She also attributes her
reduction to the fact that she took up a full-time job at that time and found that
she was too tired to drink the same quantities as before when she worked parttime. She felt that she was capable of reducing without support as she “is not an
alcoholic”. If she got up in the morning and needed a drink then she might have
sought support, but as she didn’t she felt that she could manage on her own.
That was the only one of the seven accounts of substantial drinking changes in
which direct professional advice to reduce drinking was mentioned. Note,
however, that the advice was about smoking as well as drinking; several other
207
circumstances also altered which made life change desirable; and the participant
described the change in drinking as having occurred without support. Was this,
therefore, a case of naturally occurring change? Were cognitive processes
central? Was change professionally unaided or aided? The answers to these
questions are even less clear in other instances. Take the following example:
At the time of the last interview [22 months ago] P was on a diet. P contends that
his doctor had been “going on at him” for years to lose weight but he only
decided to diet at this time as he found that his clothes were no long fitting him.
His wife was on a diet at the time and P therefore thought that it was a good
opportunity to attempt to lose some weight as she was preparing low calorie
foods for herself anyway. As alcohol has a high calorific content P had to reduce
his alcohol consumption in addition to his food intake… P’s wife unexpectedly
left him in October 1997 [20 months ago]… P abandoned his diet… However,
whilst P resumed his normal eating habits he maintained his reduced alcohol
intake as he “realised he didn’t need them (the additional 4 pints a day)”. P
contends that normally he would have “gone off on a drinking binge” after such
a trauma… P is unable to explain why this didn’t occur on this occasion but feels
that “perhaps he has grown more sensible with age”. P’s alcohol consumption
steadily declined until December 1998 [6 months ago] when it suddenly
plummeted. At this time many of P’s friends had been caught drink driving
around P’s local pub as the police had increased their profile in the lead up to the
Christmas drink drive campaign. P therefore became extremely worried that he
may get caught and convicted of drink driving as he regularly drank heavily at
the pub and then drove home (P is unable to walk to the pub as he has a
disability). P started drinking an alcohol free beer and found that he actually
preferred the taste to his usual brand of beer… P feels that in some respects he
actually prefers being sober at the pub as it gives him the opportunity to “watch
all the other idiots”. P reports that his acquaintances at the pub are all aware that
he has drastically reduced his alcohol intake and have congratulated him rather
than ostracised him.
Although there is reported to have been drastic reduction in alcohol
consumption, noted by others as well as by the participant, note how a drinking
change in this instance is portrayed as being secondary to dietary change and
weight loss. Can this be said to involve cognitive change regarding alcohol
consumption at all? In view of the fact that the participant’s doctor has been
advising him for years to lose weight, and the biggest reduction in consumption
occurred at a time when the police were particularly active in a prevention
campaign, can change be said to be unaided? The following example also poses
the question: When is change to be considered unaided? It also adds the
complicating factor that changes may not be permanent even though they may
have lasted for several months:
By about November 1997 [19 months ago] P’s drinking had reached a plateau
and was being maintained in the “very high region”. In January 1998, P decided
that he was drinking too much as he felt he was becoming physically dependent
on alcohol as he was getting the “shakes in the morning and needing to take
more and more alcohol”. P therefore decided that he needed “a break from it”. P
contends that drinking is “all or nothing” with him and that he either drinks
heavily or he remains completely abstinent. Rather than reducing his alcohol
consumption, P decided to stop drinking completely but emphasises that it was
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only his intention to give alcohol up on a temporary basis and that it was not a
permanent cessation. P’s wife obtained some medication from his GP [general
medical practitioner] in order to make “detoxification” as easy as possible.
However, P reports that whilst his GP knew that he was giving up alcohol he
received no visits from any health care professionals during this time. At the
same time P also gave up smoking. P reports that smoking and drinking “go hand
in hand” for him and therefore when he gave up alcohol he didn’t really feel the
need for cigarettes. [P remained abstinent for about 6 months when his drinking
started again and rose sharply to a very high level. A further 6 months on P again
is reported to have decided that he was drinking too much and once again
stopped completely, now describing himself as a binge drinking who is “quite
happy when I am drinking and quite happy when I am not”. P had been abstinent
for 6 months at the time of the second interview].
In the foregoing example, note the implication that a higher mental process was
involved (what the interviewer called a ‘decision’), but also the reference to the
intervention of P’s wife and his GP. Note also how those interventions are
depicted as almost incidental: what P stresses is the lack of direct contact with
health care professionals.
The Clinic Study
Despite the very different way in which the sample for the clinic study was
recruited (attending a specialist treatment clinic rather than volunteering for a
University interview study), clients’ accounts of change were equally
challenging to existing models of change. Preliminary analysis of a larger
number of 12-month follow-up interview reports (Orford et al. on behalf of the
UKATT Research Team, 2004) had already identified cognitive processes as a
major theme (a category we referred to as ‘thinking differently’) as well as use
of behavioural techniques (‘acting differently’). Other core categories were:
‘catalyst, triggers’ i.e. notable events or crises to which change was attributed
(e.g. getting breathalysed; being told I was stupid when drinking; had argument
with mother about drinking); ‘down to me’ (statements indicating that clients
believed it was only they themselves that could effect change e.g. couldn’t have
someone hold my hand all my life; realised I had to try myself; I have to take
responsibility); and ‘life goes on’ (indicating the way circumstances might assist
change). A particular challenge, and one that is of most interest here, was the
role attributed to the experience of professional treatment.
Some clients left interviewers in no doubt that the specialist treatment they had
received as part of the trial had been effective. Even then, however, the process
was depicted as a complicated one in which treatment had played a definite part,
but only a part. In the first example treatment was thought to have assisted a
process of greater awareness which had already started:
When I asked how he managed to cut down the drinking in the first place he said
“self-awareness”, and “from coming here, becoming aware of what a unit was”,
209
and to “really examine it”. He reported “seeing alcohol in a different way”, and
explained how he’d see units instead of bottles of alcohol. His motivation to seek
help for his drinking had been to “get ready” for a triple bypass op, which was in
fact then delayed for nearly a year, and to lose weight. The latter was a major
factor as his GP and consultant both told him to give up drinking and lose
weight. That is where his “awareness started” as he hadn’t seen anything wrong
with his daily 4 cans. The GP referred him to the centre. I asked what it was
about his treatment at the centre that had helped. “The questions, the talking,
being honest, being open – that was positive”. He spoke of the importance of
honesty. I asked if anything else perhaps more specific had stayed with him
from the treatment and he mentioned “costings of alcohol”, as he “didn’t used to
think about how much it was”.
In the following example, the client spoke positively about treatment sessions
and his therapist, and saw treatment as having played a significant role in
encouraging an important life change, but treatment was not clearly identified as
the most important factor:
This client’s life has completely turned around in the last 12 months… He had
been living in a house “full of lodgers” who were “lads” and there was “no way”
he could control his drinking then. He confirmed that the sessions directly led to
this move… It was the “counselling” that encouraged him to go and this was “a
big step”… I asked more about the sessions: “I felt as if I was being listened to”.
The therapist “understood me”… I asked what the main factor was in helping
him control his drinking and he said “becoming a father”, which he said is
“brilliant”. Now with the drink “I can take it or leave it”… Before the pregnancy
it wasn’t controlled, but then when his partner was expecting he felt “I need to
control it before the baby’s born”. He said when he came for treatment his
partner was pregnant. “You’ve got this big responsibility – scary for me – it’s
just hitting you”.
In other instances treatment was acknowledged to have had some beneficial
effects, but it was clearly stated not to have been sufficient in itself, and
sometimes change had been delayed until other events had taken place. In the
following example treatment had made the client think about her drinking, but
the turning point came, she said, when she enrolled for further education:
At the start of the period C [the client] had been “really worried” about her
drinking and had come for three or four sessions at the centre, after which she
“didn’t feel any different… felt exactly the same”, and her drinking didn’t
change. She became “more and more worried” and “wanted to change things…
wanted to turn my life around”. So she enrolled at college. When she started the
course she was still having a drink each evening and realised she wouldn’t get
through it drinking each evening, due to the homework etc. So it “didn’t happen
overnight” but she “did cut down”. Her course is a complete retraining and
“that’s what helped me go forward. I just made my mind up”. She realised the
choice was either death or change… I asked what other factors helped: “the
children – I didn’t want them to just think it was normal: drink in the house, their
mum drinking and their dad drinking”… About the sessions again she said “the
one thing that came from it, it made me think a lot more”. She said that although
she didn’t stop her regular evening drinking, in the morning she would be
thinking about giving up. I asked what it was about the sessions that made her
210
think more: “because I took that step and done it, spoke to someone”. But she
said how she “made promises and broke them”.
In the example that follows there is a clear description of how treatment,
involving the client’s wife, had assisted family communication, but also an
indication that the treatment had not been enough:
He went on to talk about how he’d given up drinking: “it’s coming to terms with
it yourself”, and he spoke of recognising there’s a problem, “focus in” on it, etc.
He said “I feel sorry for the people who were in denial”. I asked if he’d been “in
denial” and he said “I’ve known for a long time” there was a problem, but it was
when “I admitted it to myself” that he crossed the “main hurdle”. He spoke of
talking to other people about it and I asked about this. He said how he had seen
the counsellor and “… [wife] got involved which helped”. I asked in what way.
He said that she’d realised there was a problem but didn’t say anything: he said
that before the treatment they were “frightened of talking together” about the
problem. He talked of how the counsellor explained the problem to his wife, and
that you “need a trained counsellor” to do this as “you can’t explain it yourself”.
C spoke about cutting down during therapy, but once it was finished he carried
on drinking until he had a home detox after which he stopped drinking for 6
months. I asked more about how treatment might have contributed and he said he
“did try the things suggested [but they] didn’t work for me”… He said how
“counselling made sense of it… just what you’re doing to yourself and what
you’re doing to your body”. But he said that “sometimes knowing that isn’t
enough” and you “need another motivation”. I asked what his other motivation
was and he said “I wanted to be more in charge”, and he talked about only
“waking up at lunchtime” even though he had been physically up since 8, how
he’d be on “automatic pilot”, and how all that changed when he gave up.
In the last example the benefits of treatment are acknowledged but take second
place to social and friendship support:
C is single and lives with her sister. She has been abstinent for 12 months: “it
was hard at first to give up” and she explained that “you’ve got to want to do it”.
I asked how she had succeeded and she said by “keeping myself occupied”. She
had talked of going to bingo, knitting for charity, reading, helping an elderly
friend, attending the day-centre. She said “it was boredom that started the
drinking”… The client had said previously that the day centre was extremely
important to her, so I asked further about how it had helped and she said “the
company, the confidence to go up to a stranger and hold a conversation”. Before
“I wouldn’t”. She said she was “always in the background” and that she
“couldn’t hold a conversation”… I asked if there were any other factors that had
helped her give up drinking, she said “healthwise” and explained “I knew I’d got
liver problems”. She spoke of having more energy and “I used to sleep a lot”…
Asked if there was anything else, she added the support of friends and that “T [a
friend] would tell me straight away if I’d had a drink”. I asked how this support
had helped: “If I had got a problem I could go and talk to them”… It was [also]
quite easy for her as her sister doesn’t drink… I asked about the treatment, for
which she had previously said she’d had three sessions, and she said she found
them “very helpful”. I asked in what way, she said “just sitting down and
talking”, and specifically this helped by talking about “how I was feeling, how I
was giving up the drink”. I asked what contribution she felt the treatment had
made in her success at giving up: “it was a main factor”. I asked if there was
211
anything from it that had been helpful to her over the whole 12 months. She said
“it was just the beginning”.
Discussion
Not everyone would accept that people have sufficient insight into how they
change to make it worthwhile to ask them directly. I have always thought, on the
contrary, that psychological research could profitably have done more in the way
of asking people directly about their experiences. I therefore welcome the move
towards qualitative research methods in psychology (Willig 2001). I believe that
I am an expert when it comes to my own change processes, and I would hope
others would treat me as such. In any case when it comes to change in the
addictions, I imagine there are not many people who would claim that the
professional experts have all the answers. Assuming that the people whose views
on their own change have been summarised above might hold some insights into
how people exit from excessive behaviour, what model or models of exit
processes do they support?
Change as Personal Life Decision
Reports of interviews in both the community and the clinic studies were full of
statements that are in keeping with the idea that exiting an addiction is a matter
of the individual concerned applying some higher mental process which enables
behavioural change to take place. One participant thought she would ‘not last
very long’ unless she changed, and another was said to have decided that he
needed ‘a break from it’. A client in the clinic study reported ‘seeing alcohol in a
different way’, another became ‘more and more worried’ and realised that she
had a choice between change or death, another ‘came to terms with it’, and
‘admitted it to myself’, and another explained that ‘you’ve got to want to do it’.
Sometimes there was an indication that these changes in thinking had been
triggered by experiencing ‘the shakes’, having liver disease, or needing to
prepare for a major operation.
None of this is new or surprising. It fits with what many others have concluded
(e.g. Armor et al. 1978; DiClemente & Prochaska 1982; Sobell et al. 1993). It is
also in keeping with the excessive appetites model of addictions (Orford 2001a,
b) which sees conflict between opposing motives as constituting the core of
addiction, and construes change as a form of decision making. In no instance,
however, was change attributed solely to such cognitive processes. It appeared
that participants in these two studies did not subscribe to a view of change that
sees it solely in personal, cognitive terms.
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Change as Circumstantial, Opportunistic
There is support also in these accounts for the view that exiting occurs because a
person’s situation or circumstances have changed (Waldorf 1983). Change was
attributed to starting a full-time job, embarking on a significant educational
course, attending a day centre, or keeping occupied in various ways. One person
attributed change to anticipating and then becoming a father, and another to
becoming a grandparent. Another attributed it to making an important
accommodation change. Sometimes such circumstantial changes were
highlighted, giving the impression that the person considered such changes in
circumstances to be the main factor involved in changing drinking. This reminds
me of one of the findings of our treatment versus advice study: clients more
often attributed change to ‘change in external realities’ e.g. work or housing,
than to the treatment they had received or to any other single factor (Orford &
Edwards 1977).
An element of changed circumstances, emphasised by some, was removal from
social pressure to drink, or alternatively living with someone who did not drink,
or having family members or friends who encouraged changed drinking
behaviour, or to whom the person felt free to talk about drinking.
Change as Part of Wider Lifestyle Change
There was repeated reference in these accounts to changing drinking as an
accompaniment to changing diet and reducing weight, and in other instances to
changes in smoking. There was at least one example of change in drinking being
described as if it was secondary to wider dietary change. One participant in the
community study hinted at wider change when he suggested that drinking change
might be due to having ‘grown more sensible with age’. The latter is in keeping
with the often cited suggestion of Winick’s (1962) that addicts frequently
‘mature out’ of addiction. The idea that drinking change might be part of a
broader change in lifestyle behaviours, and even sometimes secondary to other
behavioural changes, has not, to the present author’s knowledge, been much
noted. There has, however, been at least one study suggesting that treatment
targeting smoking might have a positive effect on drinking (Bobo et al. 1998).
