Heroin Addiction Careers: Downward Spiral or Controlled Descent?
Eland-Goossensen, Anne, Hak, Tony, Vollemans, Liesbeth, Contemporary Drug Problems
For the public and for most policy makers there is no doubt that the career of heroin addiction necessarily involves gradually losing everything one has: health, income, a home, a stable network of relatives and friends, and, last but not least, any