Change as a Process Requiring Expert Aid or Treatment
It was a particular aim of the present paper to explore the role that expert
interventions might play. My very provisional conclusion from studying these
quite small numbers of interview reports from two studies are: 1) That
213
professional intervention is more ubiquitous than might be supposed – it crops
up often, and not always when one would most expect it (i.e. it occurs in the
community as well as in the clinic); and 2) When it is thought to have played a
part in change, it does so in a variety of ways, small and large, and does not
always do so in ways that we would expect.
It was not only in the clinic study that participants acknowledged some
professional influence. But that influence was rarely in the form of the often
recommended clear advice from a person’s general medical practitioner. Of the
three community study participants cited earlier, one said she had been advised
to reduce drinking and smoking as a result of hospital tests, and another
described how his doctor had been ‘going on at him’ about his weight, and also
acknowledged the role of a more vigilant police campaign against drinking and
driving, whilst the third referred to his wife obtaining medication from his GP to
help him with detoxification.
Treatment clients in the clinic study variously spoke of being helped to “see
alcohol in a different way”, making her “think a lot more” about giving up, or
making “sense of it, what you’re doing to yourself”. A further client appreciated
talking about “how I was feeling, how I was giving up the drink”. But that was
mostly seen as secondary to personal decision making (e.g. “it’s coming to terms
with it yourself”), wider lifestyle change, or to circumstantial changes such as
changes in housing, occupation or social support for drinking. It was sometimes
said to be “not enough” or “just a beginning”. In other instances treatment was
thought to have been helpful, not in promoting changed thinking, but by
encouraging social changes. For example, for one client treatment had been
influential through helping explain the problem to his wife, and for another it
was the counselling that had led to him taking the big step of moving away from
pressures to drink.
A tentative conclusion, therefore, is that no single model of how people exit an
addiction is likely to fit all cases. Thinking differently about the object of the
addiction is often thought to be important, and expert treatment can aid that
process. But change can be supported by changes in life circumstances, lifestyle
or one’s social network. Professionals can lend a helping hand in many different
ways, and the distinction between expert forms of ‘treatment’ and other helpful
interventions is not clear-cut. These provisional observations need to be tested
with further data from the BUHD, UKATT and other research projects. In the
meantime they represent a challenge to received wisdom about change processes
which, for example, focus solely on cognitive change, on expert treatment, or on
unaided change.
214
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216
Post-Traumatic Growth in Relation to
Substance Misuse
Anthony Hewitt
Much of our work with addictions is focussed on illness rather than health, and it
appears that we understand illness and vulnerability far better than we
understand health and coping. We also know that most people do recover from
their addictions to alcohol or drugs, perhaps some 80% of them without
specialist help or support (Cunningham 1999), though we still have much to
learn about how this happens. There are sometimes conflicting views (Ebersole
& Flores 1989, 463-4) within psychology of the implications of life crises (such
as addiction). On the one hand is the view that this kind of suffering is damaging
and is to be avoided; and on the other hand is the view that painful experiences
can be a gateway to positive growth.
There has been relatively little formal, academic or scientific examination of the
potentially growth-promoting aspects of life crises, either of the types of positive
outcomes that may occur following crises, or how the characteristic factors of
the crisis and associated personal and environmental factors affect the likelihood
that any individual will experience psychological growth as a result. The
emphases of practitioners and researchers have generally been on the problems
associated with life crises and transitions, with a good outcome being equated
with the absence of physical symptoms and psychopathology. The possibility of
a new and better level of adaptation in response to unusual life events is rarely
considered.
Post-traumatic Growth
There is a growing body of published research in the wider arena of PostTraumatic Growth (PTG), but still very little in this area specifically in relation
to substance misuse. An area where this phenomena has been recognised is in the
12-step literature, e.g. the AA concept of gratitude (Whitfield 1984a, 45),
relating to recovering alcoholics view of their alcoholism as a gift that brought
them to a better state than before. There is also the work of William Miller and
Janet C’ de Baca (1994, 2001) in their study of Quantum Change, i.e. enhanced
growth after some trauma or crisis, and McMillen et al. (2001).
There are a number of theories and models as to the ways in which life crises
and transitions can be an impetus for psychological growth. Some common
themes emerge in the existing literature, and are well worth considering. There is
219
a significant amount of cognitive turmoil and emotional distress. There is a large
amount of ruminative thought devoted to trying to restore some degree of
cognitive balance, and there is an increase in coping devoted to reducing the
level of emotional distress. Social influences may serve to enhance or impede the
process of adaptation and of possible post-traumatic growth. For many clients,
post-traumatic growth is incorporated into the individual’s identity and life story,
with the event serving as a marker event that divides the individual’s life into a
before and after (Calhoun & Tedeschi 1999, 22).
There are a wide variety of interventions, actions and strategies that can support
growth and development on all levels, and there is much potential in increased
awareness and experience of using these. Several authors (e.g. Bewley 1993;
Whitfield 1984a,b,c; Grof 1987; Small 1987; Sparks 1987; McMillen et al.
2001) have written about growth beyond ‘just’ abstinence or management of the
problem, often describing theoretical frameworks and specific practices and
techniques that help both with management and recovery of the problem and
promote further and wider growth (e.g. self-esteem enhancement strategies,
meditation, self-improvement training, exercise, visualization, and a wide
number of strategies from the transpersonal therapies). There is much that can be
mined from this, from the wider field of PTG, and from other existential and
transpersonal approaches.
This chapter discusses some of the findings from an ongoing series of connected
studies in the UK by the current author (e.g. Hewitt 2002), largely focussed on
PTG effects relating to addiction. It is concerned with beginning the process of
exploring and understanding the experience and phenomenon of enhanced
growth in the management and recovery of dependency and addiction, on what
happens and how.
Findings
The qualitative findings reported here are combined from two separate studies,
one completed and one still ongoing, both of which researched PTG effects in
samples who had overcome problems with drugs or alcohol. Subjects were
predominantly White British, but otherwise mixed in gender, age and education,
and several were now working in the area of addictions. About a third had a
history of problem alcohol use only, the others were poly-drug users, with heroin
the biggest factor. The majority had managed without any specialist help. They
were recruited through media advertising and chain-sampling. Data was derived
from primary analysis of 10 interviews and secondary analysis of another 11, all
using Grounded Theory.
220
There are clearly benefits in having overcome an experience of addiction or
dependency just in terms of no longer having to cope with the stress and troubles
involved. Extra to the reduction of negative consequences though, were numbers
of other ‘benefits’ identified by the sample, coded into the four closely
interlinked areas of Maturation, Increased Perspective and Experience,
Liberation and Fulfilment.
Maturation and Responsibility
All the sample felt they had a greater degree of maturity. This was both as
perceived by themselves and perceived by others. This was manifest in both the
emotional arena – for example in a number of the attributes discussed further
below – as well as the practical/domestic arena. The latter was visible in a
number of accomplishments that were often identified as ‘grown-up’, e.g. having
jobs, paying mortgages, being a responsible parent, and sustaining other ‘adult’
functions.
A life devoted to drugs or alcohol can often be very stressful, demanding,
unpredictable, crisis-ridden and dramatic. Many marked a contrast between the
‘craziness’ of their previous lives and the calmness, stability and sanity that was
more characteristic of their current lives.
It is likely that all people experience a tension at times between what may be the
‘responsible’ thing to do or be at any one time, and what may be easier or more
pleasant. The sample were clear that this balance had changed considerably for
them, in that they had often been highly irresponsible (by almost any standards)
but that this was very different now.
Additionally, many of the sample felt more responsible for how their lives were
now, in contrast to the passivity, disengagement or sense of being a victim that
had characterised their past. The necessity of taking responsibility for one’s life
has often been identified as a crucial step in managing and overcoming
addictions (particularly in the 12-step fellowships and featuring in the personal
stories of ex-addicts). This appeared to be for a number of reasons. Such a belief
is more empowering, in that the power does not then lie elsewhere, and the
person is more likely to attempt change within their sphere of influence.
Additionally, there is more scope for positive impact with the expansion of that
sphere within which the person feels responsible and effective.
221
Increased Perspective
This range of benefits could be loosely grouped into a number of interconnecting
themes affecting the person, their beliefs and attitudes, and their relationships,
including an increased range of life experience, being less judgemental,
increased self-awareness, possessing the benefits of contrast, and having had the
experience of success.
Many felt they had gained an insight in to other ways of living and had a more
rounded picture of the ways of the world (than the general population), and
which for some had encouraged useful reflection on their own lives. Others felt
that their lives had needed a radical change and that such a big shake-up had
been necessary in order to realise that. Implicit in this wider perspective on the
world was that they were less judgemental about others, often because they knew
well how easy it was to make mistakes, and how difficult it can be to correct
them.
Increased self-awareness and understanding was often identified, together with
increased acceptance and comfort with themselves. As well as being generally
less critical, demanding and judgemental of themselves, this was sometimes
focussed on becoming aware of, understanding, and integrating and living with
less desirable elements of the personality. This also related to more acceptance
and less judgement of others. All were aware of just how bad things could be,
and were therefore more grateful for what they did have, more inclined to seek
the positive in their circumstances and be more appreciative. For some it was
now easier to deal with and accept the set backs in life. Because they had had the
experience of overcoming this particular set of problems, they had the belief and
confidence that problems in general – often no matter how bad – could be
overcome.
Many had been obliged to discover alternative coping strategies to those
involving drugs or alcohol. Many of these alternative coping strategies were
positive and growth promoting in their own right. Positive recovery strategies,
such as thinking and acting positively, were reinforced, and their continued use
contributed to other areas of benefit. Others found ways to channel existing
behaviours such as risk taking into more productive areas. One example of an
alternative strategy for dealing with problems was undertaking counselling or
psychotherapy. Many had ended up being in (non-addiction-focussed)
counselling in an attempt to understand their experiences, and had learnt a great
deal from this. The tools acquired in counselling could then be applied by the
person themselves as they chose.
222
Liberation
Many of the sample felt liberated and born-again, free to live life as they felt
right. A lot of energy is tied up and expended in substance use and the associated
lifestyles, and substance use itself saps and undermines people’s energy. When
this changes, for some there is a considerable amount of energy released, as well
as the regaining of shut-down energy. Many had never felt so energised. Often
associated with this release of energy was a considerable drive. Many drug and
alcohol users devoted considerable drive and energy to their addictions, but at
some point many began to feel driven to recover. The need to escape from the
unpleasantness for many gave a very clear focus and direction, a drive to escape
– at least in so far as it was clear what they were moving away from. This was
often not a straightforward process, with a number of false starts, etc, and a
variety of trajectories, and it wasn’t always so clear – at least at first – what they
may be moving to.
What was noticeable in this sample was that the move away often gave rise to a
forward momentum that subsequently became more focussed on the drive to
develop. It is the momentum and degree of this that often appeared to take them
to the particular levels of growth and development that so many reported. This
push/pull did not appear to be so much a conscious strategy – though it could be
consciously worked with and fostered – but something much deeper, like a drive
or instinct.
‘Starting again’ also allowed a more conscious and explicit choice of factors that
would support development, particularly within the social-psychological context.
All the sample were able to identify considerable difference between the
characteristics of their past and their present in terms of their friends, partners
and acquaintances, and in the quality of the associated relationships. For many
there had been a conscious decision to change the type of people that they
interacted with and the manner of these relationships. This strategy in itself
supported further growth and development across a number of domains.
There was a distinct contrast between their current healthier ways of relating
with more functional people as compared to their previous dysfunctional
relationships. Most of the sample accepted that they had either behaved
dysfunctionally themselves or chose dysfunctional people for their own
unhealthy reasons, e.g. choosing needy and dependent partners in order to feel
wanted or in control, or incompetent or ‘untogether’ partners in order to feel
more competent. The ‘new’ positive relationships were viewed as satisfying,
relatively equal, interdependent rather then co-dependent, and mutually
supportive.
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Fulfilment
The issue of fulfilment was often important, if not essential, and many felt
generally fulfilled in their lives, particularly in relation to their work, which was
often experienced as both satisfying and meaningful, and less in contrast to the
rest of their life than it might be for someone who largely worked to survive.
Work tended to be one of a number of elements in the person’s life, and several
were working less hours than typical, or in a more flexible way in order to have
time and energy for the other things that were important to them. Examples of
these were creative pursuits, learning opportunities, the fulfilment of dreams, etc.
Fulfilment was a positive outcome, but the seeking of fulfilment continued to be
a goal, giving a positive focus and direction to further development and growth
beyond just moving away from addiction.
Several of the respondents worked within the drug and alcohol field. All this
section of the sample reported being particularly fulfilled by their work, and
many were grateful for their addictive experiences for bringing them to an area
of work they found so satisfying and interesting. Working with addictions also
gave a positive use for all the accumulated experience and knowledge, and
allowed people to feel that they were ‘giving something back’. Additionally, for
some the processes of training and development involved directly triggered
personal growth. The findings in this area correlated well with existing research
(e.g. Brown 1991; Klingemann 1999, 1514-6; Klingemann et al. 2001, 106)
focussing on the transition from deviant careers to associated professional ones.
No Regrets
Of interest was a commonly occurring set of views about the meaning of such
experiences in the context of the person’s life, specifically that they would not
wish for their past to have been different, as it had contributed significantly to
the person they were today. Indeed, without having gone through these
experiences they would not have developed as a person to the degree to which
they had. As such, the period of problematic substance use was not a ‘detour’
from the life-journey, but was in fact an integral part of it.
I wouldn’t change my life with you or anybody else…meeting people who are
much further down in recovery I don’t think most of them would change it
(#5:8,9)
I don’t regret it actually, I don’t regret it because I’m quite happy with most of
me now and its part of my experience…I learnt a lot, I probably wouldn’t have
learnt half the things I’ve learnt…I learnt a lot about myself and a lot about my
relationships with people… (#11:7)
224
Some subjects went so far as to say that such transformative experiences were
desirable, a view echoed in some of the psychotherapeutic literature (e.g.
Campbell 1949, 105; Grof 1987, 14; Jaffe 1985, 102; Hillman & Ventura 1992,
50; James & Samuels 1999). There was even a view that those who had not had
such experiences to force them to grow were in some ways disadvantaged.
Whether there is any validity or not in the theory that transformative crises such
as these are desirable or necessary, there may be benefit in framing them in this
way (after the event) in order to gain as much as possible from them.
Discussion
This research has thrown light on some of the experiences, outcomes and
strategies of those who have experienced PTG and addiction. It is intended that
the next phase will be more focussed on attempting to clarify in more explicit
detail the processes involved in PTG and addictions. “Inherent in these traumatic
experiences are losses…in the face of these losses and the confusion they cause,
some people rebuild a way of life that they experience as superior to the old one
in important ways. For them, the devastation of loss provides an opportunity to
build a new superior life structure almost from scratch. They establish new
psychological constructs that incorporate the possibilities of such traumas and
better ways to cope with them…because of their efforts, individuals may value
both what they now have and the process of creating it although the process
involved loss and distress.” (Tedeschi et al. 1998, 2)
Personal growth can be fostered by the disruption that crises generate and the
subsequent reorganisation that occurs in their wake. A number of subjects
identified turning point experiences which had a similar impact, where
heightened consciousness and a cognitive-emotional shift or insight challenged
and altered the person's normal ways of seeing and interpreting their experience.
It is worth noting though that none of these were as powerful, enduring and oneway as the Quantum Change experiences discussed by Miller & C’de Baca
(1994, 2001).
Essentially there seemed to be two broad patterns, gradual or abrupt. Most of the
sample did not experience the abrupt or dramatic ‘conversion’ recoveries of
people like Bill Wilson, AA’s co-founder, but rather experienced a gradual, fitsand-starts or cyclical growth process. There were some who did appear to
experience a more pronounced and immediate quantum change, though more
usually of what Miller & C’de Baca (2001, 18-22) called the insightful rather
than mystical variety.
Tennen and Affleck (1998, 80-82) posit a view of ourselves as relatively in
control and invulnerable, that indeed this is necessary in order to function. This
225
view is seriously challenged by traumatic events and processes, compromising
“…cherished assumptions of mastery, meaning and self-worth.” (ibid., 81). The
necessary building of a new view of ourselves and the world has to incorporate
such experiences, and thus is wider, deeper and arguably ‘wiser’ than previous.
In other words where the person has successfully re-established a sense of
mastery and meaning, their self- and world-views have grown and developed
almost by definition.
In practice both are probably involved, for example, on the one hand, automatic
and instinctive attempts to control ‘dosing’ of traumatic experiences and
memories, by a range of mechanisms to reduce attention and affect, e.g.
distraction, denial, suppression; and on the other, conscious attempts or
structured processes (such as ‘working’ the 12-steps, undergoing counselling, or
conscious attempts to ‘be positive’) that support coping and growth. It is also
likely that repetition renders some initially conscious strategies more automatic
after a while.
Some of the subjects found the narratives from some schools of psychology (e.g.
Jungian) of help. These narratives can be important when making significant
changes in life, as they support continuity and show ways forward (Calhoun &
Tedeschi 1999, 21, 60-1; Hanninen & Koski-Jannes 1999, 1838). A particularly
well developed resource of available understanding in this context was that of
the 12-step fellowships, which may help explain their success in supporting
recovery and enhanced growth. One subject found the framework and range of
psychological concepts in astrology of particular use for structuring selfawareness and development.
Implications
The possibility of PTG in those managing and recovering from their addictions
has a range of implications for increasing understanding and for delivery of
helping services. To begin with, by our usual focussing on problems and illness,
we may miss opportunities to foster and support growth, health and well being.
Additionally, we may limit the range of options the person feels exist, as J. B.
Davies’ (1997) work suggests that if we do not consider or ‘allow’ for such
positive outcomes, we reduce their likelihood.
Specific to this is the emphasis (e.g. Hanninen & Koski-Jannes 1999) on the
value of having a range of narratives to draw on to support and focus any process
of change, suggesting the need for an extension of the existing range of
narratives in addiction. Such narratives can allow for the reframing of the
negative into something positive. Related to this is the need to normalise such
experiences and to foster hope.
226
Central to all this is working within a transpersonal context. This does not
necessarily mean doing anything apparently different from what is already done
in working with addictions and dependency, but does mean working in a way
that recognises and allows positive possibilities and is able to support and
encourage them where necessary. It has been pointed out by some authors (e.g.
Morjaria & Orford 2002, 228) that though programmes based on the 12-steps can
accommodate growth and development on all levels including the spiritual, other
dominant approaches in the addiction field neglect this area.
What is perhaps unique to the more transpersonal approaches is to be prepared to
continue beyond what we may consider as the norm that we aspire to for those
we work with, to focus on the spiritual and the search for meaning. Peoples’
cultural and religious heritage may provide a lot to draw on in this respect. There
may be benefits in an increased interest and focus on what had provided meaning
to people, or may in the future. Dormant spiritual/philosophical/ideological
approaches can be reawakened or new ones discovered.
Conclusions
There has been much written on what leads to substance misuse problems, the
nature of such problems, and how to help people manage and recover from them.
There is less written about recovery beyond the issue of maintenance of sobriety.
A question raised by the above, and yet to be resolved, is the extent to which
self-attributed PTG effects such as those in the participants in this study are
beliefs (inherent or acquired), active coping efforts, or adaptational outcomes in
their own right. We have explored the experiences of those who have found
addiction to be a catalyst in terms of Post-Traumatic Growth. And perhaps most
importantly of all we have pointers towards things we can do to improve our
practice in how we support people in their recovery from their addictions,
pointers towards not just reducing illness, but increasing health.
227
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229
Stories of Attempts to Recover from Addiction
Vilma Hänninen & Anja Koski-Jännes
Introduction
Recovery from addictive behaviours is a long and complicated process in which
a person tries to carry out his or her vision of an addiction-free life. Qualitative
research methods provide useful tools for studying the ways in which addicted
people themselves make sense of this process. The narrative approach provides a
particularly fruitful perspective to this change, since it helps to illuminate how
people construe the entry to and exit from addiction as a part of their life course.
Although the narrative approach has recently gained increasing popularity in
many disciplines, only a few studies have used it in addiction research (e.g.
Hänninen & Koski-Jännes 1999; Hilte & Laanemets 2000, McIntosh &
McKeganey 2000; Blomqvist 2002).
The basic idea of the narrative approach in psychology is that people make sense
of their life by giving it a narrative form (Polkinghorne 1988). The narrative
form organises experience by providing an interpretation of causal connections
between different events. It also provides an evaluative perspective from which
the events are seen as movement in relation to the protagonist’s goals and values.
By seeing themselves as protagonists of their life story, people construct their
narrative identity (Ricoeur 1991). The narrative not only makes the past
understandable, but also helps to anticipate the future and thus guides the
person’s actions. In constructing their stories people make use of narrative
models provided by culture (Bruner 1990). In this way, the personal narrative is
a meeting point of private experience and culturally shared understandings.
The narrative reconstruction of one’s life is especially urgent in situations where
the taken-for-granted frames of life collapse. This can be caused by a radical
change in the life course, such as an illness or job loss, or religious awakening.
In these situations previously held visions of future are shattered, the former
identity is questioned, and former values are seen as unattainable or they lose
their appeal. This kind of “biographic disruption” (Bury 1982) or “narrative
wreckage” (see, e.g. Crossley 2000; Frank 1995) calls for a narrative
reorientation (Hänninen 1996). The culmination of addiction in the realisation
that a profound life change is necessary can similarly call for a narrative
reorientation. In addiction literature these events have also been described as
“epiphanies” (Denzin 1989) or turning points (Koski-Jännes 1998). Narrative
reorientation involves forming such a conception of the past which enables
finding a way out. Besides cognitive insights, it often entails ethical reevaluation of one’s life. Even when addictive behaviours are abandoned more
231
gradually through changing circumstances and maturational processes (Robins et
al. 1978; Denzin 1989; Cunningham 2002), this change may call for some level
of narrative reorientation in regard to oneself, albeit less dramatic.
Some years ago we conducted an analysis of autobiographical stories by people
who had managed to get rid of various addictions (Hänninen & Koski-Jännes
1999). Most of these narratives presented a coherent story in which it was
possible to identify a specific key to recovery. The stories fell into five types,
reflecting different cultural story models. In the “AA story”, joining the AA was
depicted as the key to recovery. In the “personal growth story”, it was thought
that recovery had been made possible by following one’s own will instead of
trying to please others. In the “co-dependence story”, the resolution required
becoming conscious of the repressed family problems that had driven the
protagonist to a chain of dependencies. In the “love story”, receiving love and
tender care from somebody was seen to have solved the problem. Finally, in the
“mastery story”, the protagonist used willpower to regain control over the
addictive substance that had turned from a servant to a master.1 In each story
type the key to resolving the dependence contained a certain conception of the
causes of addiction, a solution to the questions of responsibility, and a specific
conception of what is valuable in life now in contrast to one’s previous lifestyle.
Another study on the same subjects (Koski-Jännes 2002) further revealed that
quitting addictive behaviours often involves remarkable personal and social
identity projects. Once people have carried out these kinds of identity
transformations, they seem to be on much safer ground. The role of identity work
in resolving drug addiction was also emphasised in the 1980s by Patrick
Biernacki (1986). Similarly, James McIntosh and Neil McKeganey (2000)
noticed that recovery from drug abuse was made possible by narrative
construction of a non-addict identity. This involved looking at past addictive
behaviour in a negative light, constructing a new sense of self, and providing a
convincing explanation of recovery.
When we noticed that subjects who had managed to quit various addictive
behaviours had undergone a remarkable change in their sense of self and their
whole outlook on life, we started to wonder how this change actually takes place.
We consequently decided to study the stories of people who had recently (re)
entered treatment but who had abstained for less than six months. We expected
that the stage of change would be reflected in some way in these accounts.
In terms of the Transtheoretical model (Prochaska et al. 1992), these subjects
were expected to be either in the contemplation, preparation or action stages,
whereas the subjects in our previous study were maintaining change or they had
resolved the problem for good. However, the change process can also be
1
Jan Blomqvist (2002) found in his study of drug addicts a similar variety of recovery
stories, which he named as “maturity story”, “conversion story”, “story of insight and
liberation” and “story of rationality and willpower”.
232
approached from a more subjective, solution-focused perspective: some people
are still looking for a solution, while others feel they have already found their
way, at least for the time being. This perspective is more relevant for the
narrative staging of recovery. In a similar vein, Nora Jacobson (2001) noticed
that finding a plausible explanatory model (biological, environmental, political,
spiritual, etc.) for one’s problems and transforming one’s self to bring it more in
line with the solutions of this model, was a central feature in the narratives of
recovery from mental health problems.
Narratives of quitting addictive behaviours typically contain four main phases:
becoming addicted as the starting point; second, recognising addiction as a
problem; third, finding a key to recovery, and fourth, establishing a new,
addiction-free life. The stories of the not-yet-resolved, by definition, have not
reached the fourth phase: they do not include the happy ending of a stable
change. As our participants had sought treatment, they had passed the first two
phases. Jan Blomqvist (2002) found in his study of drug abusers that the
narratives of those who had not yet been able to recover were more fragmentary
and contradictory than those of recovered persons, and that they lacked the
perspective of an ending. He characterised these stories, following Lars Hydén
(1997), as “stories in search of their own meaning”. In our terms the people
studied by Blomqvist (2000) had not reached the third phase i.e., been able to
find a key to recovery. We assume that the third phase is that in which narrative
reorientation takes place, and an anticipatory recovery narrative starts to emerge.
By analysing the accounts of those who have not yet achieved stable recovery,
we hope to illuminate the process in which this anticipatory narrative takes
shape.
Method
To reach people still struggling with their addiction, we decided to recruit
participants from outpatient and inpatient clinics in Helsinki, Järvenpää and
Tampere. Potential participants were approached either through their therapists
or by one of us. The criteria for recruitment were that the participants had been
dependent on alcohol or other drugs and had not yet abstained for more than six
months. Those who agreed to participate were instructed “to write a story of
their dependence and recovery attempts”. In the same way as in our previous
study, the participants were asked to write their story in the third person.
Moreover, they were asked to fill in a questionnaire which included questions
about their addiction career.
We obtained stories from ten people over a data gathering period of 15 months
(2001-2002). We do not have the exact number of people whom we asked to
participate, but a rough estimate is about 80-100. Many of those who were
invited to write their story were initially very keen to take part, but then found
233
the task too difficult to accomplish. Getting the data for this study was thus quite
hard, which can be seen as a finding in itself. One of the participants was a client
of AK-J’s, and he had written his story before the data gathering period. The
final sample consists of six men and four women. Four men and three women
were addicted to alcohol; one man was addicted to drugs, and one man and one
woman to both alcohol and tranquillisers. The narratives they wrote varied in
length from one to 15 typewritten pages. The small size of the sample means we
can take a closer look at all the individual cases.
In analysing these accounts we paid attention to the hints referring to the phase
of narrative reorientation they seemed to display. In addition to the content of the
story, we looked at its form. We assumed that a coherent, chronological,
sufficiently detailed account with a distinguishable closure reflects narratively
organised understanding of the problem, while a diffuse, chaotic narration
reveals a story still under construction.
In the presentation of the stories, we have tried to avoid details from which the
subjects might be identified. We have used the alias of the writers if they have
given one and changed the names of the writers who wrote in their own name.
Findings
In line with our expectations, the stories displayed different positions in respect
to narrative reorientation. Roughly, they fell into two types. Seven of them were
categorised as “resolved stories”, and three as “unresolved stories”.
1. Resolved Stories
A common feature of the resolved stories was that the key to recovery had
already been found, at least provisionally. In four of these stories the
protagonists had started to put their insights into practice. In two others there is a
general and abstract idea of the way out, but the means for carrying out the plan
still remain open. Finally, in one story the solution was found at first, but it had
not stood the test of time.
Resolved and Taking Action
“Maija” provides the first example of resolved stories in which the protagonist
is already actively pursuing a new way of life. Maija is a middle-aged woman
who used to be a heavy beer drinker. Her story is a coherent, chronological
account of her relation to alcohol. The narrative runs to four hand-written pages.2
2
234
The case descriptions are abstracts of the written stories.
In her teens Maija had some experiences of drinking with her friends. She then
lived for seven years in a sober marriage, which ended when she became
pregnant to another man. This led to Maija and her son living with an alcoholabusing man for sixteen years. Life was hard, but she did not drink very much
herself. Finally, she ended the relationship. As her son grew up and she stopped
working in the evenings, Maija found she had more spare time on her hands. She
began to spend time in pubs and drink beer. Little by little, she began to drink
ever more and ever more frequently -- and to suffer from hangovers and moral
self-accusations.
One day, however, she was caught by her employer sitting in a pub when
officially on sick leave. As a consequence she was required to seek treatment.
She went to an outpatient alcohol clinic, joined the AA and also received
inpatient treatment. She then started to study, kept going to the AA and took on
new hobbies. Now she realises that she had drunk mainly to try and alleviate her
loneliness: “that’s why she had to frequent pubs to meet ‘friends’.” She is
grateful that she was caught by her employer and happy she is now sober.
Maija’s story contains some elements of typical AA stories, but it also deviates
from them in essential respects. Although it includes a clear turning point (being
caught), this is not an existential “rock bottom experience” typical of AA stories.
Nor does Maija interpret her addiction as a disease. Rather, she now sees her
former drinking as a deceptive solution to the main problem of loneliness that
could have been solved in other ways, too. She also depicts herself as an active
agent in every phase of her narrative, and she resolutely seeks ways to gain
control over her drinking. In this sense, the logic of her story resembles that of a
mastery story.
Maija’s story is relatively simple and straightforward. It contains all the elements
of a recovery story discerned by McIntosh and McKeganey (2000): it reinterprets the addictive lifestyle in negative terms, it re-establishes her former
sense of non-alcoholic self, and it provides a clear-cut anticipation of the way
out of addiction. Maija thus seems to have found her key to recovery, which
guides her choice of means to fight the problem. Moreover, she has already
started to put her solution into practice.
There were also three other somewhat similar stories in which the increasing
negative consequences of an “excessive appetite” drove these individuals to
search for a solution. After finding one, they began to take action. One of them
was “Liskolintu” (Dragon bird), who after years of heavy drinking concluded
that as he hardly ever drank at home, the main problem was his “restaurant
behaviour”. After this self-diagnosis he began to spend more time out of doors,
at his summer cottage and in coffee shops rather than restaurants with his
friends. Willpower, optimism and avoiding drinking buddies were his recipe for
success. Another one was “Riku”, who after going bankrupt and a divorce had
begun to mend his depression by spending time in pubs. However, an official
caution from work, his deteriorating appearance and alienation from his children
got him thinking. As a result he decided to seek help to “bury his
disappointments in life in something else than alcohol”. His way of fighting the
235
problem was based on “a conscious change of routines”. Then there was
“Timppa”, who presented a traditional AA story: after years of excessive
drinking, feelings of guilt and hopelessness as well as futile attempts to quit, he
was finally delivered by the AA. Living one day at a time, helping others and
remembering his former hangovers and fears were his ways of fighting the
problem.
All these stories were relatively simple and kept to the essentials of their
storyline in which the hero first managed to face the problem and once he had
found a solution started to take action to break loose from the trap. They also
included some cognitive reappraisal or reassessment of the protagonists’
previous drinking in clearly negative terms.
Resolved and in Preparation
The next two stories also included the initial elements of the previous storyline,
but these stories were more complicated, and they did not spell out any concrete
ways of reaching the goal. “Eva’s” story provides the first example. Eva is a 40year-old woman who has suffered from dependence on alcohol and
tranquillisers. Her story is a six-page chronological account of her life course.
When Eva was a child, her mother used tranquillisers and her father drank. Her
parents divorced when she was eight years old, and she lived in turn with both of
them. Fear was her dominant feeling that she tried to escape in various ways.
When Eva was in her teens her fear was replaced by anger, which she expressed
by social rebellion. Later on, she started consciously to search for ways to feel
better. Alcohol was the first remedy she found. “When she was drunk she could
be in contact with herself, like herself and to some extent even other people”.
For a long time she resisted the idea of taking pills, but eventually she fell for
sedatives as well.
At the age of 24 Eva tried to quit by joining a religious group. However, the
secure and steady sober life could not alleviate her anxiety, so she returned to
drink again. Her life then came to consist of circles of drinking or using
sedatives, sobering up, and relapsing again. She tried to find consolation from
sexual relationships, but they all turned into sources of still more anxiety. “Eva
sought relief from painkillers and cough medicine that she used together, and
finally from liquor. The familiar chain of catastrophes started again.” Even the
most satisfying relationship in her life broke up because her suppressed bad
feelings kept resurfacing.
Eva tried to find help from various treatment institutions, but none of them
helped for more than a short while. Finally she ended up in the same hospital
where her mother had been treated. She managed to quit drinking, but only with
the help of tranquillisers. She continued to abuse them until she finally decided
to quit using them too. She feels that the only solution is to take responsibility
for her life and to assent to the pain, not to escape it.
The main themes of Eva’s story are her feelings and her attempts to manage her
emotions. Eva’s life seems to progress in successive circles in which various
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ways of escaping anxiety first help her, then turn into further sources of anxiety.
From a narrative point of view this story bears resemblance to the cultural codependence story. According to this story type, hidden problems in the
childhood family lead to nameless anxiety, which is escaped by successive
addictions. The cure can be found by becoming conscious of these problems and
by facing the pain one has tried to escape. Eva’s story thus presents an
explanation of addiction, and a conception of the way out. In this way her story
could be seen as an anticipatory recovery narrative, but its insight remains to be
carried out in practice and its vision of the future without chemical support is
still vague.
Another rather similar story is presented by “Maex” who attributes his problems
to his father’s alcoholism and the divorce of his parents in his childhood. After
the birth of his second child, however, Maex realised that if he wanted a better
life for his own children, he had to quit drinking. Yet the means with which this
goal is to be reached remain unclear while Maex is still in inpatient treatment,
leaving a sense of ambivalence about his story.
Resolved and Relapsed
Even when a story presents a relatively clear anticipation of the way out of
addiction, it does not necessarily stand the test of time and reality. Consequently,
individuals who have managed to stay sober for some time may find themselves
facing the same problem again. The following account displays this kind of
situation.
“Sakari” wrote his first story when he was in Minnesota type of treatment at the
age of 65. He had been a daily drinker for most of his life, yet had rarely been
totally drunk. His story is a 10 page text which presents his life course in
chronological order.
Sakari’s childhood home was a wealthy one with fancy parties and civilized
discussions. He and his brothers were looked after by a nanny, and he had an
emotionally distant relationship with his parents. Eventually, his father began to
drink heavily and to lose property. Sakari dropped out of school, eager to start
earning money. In his teens he came up an invention which provided him with a
good fortune for the rest of his life. Soon he was employed by a well-known
company. Drinking with colleagues and clients was customary at the workplace,
and Sakari adopted similar habits, although with increasing concern. When
promoted, he wanted to sober up the company. His senior colleagues started to
complain about this young smug director, but it was not he but they who were
kicked out.
Then Sakari´s father died of alcoholism, having lost all he owned. Sakari´s first
marriage broke up due to “character differences”. Some wild bachelor years
followed with sailing tours, whisky and women. Eventually he met his second
wife, and two children were born. Some years later a crisis broke out in his firm,
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but Sakari managed to clear it up and make the company prosper. His drinking
had increased, however, and there was even “mild violence”, which led to the
breakdown of his second marriage.
But once again Sakari found a new young wife and two more children were born.
He took early retirement and the family moved to the country. They started to
build a house, plan a garden, and go in for biodynamic farming. In the summer
Sakari gathered wild berries and in the winter skied hundreds of kilometres. He
still drank on a daily basis, even though he “never felt the need to empty a whole
bottle of cognac in one day”.
When the children went to school, Sakari’s wife and children moved to their city
apartment. He stayed in the country on his own - but not for long. Again, a new
woman appeared in his life “as a housekeeper”. With time he had also made
friends with his second wife. All these three women with their daughters often
spent holidays together with Sakari.
Alcohol had not interfered with Sakari’s activities, but eventually his doctor
began to warn him about his drinking. It was around about this time that his
women also wrote him a joint letter stating that “you are so dear to us that we do
not want to see you destroy yourself”. His first bender triggered by his brother’s
death finally convinced him that he needed to change. He took part in a
treatment programme that he found “a high-quality, stimulating course on selfknowledge and life skills”. He attended it as enthusiastically as “the long course
at the Management Institute” and finished it with a sense of optimism.
Sakari’s account is a good example of a linearly developing male story with an
autonomous, agentic, even heroic protagonist. It describes a life in which one
successful project is followed by another, and one charming woman by another.
By telling about his achievements, Sakari presents himself as a competent,
assertive, innovative, physically able man. His closest relationships are described
as loving and supportive. Drinking seems to have been just a part of his wealthy
lifestyle. The only stains on this otherwise almost perfect success story are the
rare descriptions of problems related to drinking. In this story, Sakari seems
rather confident that he will be able to manage this problem as well as all the
previous projects in his life.
A couple of years later, Sakari wrote two supplements to his story. These are not
narratives but lists of separate lines or points on the basis of which the
continuation of his life can be reconstructed:
After the treatment, his drinking ended for a year. Then he started to drink again,
in ever larger quantities. His younger brother’s death had brought him stressful
duties, and he needed alcohol to cope with them. His depression increased, he
had sleeping problems, he lost weight and had difficulties in accepting his
increasing age. Eventually, he was ready to seek treatment again.
In contrast to the initial story, Sakari speaks in these supplements about his
negative feelings and problems. He admits his depression and explores its
causes. He says he has always wanted to start new projects and hobbies, but now
he has no plans for the future.
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When comparing the initial story with the supplements, we could say that in the
former Sakari still understands his life in terms of successive successful projects.
He does not ponder on the causes of his drinking, nor question his former
lifestyle or identity as a man for whom very few things are impossible. The
supplements, on the other hand, display a breakdown of his optimism, as well as
the coherent storyline, and a realisation that something more serious is going on,
calling for a more profound reorientation. However, no hints of a new solution
are yet visible.
2. Unresolved Stories
Three of the accounts were categorised as unresolved. In these stories the writers
focus on exploring the nature and causes of their addictive behaviour. These
stories are typically heterogeneous, even somewhat chaotic. For example,
Minna’s story is short, mixed up and pessimistic. It contains a revealing
schematic presentation in which she depicts the contradictory forces of her
current life situation. The two other unresolved stories are long and complex.
They display serious attempts to grasp what is going in the lives of their
protagonists.
“Boy” is a man of 40 who has been addicted mainly to amphetamine. His text
runs to 15 pages and it consists of a chronological story and additional thematic
analyses. In his cover letter he says that writing about his life has served some
kind of therapeutic purpose, allowing him to talk honestly about things of which
he has been very much ashamed.
Boy’s parents were heavy drinkers. They were separated when he was 10 months
old. Boy and his brother were left with grandma. Since then his mother never
had any contact with the boys. His father remarried and took the boys, but the
couple was soon separated and the boys were sent to grandma again. Similar
episodes with father occurred a few more times, always with the same result.
Boy was a restless child who easily got into fights, committed minor crimes and
lied a lot. At the age of 16 he began to smoke cannabis on a regular basis. After
finishing school he moved in with his future wife who was six years older than
him. Boy was still using and selling cannabis, but he managed to make a career
for himself in the trade sector. Wanting to spend more time with his children,
Boy left his job.
Then, however, his dealer offered him 10 grammes of amphetamine to sell.
Having tried it before and found it really satisfying, Boy used most of it himself.
After this he switched from using cannabis to amphetamine. He began to spend
more time alone at his summer cottage, where he used this drug. There were
more and more quarrels at home and, under pressure from his wife, he admitted
himself to treatment for substance abusers.
While in inpatient treatment, he fell in love with another patient. This made his
substance abuse problems a side issue. The girl relapsed and Boy returned home,
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continuing to use amphetamine. His wife became increasingly worried, as his
"acting out" and suicidal behaviour increased. He became suspicious and
volatile. Then he had a religious awakening experience, but that did not change
his drug use. He ended up in hospital due to an amphetamine psychosis and he
stopped using drugs.
Boy then began to study nursing. After graduating he got temporary jobs at drug
treatment units. He was liked by both his co-workers and patients. After a few
years, however, he relapsed to amphetamine. His wife began to demand a
divorce and he lost his job. Angered by this “unfair treatment”, he continued to
use drugs and ended up in inpatient treatment again. There he started a new
relationship which did not work out. He then found another female patient with
whom he planned to start a new life.
This was the narrative part of Boy’s account in which he describes his life course
in detail, but does not reflect upon himself, his feelings or the causes of his
problems. However, the story was followed by a more private and revealing
thematic analysis of his life.
Boy starts this part by telling that he “knew he suffered from childhood traumas,
a sense of inferiority, difficulties of expressing his sexuality and many other
things, which led to depression that Boy had medicated with amphetamine.” He
reveals that he has also had homosexual experiences and one of the things he
does at the summer cottage when he is using amphetamine is to dress up as a
woman. He then proceeds to analyse his relationship to religion, stating that the
Bible has helped him out in times of difficulty. He has also had an angel
experience. He still goes to church occasionally and participates in NA activities.
Religion gives him serenity. As to his future plans, Boy tells that he will look for
a job once his treatment has ended, but not as a nurse. He is not going to forget
his “illness”, but will go to NA.
The picture conveyed by this story is one of an honest but also a very mixed up
person. It seems that throughout his life, Boy has been dependent on various
external sources of comfort and good feelings. In this respect there is repetition
rather than change in his story. The roots of his addiction probably lie so deep in
his traumatic early life experiences that it is extremely difficult to tear them up.
It is also noteworthy that under the theme of “sexuality”, he mainly writes about
his dressing up as a woman and use of amphetamine, whereas under the theme of
“treatment”, he speaks about new female partners. Women seem to represent
mainly nurture for him, while sexual satisfaction belongs to another sphere.
The main storyline in Boy’s account is a typical drug-addict story in which a bad
childhood leads to antisocial behaviour and via cannabis to stronger drugs,
which are extremely difficult to quit. Eventually, everything is lost, and the
protagonist is forced to seek for a new life. For several reasons, however, we feel
that Boy’s account is still an unresolved story. Its division into the story proper
and the thematic analysis suggests that there are elements in his life that he has
not been able to incorporate in his story. The number of details also seems to
indicate that he still has difficulty selecting the most essential ingredients for the
plot of his story. Most importantly, the story does not include any clear
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conception as to how the new life will be different and better than the old one. In
the words of McIntosh and McKeganey (2000), it does not portray a conception
of a non-addict identity. Most probably, however, his reflections and disclosures
have helped him move forward in confronting his problems.
“Anna” is a woman in her late forties. Her story is a lengthy (13.5 typewritten
pages) exploration of her dependence on alcohol and smoking. As requested, the
narrative is written in the third person. In fact there are several layers of her in
the text: besides being the protagonist, she is also presented as the narrator and
the commentator of the narrator. “Let’s allow Anna to speak for herself and let’s
forgive her hesitation and deceptiveness”.
The narrative does not unfold in chronological order, but starts from the present
and consists of ever deepening dives into the protagonist’s past. It is, however,
possible to reconstruct the events of her life as follows:
Alcohol has been present in Anna’s life from the very beginning, as her father
was a heavy drinker. When she was in her teens, her mother committed suicide,
which was a silenced event in the family. Her father’s drinking increased after
mother’s death. Anna stuck to her boyfriend, but they split up when she had an
abortion. She wanted to become an artist.
After finishing art school, she moved to a bohemian neighbourhood where there
were plenty of artists and intellectuals who spent their time in the near-by
“living-room pub”. Anna started a relationship with a drinking writer,
developing a dependence on alcohol herself. Together they tried to quit drinking.
After eight months of sobriety, Anna fell into a psychosis. When she returned
from the hospital, no one spoke about her psychosis. Her partner left her, and she
made two unsuccessful suicide attempts. To alleviate her loneliness she started to
spend time in pubs again and found a new partner. Pub life was a central part of
their joint activity.
A serious illness forced her to stop drinking, however. Yet it was almost
impossible for her to stay sober and to maintain the social relationships that were
so important for her. Drinking was necessary in order to get close to others,
whereas smoking made her anxiety bearable when she was alone. All along,
Anna continued to try and improve herself as an artist, but she felt that all she
could accomplish was the rudiments of painting. Finally, she sought help from an
outpatient clinic for alcoholics.
On the level of events, Anna’s story is a classic tragedy with gloomy secrets,
betrayals and losses. More than that, however, her story seems to be about her
desperate attempts to find the truth from beneath the web of deception and selfdeception in which she feels she has lived.
In the course of the narrative, Anna explores her identity. First, she characterises
her story as one about “how a talented woman became an alcoholic”. Later on
she introduces herself: “She is an intellectual or something. Unemployed, artist,
no, an amateur, half-professional, no, a Jack-of-all-trades in this field. Ill. Yes,
and an alcoholic, a nicotinist, a slave”. She also evaluates the different social
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categories she could adopt, such as illness, unemployment, alcoholism and
depression: “Being ill is being deficient, being not fully a human being, not fully
part of society. An ill person does not have to be efficient. She can rest in peace.
Unemployed? To be ill is more acceptable than to be unemployed. She knows
her illness affords her a more accepted role than being out of work, depression is
more acceptable than alcoholism or dependence on drugs.” All in all, Anna’s
identity is extremely vague: she finds the categories into which she could be
fitted as unsatisfactory, and the only identity she seems to value, that of an artist,
is not externally validated.
Neither does Anna know what to think about her social relationships. Her partner
and the pub community are her closest people, whose company she desperately
needs. “It has been easy to be with these people who are like her, these ragged,
marginalised, good, deeply feeling people, who can laugh and sing and who
bravely fight for their existence and for the diversity of their way of life.” On the
other hand, she suspects that this image is illusory: “But… but… she has also
met the cowardice, the contradictions between words and deeds.” Yet she has no
other social network on which to rely.
Anna is sceptical even of her own intellect, suspecting that it will only prevent
her from seeing the truth: “Anna, says the outside observer, what has this got to
do with your dependence problem? You try to hide your problem behind
overarching reflections. (…) You are evading and being hypocritical.”
She analyses her dependence: being dependent is hanging on to something, when
there are no other things to hang on to. “I take hold of something in order not to
drown, to prevent the winds from taking me away. I make myself real by
drinking, by smoking.”
The only things that Anna seems to trust are her dreams and mental imagery. She
describes several instances where a dream has shown, metaphorically, where she
stands and what she has to do. One of these dreams was a modern version of the
ferry of Kharon: a black Formula car, which has come to take her. Vacillations
between health and illness, hope and despair, strength and vulnerability seem to
be the constant companions of her life. She finds her strength in “her desire to
draw, desire for a picture”. Realising her limits, she has been tempted to give up,
but she has not yielded. Along with her stubborn creative ambitions there is,
however, also a force in her mind that she depicts as a “quicksilver devil”: a
creature that haunts, derides and accuses her and tries to invalidate her every
attempt to solve her problems.
In Anna’s narrative, then, there is no coherent plot that would give her a solid
sense of identity, an explanation for her dependence or a vision of the path out of
addiction. Her story does not resemble any cultural story model, but it contains
an abundance of ingredients for many kinds of stories. She seems to have
collected and presented the bits and pieces of her life, but she does not yet
242
construct a closed narrative out of it. In the light of her conscious attempts to
find what is real behind words and appearances, we tend to believe that she
deliberately wants to avoid telling a conventional story before she can be sure
that it is true.
Discussion
In our previous study (Hänninen & Koski-Jännes 1999) we found that people
who had managed to overcome their addictive behaviours often utilise certain
cultural story models to give structure to their particular path into and out of
addiction. These models are often adopted in treatment institutions. For instance,
Hilte & Laanemets (2000) found in their study that the stories female addicts
told about their addiction reflected the ideologies of the institution in which they
were treated. In some of the accounts at hand, these cultural story models were
discernable, while in others they were missing or the search for such a model
was still going on.
Our initial plan was to compare the stories collected for the study at hand with
those we gathered for the previous study from fully recovered people. However,
in addition to the phase of recovery, the new sample differed from the initial one
in other respects, too. As the former sample was drawn by newspaper
announcements, it was gathered from a wider pool of people and thus also
reached individuals who had suffered from nicotine addiction, excessive
gambling and eating disorders, for instance. The first sample also included
people who had not sought help from any therapeutic institution. The samples
thus differed so much that direct comparisons were not warranted. This is why
we decided to focus on the specific features of the current sample, trying to see
how the relatively recent changes are described and how the new narrative starts
to form.
The narratives we analysed here could roughly be categorised into unresolved
stories and those in which the protagonist seemed to have found some sort of key
to recovery. The unresolved stories were more incoherent, fragmentary and
contradictory than the resolved stories, and they lacked a “sense of an ending”;
they resembled “stories in search of their own meaning”, as described by Hydén
(1997) and Blomqvist (2000). The unresolved stories did not resemble any
cultural story model of addiction, which may mean that their narrators had not
yet found one that would suit them. In the case of Anna, there seems even to be a
conscious reluctance to surrender to any pre-existing story model or to define
one´s self in any way. This kind of reluctance to form a consistent self-narrative
may be seen as characteristic of post-modern times.
Among the resolved stories, some were still just anticipating recovery, while
others had already started to carry it out in practice. The stories thus suggest that
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in order to get going on the way to recovery, people need to form a credible
model of their problems, which can be used to guide their attempts at recovery.
This model does not need to be “objectively” true or scientific, but it has to fit in
with one’s personal experiences and provide some perspectives on how to move
forward. Similarly, Jacobson (2001) found that narratives of recovery from
mental health problems could be based on many kinds of models - as long as
they made sense of their proponents´ experiences and could be used for
reclaiming their lost sense of self.
One of our findings in doing this study was that it is extremely difficult to solicit
these stories from people who are still struggling with their problem. It seemed
as if these people were aware of the incoherence of their experiences and that
they were therefore reluctant to write a story about it. It might have been easier
for them just to talk about their life without trying to piece things together in
some way. A common feature of the stories that we were able to solicit was that
almost all of them were written by people whose parents were also substance
abusers. This may have helped them to write about their life by implicitly
justifying their deviation from average life trajectories.
In the above, we have started from the assumption that people write their stories
mainly in order to understand and organise their experiences. It should be noted,
however, that people tell stories for many other purposes, too - consciously or
unconsciously. Sometimes storytelling serves to cover up threatening things
about oneself, or to postpone entering into difficult issues, or just to relieve
tension (Rennie 1994; Stiles et al. 1999). It is no wonder then that the model they
adopt may sometimes also prove wrong or insufficient, leading to renewal of
addiction, as in the case of Sakari and later perhaps also with some others whose
accounts we regarded here as “resolved”. By “resolved stories”, we thus refer
here to the quality of their self accounts and not to what will actually happen to
these people over time. These stories are resolved in the sense that the person
seems to have made a decision and started on a new road, instead of repeating
his or her old behavioural patterns.
On the basis of these findings we tentatively suggest that facing the problem of
addiction with all its consequences often creates narrative wreckage leading to a
narrative reorientation. This reorientation may vary from minor changes to a
major reconstruction of one’s identity. The reorientation phase starts from a
hunch of a possible way out, which is then made concrete and implemented in
action. If the narrative anticipation of recovery passes the test of reality, the full
recovery story results; if not, a new cycle begins.
In our view the narrative reconstruction of one’s experiences along with this
development is not just an epiphenomenon, but it plays a dynamic, sometimes
even guiding role in the process of change.
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The Individual Narrative as a Maintenance
Strategy
Dorte Hecksher
Introduction
The path to and away from addiction has been described as a transformation or
change of identity. In research this change is explored as a social process related
to the social context of the recovering addict, in which the concept of identity
encompasses the social roles and different social identities people hold
(Anderson 1994; Anderson & Mott 1998; Baker 2000; Biernacki 1986; Ebaugh
1988; McIntosh & McKeganey 2000, 2001, 2002); the change is also explored as
an individual process related to personal narrative and self-conceptualisation
(Hänninen & Koski-Jännes 1999, 2002; Koski-Jännes 1998, 2002). In this paper
the transition from an addict to non-addict lifestyle is studied, and maintenance
strategies related to the individual process of leaving behind addiction are
explored.
Identity Transformation as a Social Process
In a classic study published in 1986, Biernacki explored how substance abusers
manage the transition from living as an addict to adopting a more ordinary way
of life. Based on concepts from symbolic interactionism, the study aimed to
analyse diverse processes of natural recovery through the transformation of
identity. Identity encompasses both the past and the future: the past in terms of
the individual biography, and the future in terms of what the individual strives
for or fears becoming. Biernacki designated three typical styles of identity
transformation: 1) The creation of an emergent identity, which was virtually nonexistent during the substance abuse. 2) The reversion to or re-establishment of an
old identity, which was not destroyed by the life as an addict. This identity might
have been held in abeyance during the substance abuse. 3) The extension of an
existing identity, which replaces the primacy of the addict identity.
A person can experience all these processes of identity transformation, but
usually reports one central process. Through interaction in the social world the
individual creates a new sense of self, and Biernacki emphasizes that a
successful transformation depends on the available identity material in aspects of
the social settings, such as vocabularies and social roles in the different contexts.
The individuals direct themselves toward aspects of the social world that reflect
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their ideas of a positive sense of self. Biernacki focuses on the transformation as
a social process, in which the individual tries to establish a new configuration of
identities based on novel relationships, values, and social worlds unrelated to the
world of addiction. In this way the addict identity is excluded or becomes
depreciated. In this study a widespread maintenance strategy was the interview
subjects’ dissociation from life as an addict and the addict identity. This was
achieved by: a) moving oneself away, geographically, from the addict
environment; b) social dissociation in terms of developing social and
instrumental relationships outside the addict world; and c) a mental dissociation
in the conceptualisation of the self, in which the individual no longer identifies
him- or herself as an addict. In a study by McIntosh and McKeganey (2000,
2001, 2002) it is argued that successful recovery often is motivated by a desire to
restore an old identity spoiled by the life as an addict. In this study recovering
addicts were interviewed about their path to addiction and their experience of
“coming off”, a process described as a normalization into a more conventional
way of life. One conclusion was that the transformation from addict to nonaddict lifestyle involves a change in the content, structure, and meaning of daily
life. This change relies upon ability and the possibility of developing new
activities and relationships to support and reinforce the new identity and new
self-concept, and through these means, to dissociate oneself from the addict
world. The conclusions of this study are in line with the work of Biernacki
(1986), but McIntosh and McKeganey emphasize the establishment of a renewed
identity as being most fundamental, and they found that re-creation of a spoiled
identity was the central feature in the transition from addict to non-addict.
Identity Transformation as an Individual Process
Transformation and identity maintenance is, however, not restricted to resocialisation or normalization, but also involves a psychological process of
transformation. Koski-Jännes (1998, 2002) and Hänninen and Koski-Jännes
(1999, 2002) explore this theme in a series of publications on people who have
been able to overcome their addiction or dependence. A study by Koski-Jännes
(1998) explores narrative accounts by individuals overcoming their addiction,
and focuses on the means of maintaining this profound behavioural change.
“Turning point experiences” is used as a key concept in this study, and is
understood as moments:
…usually characterized by a heightened consciousness and a cognitive emotional
shift or an insight, in which the person’s regular pattern of seeing and
interpreting things is challenged and altered (Koski-Jännes 1998, 231).
One central conclusion is that accounts of turning points “seem to function as
important components of the stories people use to try to make sense of their
experiences (ibid.).” Narratives provide reasons for change of lifestyle, and a
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coherent account of a new beginning and desired goals, and in that way support
the new identity and self-concept. The ability to tell a satisfactory life story is a
significant maintenance strategy, in which the narrative enables the individual to
generate meaning from an otherwise chaotic and less desirable life story. The
processes of perceiving and interpreting events, emotions, and cognitions are
related to the turning point episodes, and Koski-Jännes describes these processes
as “the individual’s self-schemata being stirred”. Turning points can be defined
as moments (or episodes) leading to profound changes in self-concept or selfschemata, which again can contribute to change of identity. Hänninen and KoskiJännes (1999) published a study on how people recovering from addiction
understood the process of change. It was based on an understanding of the
narrative as vital during times of profound life change. In this study the
individual stories or narratives were providing meaning or making sense of the
experiences of the individual, and served as a signal to others for how to
understand addiction. The primary maintenance strategy presented in this study
was the ability to develop and maintain a coherent and morally grounded story.
The successful strategy consists of both moral devices and basic values, which
give the individual the reasons and the means to maintain a more acceptable
lifestyle. Another study by Koski-Jännes (2002) supports and elaborates the
assertion that the process of recovery from addiction has to be viewed as an
individual or psychological process, and not only as a process of re-socialisation.
The theory of identity formation by Rom Harré is used in this study, building on
the notion of parallel social and personal identity projects. The study explores
how both “…personal and social identity projects can be activated by quitting
addictive behaviours (Koski-Jännes 2002, 200).“ The two kinds of identity
projects are interdependent in that the individual has to find a place for him- or
herself in the social world, and at the same time sustain his or her sense of
personal uniqueness and personal story. The central point in this study is that
genuine change, as seen in permanent recovery from addiction, requires changes
to a person’s core self-schemata. The maintenance strategies identified by KoskiJännes are the individuals’ ability to discover or rediscover personally or socially
attractive values, ideals and goals, all of which become part of the new narrative.
The studies above outline different perspectives on the process of transiting from
an addict lifestyle to a non-addict lifestyle. In the studies by Koski-Jännes (1998,
2002) and Hänninen and Koski-Jännes (1999, 2002) the process of exiting from
addiction is explored on the basis of a psychological conceptualisation, in terms
of the individual narrative, identity projects, and change of self-schemata. The
study presented in this paper follows a similar path and is based on an explicit
psychological conceptualisation. The paper focuses on the diversity in the
psychological processes related to the transition from addict to non-addict
lifestyle.
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The Interview Study
Subjects and Methods
The present study is a qualitative part of a large-scale quantitative follow-up
study on 372 substance abusers (of which 98 % had been using heroin) in the
years following residential treatment. The study was initiated in 1996 in
Denmark (Pedersen 2000). At the time of the second follow-up, a minimum of
two years after termination of treatment, a small number of the sample (n = 48)
reported they had been living without drug abuse since residential treatment. A
number of these former substance abusers were contacted and 15 were
interviewed. This interview material constitutes the main data in the present
study. The interviewees were selected among n = 48, with the aim of maximal
variation with regard to age, sex, and years in substance abuse and treatment
institutions. There were 6 men and 9 women in the interview sample. The
interview subjects had been abstinent for between 4 and 8 years at the time of
the interview. Nine of the 15 interview subjects had been in treatment at a
treatment centre based on the principles of the AA and NA. Four had been in
residential treatment focusing on social education and one had been in a
therapeutic community. All of the subjects had been into heavy substance abuse
prior to treatment. Five of the 15 interview subjects now work as counsellors in
substance abuse treatment services; of the rest, one is employed as a caretaker at
a treatment centre for substance abusers, and one is at a drop-in centre for both
alcohol and substance abusers. Six subjects are in the process of education or
training. One is employed in industry and one in a nursery. In this paper three
cases have been selected for analysis. These cases have been chosen because
they represent three fundamentally different ways of solving the challenge of
identity transformation, and are characterized as unique cases representing
extremes among the interview subjects.
Basic Concepts
How former substance abusers manage a life without drugs or alcohol is
explored through an analysis of interviews and quantitative data. The central
hypothesis is that durable behaviour change, as seen among these former
substance abusers, relies on a fundamental change of identity and self-concept,
and that the ability to maintain this identity is an ongoing process. The individual
identity is understood as the way the person perceives him- or herself. This selfperception is based on several aspects, all of them contributing to the
maintenance and development of the individual identity (see Table 1): a) the
self-concept, b) coping strategies, and c) the narrative or individual biography.
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In the process of changing the perception of oneself from a substance abuser into
a non-user, all these elements contribute to the transformation and maintenance
of the individual identity. These concepts are used as analytic tools in the present
paper.
Table 1. A pragmatic understanding of the individual identity.
a)
Self-concept — the collection or total repertoire of knowledge of our selves.
Comprising generalizations about the self, derived from experience, the selfconcept is regarded as the verbalisation of identity, and helps to integrate
behaviour, attitude, and emotion into a more or less coherent collection of selfimages. (1)
b)
Coping strategies — perceived as typical, usual and relatively stable behavioural,
cognitive or emotional ways to cope with the problems and stressors of everyday
life (e.g., seeking social support, planning activities, mental or behavioural
disengagement, or positive reinterpretation). (2)
c)
The Narrative or the individual biography — the ability to unite the identityrelated elements in an individual matrix of interpretation; to establish coherence
among the past, present, and future (in terms of aspirations and fears); and to find
meaning in the personal past that can be applied to the present and the future. (4)
(1) James 1890/1918, 1985; Markus & Wurf 1987.
(2) Carver et al. 1989; Menaghan 1983; Rossan 1987.
(3) Bruner 1987; McAdams 1987, 1994, 1996a, 1996b.
This perspective on the concept of identity draws on the theoretical work of
William James, Jerome Bruner, and Rom Harré and on a cognitive and
information processing approach (Markus & Nurius 1986, 1987; Markus & Wurf
1987). It is also inspired by the empirical work by Rossan (1987) and KoskiJännes (1998), Hänninen and Koski-Jännes (1999, 2002), and McAdams (1987,
1996b). In the present study the central question is how this change in identity
and self-concept is created, maintained, and displayed in the individual reports.
Also of interest are the challenges the individual faces in the process of creating
an identity, given his or her history as a former substance abuser.
Analysis
The interviews focused on the interview subjects’ perception of themselves,
prior, during, and after substance abuse. To explore the psychological processes
of identity transformation and identity maintenance, it was decided to combine
interview data with data from the questionnaire and to interpret these data in
terms of the conceptualisation of identity maintenance outlined above (Table 1).
This analysis combined an inductive and an interpretive approach (Kvale 1996).
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A Continuum of Strategies
Identity is in part produced by the individual’s conception of his or her
biography or narrative. The narrative generates coherence among the past,
present, and future, and is the individual matrix of interpretation; it implies that
the way the individual deals with his or her story can serve as a maintenance
strategy. The interesting question is how these former substance abusers solve
the challenge of handling their past in relation to their present. In the present
study different ways of constructing biography, and through that a sense of
identity, are explored and described as maintenance strategies. In the interview
sample (n = 15) a range of different strategies emerges for dealing with a past as
a former substance abuser. In this paper three cases are presented. They are not
to be seen as exhaustive for the dataset or as the only ways of addressing the
task, but as special cases representing three diverse ways of how to assimilate a
history of substance abuse. The question is which challenges the three face and
how successful they are. The individual cases display variations in dealing with
the past, but the overall tendencies are illustrated in Figure 1, in which the three
cases presented here are placed on a continuum illustrating patterns of dealing
with the past: (1) The individual accentuating the vital importance of the past in
relation to the present life constitutes one end point of the continuum; (2) the
individual assimilating the past as one part of the individual story is placed in
the middle; and (3) the substantial concealment of the past in the present life
constitutes the other end point of the continuum.
Figure 1. A continuum of strategies.
Accentuating the
vital importance
of the past
Assimilating the
past as a part of the
individual story
Concealing the
past in the
present life
(1) John, age 45
(2) Hannah, age 44
(3) Lisa, age 28
John’s case: Accentuating the Vital Importance of the Past
(1)
John has a history of more than 20 years of substance abuse, but is now working
as a counsellor in an outpatient treatment centre for substance abusers. At the
age of 39 he entered treatment at a Minnesota-inspired residential treatment
centre. When he describes himself as a drug addict, he uses words such as
“unpleasant”, “violent”, “criminal”, and “self-centred”. In treatment he had a
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hard time accepting the programme, but at some point became aware that, no
matter what he did, he would continue to feel terrible. Through assisting in the
recovery of other substance abusers he has finally found hope that things can
change, and in embracing hope, has “surrendered” to the programme. He
describes this as a major turning point in his life and self-image, since he has
always insisted on deciding everything for himself.
Ascribing Meaning to Past and Present Behaviour
John ascribes certain meanings to his past behaviour, which he views as
expressing a general pattern of dependency. The principles of the AA
(Alcoholics Anonymous) and NA (Narcotics Anonymous), articulated in the
Twelve Steps and the Twelve Traditions, serve as the basis for his work as a
counsellor, and as a guide in his personal life. The ideology of the AA and the
NA is, among other things, built on the notion of addiction as a lifelong
condition from which you can sober up but never recover from completely. This
is the cornerstone in John’s perception of his past, present, and future. He
explains his behaviour as a child and a youngster according to the ideology of
the NA and perceives that behaviour as one step on the way to addiction “…I
had the patterns of dependency, long before I even started to do drugs.” In the
past he considered it a basic right to be able to meet his own needs immediately,
even at the expense of others. This behavioural and cognitive pattern has pursued
him into his clean life. He explains his behavioural pattern and how he deals
with it:
I sometimes lose track of my healing process and of myself. And I relapse back
into it [the pattern] again; it is all about meeting my needs here and now…I
would ignore other people to meet my own needs - until I realize what is going
on…when it happens, I always discover that I am one step in the wrong
direction, heading away from my recovery process. To make my Steps all the
time; to solve problems as they come; to pay my bills; to go to NA meetings; talk
to my sponsor - these are the things that keep me away from drugs. When I start
to move away from them, then the old pattern quietly starts to take over.
The Principles of NA
The problems John faces in his present life are understood in relation to the
pattern of dependence. In this way the Twelve Steps programme is an integrated
part of his life and guides his actions: The principles of NA serve both as a
personal behavioural guide and a way of understanding and ascribing meaning to
his actions. The programme provides an interpretive frame for understanding his
actions, feelings, and thoughts, as well as the moral standards for his private and
professional life:
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I have started to take responsibility for my life, I do my job, I take care of my
home, I pay my debts, I never see my wages, all the money goes into my bank
account…I am very conscientious at work too. I see to it that things are done... I
don’t postpone things too much, if I can avoid it…I live according to a set of
very firm rules in my own behaviour; in all, I don’t lie any more; I don’t steal
any more; I don’t work on the side any more; …I don’t purchase smuggled
goods; I don’t purchase stolen goods.
This moral codex guides John in trying to be a good example for others to
follow, but also puts a strain on him to be close to morally flawless while
working as a counsellor. It creates a certain pressure, which he deals with
through his religious beliefs. According to Carver et al. (1989), “turning to
religion” is a coping strategy, which serves as a source of emotional support, and
as a vehicle for positive interpretation. For John to stay off drugs is a
fundamental requirement for sustaining his job, his income, his relations to his
friends, and his status in the local NA community. When asked what has kept
him in recovery, he replies:
…my job has also been an escape. But it has been an escape into something
healthy, because I deal with people on the job, and I live in the same town, in
which I am part of the NA community. I have had to be very tough on myself. I
have had to be serious, and not fool around at all. If I fool around, then it’s just
like this (snaps his fingers), there goes the whole NA community.
The general attention to John’s behaviour makes it difficult for him to act in
ways that are inconsistent with his moral standards.
The Identity as an Ex-addict
John’s relations with other people are strongly influenced by his understanding
of recovery and addiction. He is highly selective when it comes to whom he
spends his time with, and all of his close friends are people from NA. None of
them are too easy on their own recovery. When asked whether he conceals his
past, John replies:
…Nowhere have I tried to hide my past as a substance abuser. And I don’t care
whether people know about my past. Because I think, if they can’t accept that I
have been doing drugs, then they have a problem. I don’t care at all…I am not
ashamed…even my financial adviser knows about it…I have accepted it myself.
If other people can’t accept it, it is their problem.
In this respect John is not adapting to “a conventional way of living” (cp.
McIntosh and McKeganey 2002). His past has become a central ingredient of his
present life, and he does not care whether or not others accept him and his past.
When asked whether his past life has enhanced him in any way, he replies that
his life as an addict has made it possible for him to be a happy and content
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person today. In a strange way, his living as an addict in the past has now opened
doors to a career he would never have had a chance at without his history of
doing drugs. This is a positive reinterpretation of John’s past, in which his
history as a substance abuser is interpreted in terms of the principles of the
Twelve Steps, and is seen as the basis for his current position.
Self-concept; Coping Strategies and the Individual Narrative
Talking to John and analysing the interview leave the impression above all of a
conscientious man trying his best to re-create himself as a clean former
substance abuser. He perceives himself very much the same as before, the
fundamental difference between past and present being his moral codex. This
codex is derived from the Twelve Steps programme. John’s self-concept is based
upon a generalisation of images of himself - as a former substance abuser, a
participant in the NA movement, and a conscientious and responsible employee,
parent, and partner. In these relationships he relies upon the principles of the
Twelve Steps for moral guidance. In this way the dominant conceptualisation of
himself is that of an ex-addict whose past is accentuated and seen as a vital part
of his present life. John perceives his past as a crucial and inevitable condition
for his present life, and the success he experiences in his present life is very
much perceived as an outcome of the challenges and obstacles he faced in the
past. As such he is building his present identity upon his identity as an addict
(cp. Biernacki 1986). His ongoing coping strategy is a fundamental positive
reinterpretation of his past. Carver et al. (1989) use the expression “positive reinterpretation” to designate a coping strategy involving the reinterpretation of
events, thoughts, and behaviour, and viewing in them the potential for growth.
This is an emotional type of coping aimed at resuming a more problem-focused
coping strategy (This concept of positive reinterpretation and growth is in line
with the concept of positive reappraisal used in the transactional approach to
coping by Lazarus and Folkmann [Lazarus 1993; Lazarus & Folkmann 1984]).
John’s problem-focused coping strategy implies living according to a set of very
strict rules, which makes it possible to him to stay abstinent. The success of his
positive reinterpretation is based upon the ability to stay off drugs. One
consequence of this strategy might be that it doesn’t lead to further integration of
feelings, cognitions, and behaviour related to life as a non-addict. John continues
to view himself as an ex-addict and to live the life of an ex-addict, interpreting
experiences in terms of that self-concept. Experiences, in contexts or
relationships supporting a non-addict rather than an ex-addict identity, might still
be interpreted in terms of John’s self-concept as an ex-addict. In this way he
holds on to his identity as an ex and his positive reinterpretation of his past.
Overall, the way John construes his narrative serves as a maintenance strategy in
terms of holding on to an almost fixed and predetermined purpose in his past,
present, and future.
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Hannah’s Case: Assimilating the Past (2)
With a history of more than 20 years of using drugs and making money
preferably through prostitution or selling drugs, Hannah entered residential
treatment at the age of 39. At that time she was in prison but had the option of
treatment instead. The treatment programme was based on the ideology of AA.
Because of Hannah’s changeable and unpredictable drifting in and out of prison,
and her chaotic drug use, her now grown-up daughter was raised by Hannah’s
own mother. Hannah herself now lives with her partner, joins the local NA and
AA for regular meetings, and sees her daughter frequently. She has been off
drugs for five years, and works as a counsellor, together with trained staff
members, at an outpatient treatment centre for substance abusers.
Being or Not Being an Addict
Hannah views her life as a substance abuser as boundless. She used to feel as if
it were somebody else carrying out the activities that went beyond the normal
limits. She explains this feeling:
…it was as if I could not recognize myself in the substance abuse. It was as if
there were two people fighting inside of me all the time, one who said: ‘Why are
you doing this, Hannah, you don’t have to do drugs and all that’…and at the
same time there was another [voice] saying: ‘Yeah, but you have to, you can’t
stand it, not doing drugs’. And I think that there has been a struggle going on
inside of me for many years, until…all those boundless things I did to supply
drugs, I couldn’t stand thinking about it. It was as if it wasn’t me, I imagined that
it was somebody else.
She experienced the activities as threatening to her self-concept and used a
strategy of denial of reality while she was into drugs. One feature of “denial of
reality” as a coping strategy is that it allows events to become more serious,
making further adaptive coping even more difficult (Carver et al. 1989).
Return to a Moral Codex
A main feature of Hannah’s account is her return to a moral codex learned prior
to the onset of substance abuse, and in some ways, a return to a concept of
herself as she probably would have turned out if she hadn’t been into drugs for
all those years. She states:
The longer I have been clean, the more clear it gets to me, how I would have
turned out if I had not ended up doing drugs. You know being happy and
positive and outgoing… I damned well know what is right and wrong. And my
moral standards are very high. I know of other ex-addicts whose morals are
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frayed at the edges, I can’t deal with that. I tell them that maybe it’s all right for
you, but I don’t do that kind of thing…like those guys on social welfare or
rehabilitation payment…working 12 hours every day on the side. And also those
who buy stolen goods … these kinds of behaviour are not allowed in my world.
…I am convinced that it is something I have brought with me from home…to be
honest, no stealing or lying…I have brought some moral concepts with me from
home.
Her present moral standards are in opposition to her life as a drug addict. She is
not explaining her past behaviour and moral standards (as a substance abuser) as
a result of a certain pattern of dependence. Instead she copes actively with the
difficulties of her present life:
To be social and outgoing... I know of some [other former substance abusers]
who have a hard time doing that and they mostly want to be by themselves. I
haven’t been that way, I was very fast to go out and get together with other
people, and I am also capable of roughing it when things don’t turn out well… I
don’t give up, if things are unfair or I think they are unfair, I tell people.
Hannah uses a “problem focused coping strategy” (Carver et al. 1989). This
implies taking active steps to confront and handle problems, a strategy she
describes as being based on her life prior to living as a substance abuser.
Bracketing
The way Hannah describes her past can be conceptualized as a way of bracketing
her life as a substance abuser. She has gained experience from that part of her
life, but she also wishes to leave it behind. Hannah views the relationship to her
daughter as the major hurdle in her personal life at this time, and in this
relationship she is not capable of bracketing her emotions:
And my daughter, that has been the most difficult part of it. And still is…it has
been really painful to me. There’s too much shame and guilt and…she’s been
with me all over the place, there has been no doubt in her mind that I did drugs,
she’s found the syringes and needles …she woke me up when I flaked out…I
really let her down…In the first years [following my recovery] my daughter was
very self-protective as far as emotional attachment goes. Because I think she had
shut herself down - I was her mother and that was it... she had closed herself up
in relation to me, as I had in relation to her - emotionally. We had to start all
over again very slowly…but I am very confident, because…it’s beginning to
loosen up… I am so grateful that I have her, but at the same time it has been and
still is the most difficult part.
Instead of bracketing and denying the fact that she failed in the relationship with
her daughter, Hannah accepts that they both have to live through the feelings of
loss and abandonment. This is a restraint type of coping, which implies waiting
until an appropriate opportunity to act presents itself, holding oneself back and
not acting prematurely (Carver et al. 1989). For Hannah this is an active coping
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strategy in that her behaviour is focused on dealing with the problems in the
relationship to her daughter in the only way possible at the moment. Hannah is
not able to explain this part of her past in relation to the pattern of dependency,
as was seen in John’s case. There is neither forgiveness nor oblivion in the
relationship with her daughter; instead, together with her daughter, Hannah has
to prepare the ground for new experiences, which can help them to narrate a new
story.
“Being Ordinary” Instead of “Being an Ex”
Hannah states that in the past she always felt as if she did not really fit in
anywhere, not in her family, in society, or in the world of addicts. However, she
continues:
…I’m not actually different from them…at the beginning of my clean time…I
really felt special and different. But I don’t anymore. … I know that it has to do
with me moving out into the world. I still relate to the Twelve Steps programme,
but I have also moved away from it, as far as my relation to my work and all the
different colleagues I have, I learn a lot from that. And I have found out that I am
not so different, …it is not just addicts who have trouble managing [in life]… In
the first years you think that you are so special, and that it is only we who can’t
manage. Of course there are specific things, but mostly it’s something everybody
would experience problems in trying to manage. It has helped me, not feeling
different. I don’t think about it anymore, I actually often forget that I am an exaddict, …when I am with other people.
She has come to view her problems as common, and as something everyone
living a quite ordinary life might face. She understands herself as a person,
facing the same kind of troubles, and having the same kind of experiences in the
world as her neighbours, colleagues, and friends do. She describes how she
forgets that she is a former substance abuser. In this way she no longer defines
herself in relation to something she used to be, a phenomenon described by
Ebaugh (1988) as “the identity as an ex”. Instead she defines herself in relation
to her present life. Hannah’s relationship to the NA community has changed over
the years. She explains that NA used to be:
…98 % of my life, then 90 % and 70 %. In the first years, it was most of my life.
Now I have a life outside of that, which fills me up.
Life outside of the NA community seems more important to her. She states that
she now prefers to attend meetings at AA, a decision based on a closer
identification with the people attending AA meetings than the people associated
with NA:
…I have started to join the AA more often than before, and it’s simply
something to do with the people in AA, who…have a job and know about things.
When I have had some difficult times, they know about it and can give me some
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advice in terms of how to deal with it… I have moved away from the NA…a lot
of my work at the shelter is with the same people, so I have had to move.
She clearly feels a distance from the world of former substance abusers, and
doesn’t feel that she belongs anymore. Her conceptualisation of herself is that of
an ordinary person with a job more than that of a former substance abuser:
I live out here [in the suburbs], look like all my neighbours, go to work every
day (laughs) at the same time as them and return home at the same time, eat my
dinner, relax on the couch, go to see some friends…I think it is wonderful. To be
a part of the society, to be an ordinary citizen, who generally speaking takes care
of herself, pays taxes. I think it is marvellous.
In her present existence Hannah strives to be able to live an ordinary life.
The Self-concept, Coping Strategies, and the Narrative
Hannah’s case is characterized by her strategy of “assimilating the past”. Her
past as a substance abuser is incorporated into and merged with her present
image of herself. At first, her past as a substance abuser was an important part of
her self-concept, but it has now lost that kind of overall significance. Keeping
the continuum (Figure 1) in mind, one can say that she has moved away from the
position of accentuating the past, in terms of relating to the ideology of NA and
AA. She no longer sees herself as primarily an ex-addict. She has also given up
the view of herself as a “terrible boundless person” (which was the way she
perceived herself as an addict) in favour of conceptualising herself as a
responsible person with both moral and emotional integrity. The narrative she
lives by is that of a woman with potential as an individual, an employee, a
partner, and a mother. Hannah is actually leaving behind the world of addicts or
former addicts to enter the world of more conventional and ordinary living, a
process described in the studies by Biernacki (1986) as well as McIntosh and
McKeganey (2002). At first it may seem as if Hannah is bracketing her past as a
substance abuser, but now her life as a substance abuser is perceived as only a
part of her past, and there are many new experiences in her current life that are
far more important and constructive for her. She uses a coping strategy of
acceptance, in terms of accepting her past and realising that she cannot change it,
and works instead on changing her current relationships and her behaviour. This
strategy is combined with the restraint of her urge to make things move more
quickly in relation to her daughter (cp. restraint coping strategy), and the
realisation that she is capable only of changing her present, not her past. In her
present life she faces the problems created by her past, realising that even though
the significance of the past gradually wanes, it still carries serious consequences
for her relationship to her daughter. She draws on the moral and emotional
integrity that she had to a certain extent internalized prior to life as a substance
abuser. This is combined with her ability to integrate new experiences and face
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new challenges, and to perceive those as the building blocks of her new selfconcept. All together these strategies make up her ongoing maintenance strategy.
Lisa’s case: Concealing the Past in the Present Life (3)
An example of concealing the past as a maintenance strategy can be found in the
story of Lisa. She is 28 years old, and she appears to be like a lot of other young
women in their twenties: she has just finished her education as a preschool
teacher, and plans to move in with her partner. She reports an ordinary
childhood, and neither her parents nor her siblings have had problems with
alcohol or drugs. She had been using cannabis, speed, different kinds of
sedatives and tranquillizers for several years. In all Lisa has experienced
approximately six years of problem use of different drugs. She has been in
residential treatment twice. Prior to the last episode of treatment she injected
heroin for one year. Following the last stay at a treatment centre, where
treatment was based on social training and individual psychotherapy, she moved
in with a partner, also a former substance abuser. They lived together for a while,
and went through several episodes of using drugs. Each time they went to great
lengths to keep their drug use a secret. It was a major strain to live with the
threat of being observed by someone they knew, and the episodes of drug use
were always filled with paranoia.
The Self-concept of “Not a Real Addict”
During her first phase of treatment, Lisa felt as if she were not a “real addict”
like the other substance abusers. She describes this feeling:
At that time I hadn’t been all the way down ... I thought that it was cool to be
there, they were nice people. But they were tough addicts, prostitutes and
murderers….
After her first stay at a treatment centre, she started to use heroin. Up to that
point Lisa had managed to make money for her drug consumption primarily
through shoplifting. But soon that wasn’t enough. She continues:
I always knew, …that when I started to consider making money as a prostitute,
and things like that, then I would quit the drugs. And that’s what I did.
Her lack of identification with the other substance abusers probably made it
easier later on to distance herself from the identity as an addict and as a former
addict.
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Striving to Create a Normal Life and the Risk of Being Disclosed
Upon the second phase of treatment, Lisa experienced the joy of living an
ordinary daily life. She describes the feeling of normality:
...Along the way you just feel more…you just feel more normal. You aren’t sick
in the mornings; you are able to sleep at night without…so it just turns into an
ordinary daily life again. I thought it was just wonderful.
A precondition for living a normal life seemed to be a rift with all acquaintances
from her past as a substance abuser, and also with people from the residential
treatment centre. In the first period following residential treatment Lisa spent a
lot of time with a group of other former substance abusers. But life as a former
substance abuser, including contact with other former substance abusers,
conflicted too much with how she wished to live and perceive herself:
…I think it was too much in the end, I had it up to here…I just thought that now
I had to get out and live in a completely normal way.
She no longer perceives herself as an ex-addict. If asked about what makes her
hold fast to her new lifestyle, she replies:
Mostly it is because I am feeling so well..… I would not change that for
anything, not the way I feel today…I am not the typical substance abuser
[laughs], I’m not into that kind of scene.
Lisa feels there is a gap between her self-concept and the way she understands
substance abusers in general. She is developing a perception of herself as a
grown-up person responsible for her own survival:
…I have always been supported by the social welfare system. This is the first
time I’ll be earning my own money.
Lisa describes how she feels alienated from the person she used to be as a
substance abuser, and at the same time she recognizes that her past is a part of
her present. She just wants to keep this past a secret known only to herself, her
partner, her family, and a few close friends. She distances herself from activities
that go beyond the limits, which represent activities of the kind she engaged in,
in the past:
…I can’t recognize myself, it’s like a movie you’ve seen a long time ago, with
somebody else…and then on the other hand it is so close to you…that it has
become part of you. It is not something I talk to people about, I don’t tell them…
in some ways I am still the same person, as I have always been …then there are
some cumbersome things, which you carry with you, and which you could have
been without. You are suspicious of people, you hold yourself back and …but
apart from that I think that I have obtained some kind of insight…in life (laughs)
…you get some scars, but you also get stronger…
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The suspiciousness toward other people is perceived as a remnant of living in the
addict world, a tendency which influences Lisa’s way of relating to other people
today.
Her strategy has consequences for her relationships with other people, both in
terms of not letting herself become too attached or too close to others, and in
being suspicious of other people’s motives. When asked how she gets along with
her friends, and what they do together, she replies:
Mostly we just hang out together. I don’t have friends with whom I sit and turn
myself inside out.
She does not share this intimacy with her partner either, and explains:
…I have never done that with anyone…. Besides I am rather good at skirting
around things if someone...gets too close…there are certain things which… yeah,
which you just keep to yourself.
In this way she describes such behaviour as a general characteristic, but her
strategy also seems to be driven by the fear of being disclosed. She expects to be
condemned if other people find out about her history of substance abuse. Lisa
has established a life separate from her past, but sometimes the past influences
her current life anyway. In terms of meeting new friends she states:
Generally meeting new people, I don’t think it’s cool. Also it’s tedious to lie
every time you meet someone - because that is what I do. I think it’s annoying,
but it can’t really be any different…But I have taught myself that…I never say
anything before I have…I just don’t sit and talk away, which many other people
do. People always let me know that I am a bit withdrawn and shy, but that is not
what it’s about…
Self-concept, Coping Strategies, and the Narrative
There is a vital part of Lisa’s history that she does not wish to share with
anybody, so she uses a strategy of concealment and avoidance. She tries to cover
up incompatibilities in the stories she tells people. She is afraid of saying things
she might regret afterwards, so she often chooses to say nothing when in the
company of other people. The strategy of avoidance implies avoiding new
relationships; avoiding being in her hometown more often than necessary (which
involves the risk of facing the past); and avoiding the risk of revealing anything
about the past to anybody irrelevant. It is an emotional coping strategy based on
the anxiety of being found out. It implies that her past is subtly directing her
present. She has to keep a certain distance from other people in order not to
reveal her past, and thus gives the impression of a guarded and withdrawn
person. Other people might perceive her self-protective and constrained
behaviour as a personality characteristic, and as her ordinary way of relating to
262
others. In this way Lisa’s strategy makes the development of a network and new
social relationships a difficult challenge. As seen in the studies by Biernacki
(1986) as well as McIntosh and McKeganey (2002) the establishment of new
social relationships is central to the process of recovery. But in some ways Lisa
has successfully managed to build a new life and identity as an ordinary,
mainstream young woman, who is self-supporting, lives in her own apartment,
and has a steady partner. Her new self-concept is supported by her current way
of life but does not integrate elements of her past as a substance abuser. On the
contrary she avoids any contact with people belonging to her past, and she does
not tell new acquaintances about her previous life. In this way a central aspect of
her biography remains a secret, and she has thus created a narrative of
concealment.
Discussion and Conclusion
In a study by Michael Bury chronic illness is described as a critical situation in
which the individual faces profound disruptions in the explanatory systems
normally used. Such disruptions demand a fundamental rethinking of biography
and self-concept (Bury 1982). Along these lines the transition to a non-addict
lifestyle can be viewed as a critical situation, in which the individual has to
rethink his or her biography and self-concept. The focus of this paper has been
the construction of the individual story as a maintenance strategy. A person’s
way of dealing with the past has been studied as an individual process, but this
process is also embedded in a social context in which the individual story can be
confirmed or disproved, as illustrated in the study by Biernacki (1986). Figure 1
illustrated three separate ways of living with the history of substance abuse; it is
possible to find other strategies for dealing with the past and place those on the
continuum as well. The cases presented here are to be seen as special cases
illustrating the diversity of ways of dealing with the past. They illustrate the
three different identity transformation processes delineated by Biernacki (1986).
In John’s case his existing identity as an addict is extended but not
fundamentally changed. Hannah’s history illustrates the reversion to an old
identity, and Lisa’s story exemplifies the creation of an emergent identity that
did not exist during substance abuse. The present study, however, goes beyond
the conceptualisation of Biernacki. Through the individual reports of former
substance abusers, it explores the process of identity transformation and the
consequences of maintenance strategies. As described by Koski-Jännes (1998)
and Hänninen and Koski-Jännes (1999), an individual story can provide meaning
and make sense of experiences. This was especially apparent in John’s case. He
viewed his past as a substance abuser as an irreplaceable component of his
present life, and as such, his present always referred to his past. In Hannah’s
case the significance of her individual story of addiction diminished over time as
new life experiences increased in importance. In this way her past as a substance
263
abuser lost significance as a main reference point in her life, and no longer
worked as a matrix for interpreting experiences and emotions. Instead she
created a new story in which she made an effort to act as a responsible parent,
colleague, and partner.
A challenge faced by the former substance abuser is the gap between his or her
life experiences (e.g., experiences of criminal activities, prostitution, and
substance use–related behaviour) and the experiences of people without a history
of substance abuse and addiction. These differences in experience can create a
distance, noted in the interviews, which challenges the subject’s efforts to
establish what Biernacki (1986) and McIntosh and McKeganey (2000, 2001,
2002) conceptualize as an ordinary or conventional way of life. This distance can
also be established to hold on to an ex-addict identity, as in the case of John, or
to conceal the past in a present social context, as in the case of Lisa. However
the case of Hannah shows how it is possible to let the old identity and selfconcept gradually be replaced by a new identity and new self-concept. This was
possible because Hannah let new experiences influence and shape her individual
matrix of interpretation.
The three cases represent diverse ways of solving the challenge of identity
transformation and maintenance, and demonstrate diverse strategies for coming
to terms with the past several years after living as a substance abuser. In John’s
case his self-concept hasn’t changed fundamentally; it is only the rules guiding
his behaviour and the surrounding setting that have changed. Hannah’s case
shows how the past prior to life as a substance abuser, together with life after
substance abuse, provides the building blocks for her new self-concept and
thereby her new identity. And if Lisa’s story is compared with the stories of John
and Hannah, it is clear that Lisa hasn’t led the same kind of addict life as the
others - neither in the duration of the addictive behaviour nor in the severity of
drug-related behaviour. This may be one of the reasons why Lisa has been able
to start a new life in a new environment and dissociate from her past as a
substance abuser, and through this means, to construct an identity quite unrelated
to her past. One general implication of this study is the importance of viewing
recovery from substance abuse as a lengthy process that often lasts several years.
At the same time it is important to recognize that the problems faced by these
people change over time. For some the obstacles in life become more and more
“ordinary”, while others continue to relate their problems to their past as
substance abusers, and to interpret events according to that matrix. The present
study shows how this can be due to differences in identity and maintenance
strategies.
264
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Turnings in Alcoholism:
A Thematic Analysis of Life Histories
from the Lundby Alcohol Subset
Leif Öjesjö
Turning points or epiphanies have been defined as moments and experiences that
leave marks on people's lives, in the present context a point at which the decision
to give up an addiction is taken or consolidated. They are often moments of
crisis. Some are ritualised, some are routinised. Others still are emergent and
unstructured, and the person enters them with little if any prior understanding of
what is going to happen. According to the literature, this turning point is usually
accompanied by some experience or event which serves to stimulate or trigger
the decision. These triggers can be either positive – e.g. securing a job, receiving
an inheritance, winning in the lottery, starting a new relationship, or the birth of
a child – or negative – e.g. a sudden deterioration in health, being faced with the
prospect of going to prison, or the death of a partner or close friend (Denzin
1987; McIntosh & McKeganey 2000; Miller & C'deBaca 2001). Koski-Jännes
(1998) has reported data from a Finnish sample of media-recruited subjects who
had been able to resolve their dependence on alcohol, drugs, binge eating and
other excessive behaviours. The turning points seemed to involve a heightened
awareness and a cognitive-emotional shift in which the individual’s regular
pattern of seeing, interpreting and approaching things was suddenly changed.
Recovery implied the idea of turning points in a positive direction, from
suffering to improvement, and was often followed by a change of self and
identity.
Fateful moments (Giddens 1991) are those moments when individuals are called
on to take decisions that are particularly consequential for their ambitions, or
more generally for their future lives. The decision to get married, or later perhaps
the decision to separate and the actual parting, taking examinations (or failing),
giving up one job in favour of another, starting a new business, or losing money
and going bankrupt, are just a few examples. These moments are times when
events come together in such a way that the individual stands at a crossroads in
his existence; or where he learns of information with fateful consequences. They
are turning points that have implications not just for the circumstances of an
individual’s future, but through lifestyle consequences, for self-identity as well
(Giddens, ibid.). Hopcke (1997) uses the Jungian expression synchronicities to
describe the meaningful sequences of similar unusual (accidental) events and
emotional experiences symbolic in nature, that may occur in these transformative
moments of existence. The person has the feeling that something highly
267
meaningful has happened, after which one is never the same again. Miller and
C'deBaca (ibid.), drawing on both the concept of a quantum leap and the
unpredictability inherent in quantum mechanics, call the phenomenon quantum
change, which means highly memorable special moments of enduring personal
transformation.
Aims
The central research question here was to describe turning points in the course of
Alcoholism.
A turning point was defined as a memorable event that leads to a change in
alcohol-related behaviour. Both positive and negative implications of the turning
points were explored.
Material and Methods
The Lundby Data Base is a psychiatric, prospective, epidemiological study
where researchers from Lund University have been following a general
population cohort from southern Sweden since 1947. Essen-Möller (Hagnell et
al. 1990) originally described the 2550 men and women who were living in the
community on July 1, 1947 (time 1). Hagnell and collaborators reinvestigated the
cohort irrespective of domicile ten (1957) and twenty-five (1972) years later.
The dropout rate has remained very low (less than 3%). Complementary
information about the deceased has been added. A follow-up of the mental health
of the total population cohort fifty years after the initial study is now under way.
The Analysis Subset
The subset was selected from the project material and was narrowed down to the
41 men who developed Alcoholism (Alcohol Dependence or Alcohol Abuse) in
the 15-year period between 1957 (time 2) and 1972 (time 3). As part of the total
population these men have been interviewed in 1947, 1957 and 1972 (Öjesjö et
al. 1982).
At the time 4 follow-up (1993-95), it was found that 18 (44%) of the men had
died. The average age at death was 56 years (range 25-86 years) (Öjesjö et al.
1998). Twenty-three subjects were alive. The age of the survivors varied from 48
to 90 (median age 54 years). Occupations were also varied, with the skills range
encompassing both blue-collar and white-collar jobs, for example labourers,
268
drivers, technicians and self-employed businessmen. Sixty per cent (15/23) were
retired from work at follow-up. One was unemployed. Eleven subjects (48%)
had a current Alcohol Dependence or Alcohol Abuse. Twelve (52%) had
recovered. The remissions were age-related, starting at age 30-39 and
culminating at age 40-49, although a substantial number of remissions occurred
after age 50 (approximately 20%) (Öjesjö 2000; Öjesjö et al. 2000). The 23
survivors were asked once more to take part in a personal follow-up. They were
all offered a lottery ticket after the interview by way of a small compensation for
their participation.
The author successfully interviewed all but two subjects. The number was
expected to give a material diversified enough for a qualitative analysis and for
comparative purposes. Interviews were conducted preferably in the interviewee's
home, but also at their workplace and at institutions when necessary. The
interview was face-to-face, open and flexible. It lasted approximately one hour.
Subjects were asked to tell their life story in their own words, and the
researcher's task was to listen with empathy and to give positive feedback and
ask for details by posing further questions focusing on health, drinking habits,
problems and turning points, especially in the period between time 3 and time 4.
The interview data were complemented with information from collaterals,
hospital records and the official death register.
As participants in the Lundby Cohort Study, which has been approved by the
Ethics Committee of Lund University Medical Faculty, the respondents were
assured of confidentiality and anonymity. For these reasons the names and the
places have been disguised, but not the incidents; other parts of the text have
also been made as anonymous as possible. Nevertheless, publication of the
material obviously calls for great care. In fact it may well be an advantage that
publication has been delayed by almost a decade since the time of data
collection, for this will certainly give adequate protection to the informants.
Findings
The reconstruction of a life history requires first of all an analysis of the data
upon which it is based. The following case vignettes are intended to be
exemplary, not exhaustive. It was clearly not feasible to consider publishing all
the evidence collected (out of consideration for the reader, ethical safeguards,
and practical matters such as space limitations).
269
Positive Turnings
Alan had become a sailor when he was 15. He was adventurous and had travelled
around the world. At sea, his fellows introduced him to alcohol. “We were
drinking like mad in those years. Not a single sober day! Liquor and women
were the only things we talked about” (interview at time 3). Harbour fights and a
tough attitude had brought him in contact with the police several times. In his
late twenties Alan wanted to settle down and have a family. He went ashore and
took a job as truck driver. His alcohol consumption decreased. After a serious
traffic accident Alan decided to become a teetotaller.
Bill had started drinking heavily in his late teens. He earned his first money by
joining his father who was a market dealer. Later on he went to prison for
violent and other criminal offences. There, Bill was introduced to drugs and
needles. “World events just passed by…” (interview at time 3). At time 4 he had
quit his former life. The change came in his thirties after receiving treatment and
when he was able to reconnect with his family. Bill said that he was really
motivated to change his life and was lecturing at schools about his experiences.
He felt that telling his life story to others helped him constitute his new identity
as a recovering addict.
Carl had got a job at an institution as a technical assistant. Although he didn't
have proper academic qualifications for the job, he considered himself to be at
that level, yet he found the work boring because he felt that his research talents
were not put to the best possible use. Alcohol had come into his life from
drinking with his friends late at night. He was increasingly on sick leave because
of depression and alcohol and drug abuse. At time 4, Carl was on early
retirement pension and was living with his family. His life had taken a positive
direction.
After completing his college education, Dave had got a job as an administrator.
He had married, but his wife had left him for another man. Dave moved to town
where he had to take a less qualified position. It was then that Dave began
drinking alone in the evenings. At time 4 the picture had changed. Dave was now
at ease with his life. He had fallen in love and had remarried. He had also retired
and he had recovered from his alcoholism.
In Eric’s case, there was evidence of alcohol abuse since his early teens. His
“career” had consisted of short and temporary jobs such as apprentice, farm
labourer, and dishwasher: “He was dishonest and he wasn’t willing to keep a
job. When spring came he wanted to leave at any cost” (grandparents
interviewed at time 3). “I was a vagabond…Lookin’ for something I couldn’t
find. Nobody wanted to deal with me. I had no friends and nowhere to go… no
purpose. I felt hopeless and (I) was drinking to silence my anxiety” (quotations
270
from records). Eric found himself increasingly unemployed or on sick leave,
wandering aimlessly, just drifting from day to day, tired from alcohol and
tranquillizers, desperate and on the verge of suicide. At that time Eric became
preoccupied with religion, and he carried a Bible everywhere. He remembered
that he prayed, and cried for help. Soon after, he was committed to a mental
hospital. At time 4 Eric had recovered. He told the researcher that his new
spiritual practices had been decisive.
Negative Turnings
Fred had been a commercial traveller. There was always a lot of booze and
entertaining. He then became manager of an old family company. When the
business had to be sold due to a slump and the owner's conservatism, Fred was
hired to manage a shop that was part of a major franchising corporation. He
never liked his new stressful job, and he drank to relieve the tension. He felt
increasingly lonely and depressed.
Fred eventually committed suicide by gas in his home.
Greg had always been “highly strung”, and he had great difficulties in holding
down his jobs. Most striking to the researcher at time 3 was his excessive
alcohol and drug intake, his ungovernable temper and lack of friends. His
drinking had caused problems in nearly every aspect of his adult life – Greg had
been fired from several jobs, he often had fights with his wife, and was arrested
on numerous occasions for disturbing the peace. Greg had also made many
emergency visits to the psychiatric clinic, where he was diagnosed as being
depressed. He saw no meaning in his life and spoke frequently of being better off
dead and of committing suicide. Finally, his wife asked for a divorce. Soon after
this, Greg called her again, threatening to take his life. She could hear he was
drunk and believed this to be yet another ruse to try and get her to come home. A
few hours later, Greg threw himself in front of a train and was killed instantly.
Harold had moved to town where he had his own shop. To begin with,
everything was fine. Then, the supermarkets took over the marketplace. Harold
worked desperately to keep the firm going. He restructured and took out loans.
Nothing helped: “It was tough. Who cares?” (time 3 interview). His increasing
drinking only made him feel worse. He had become aggressive and had delusions
of his wife being unfaithful and swindling him. A general practitioner had him
referred to an alcohol clinic for treatment. When Harold was discharged after
several months, he found his shop closed. Harold got a new job as a factory
worker, which he never accepted. Harold was living sober, but in a constant
mood of depression. Harold said that he felt trapped and had lost all hope for the
future. In the end he hanged himself from a tree in his garden.
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Discussion
Longitudinal analyses are essential in seeking to explain issues of temporality
and individual continuity, growth trajectories, life transitions and turning points.
In life, the environment is not a single thing; nor is it a stable unchanging entity.
Ironically, statistics, designed though they are to clarify longitudinal patterns,
can also make it harder to recognize changes. By aggregating across data points
and across people, lives can be made to look a lot more stable than they usually
are; for instance the timing of an event can be influential depending on when it
occurs during the life course, as can its intensity and duration. The present paper
should provide a significant contribution to the existing research literature
thanks to its longitudinally observed general population sample. The detailed
knowledge acquired of the lives of both recovered and non-recovered alcoholic
subjects through repeated interviews over many years might be considered
especially valuable. Even in a small sample one is struck by the diversity of the
stories, but also by the common threads that run through them.
What kind of events were connected with turnings towards recovery? In Alan’s
case the turning point came after the car accident. For Bert the change came in
his thirties after he had been in treatment and he had managed to reconnect with
his family. For Carl the disability pension gave him a chance to live a new life.
For Dave it came late in life after he had fallen in love. Dave also reacted
positively to the social pressure from a partner, who had forced him to choose
between a normal life and continuing an addiction career. A separated or
divorced person like Dave needs support and moral courage to face the task of
establishing a new sense of self and identity in order to try new relationships and
find new interests. Many people in such circumstances lose confidence in their
own judgement and capabilities, and may come to feel that planning for the
future is valueless, see Fred below. Overcoming these feelings demands
persistence in the face of setbacks and a willingness to alter established personal
traits or habits. Of course, there are alternative interpretations as well (Öjesjö
2002). The stories confirm that the journey to recovery is not always a
straightforward, linear process. Sometimes it is a matter of just being in the right
place at the right time.
Sometimes it is the opposite, i.e. being in the wrong place at the wrong time.
What were the negative events that made some men give up all hope? These
cases often involved chronic feelings of depression and unsatisfactory
relationships. Of course, not all negative turnings lead to suicide. For Fred,
however, the negative turn came with his new stressful job. The final verdict was
suicide; alcohol and acute loneliness were both thought to be the culprits. Greg
threw himself before a train after his wife had decided to leave him. Harold’s
drinking became a problem when the supermarkets put him into an impossible
272
financial situation. For some, spiritual experiences act as a source of meaning in
the recovery process. The trigger may sometimes be an important transition or a
major negative event, such as the death of a loved one, a critical loss, or a health
threat, or hitting the bottom. For others, it may be the accumulation of distress
over time rather than one particular powerful stressor that sets the stage for
conversion (Denzin, ibid.; Morjaria & Orford 2002; Vaillant 1995). The convert
attempts to give up not just old “love objects” (e.g. alcohol, sex, unfulfilling
relationships), but the life built around them. In their place, one looks for another
organising force, a new centre of loyalty. As it seems, it is only after these
efforts have failed, and failed repeatedly and convincingly, that radical change
becomes a serious possibility. Eric was presented as an illustration. He had
become desperately unhappy. The change came after his hitting-the-bottom
experience (he still recalled the date, time, praying and other details) and his
religious conversion. Miller & C'deBaca (ibid.) suggest that quantum change is
an enduring inner transformation, and an experience that is frequently
accompanied by great emotional release and a deep sense of relief. Then, with
time, new patterns of thought and action may emerge.
Conclusions
Whether or not a particular event constitutes a turning point, can only be
determined in retrospect. The main line of demarcation between an important
and memorable event and a turning point may be in the logic of development of
changes after the latter, while it does not need to change after the former. A life
seldom changes overnight through recognition. Indeed, the process of change is
usually much longer and not restricted only to the turning point events.
Acknowledgements
Valerie DeMarinis read the research material. Anja Koski-Jännes and Jim Orford
made useful comments on an earlier version of the paper.
The study has been supported by the Swedish National Institute of Public Health
(Grant 421-96-1031) and by the Council of the Swedish Alcohol Retailing
Monopoly (Grant 98:3:19).
273
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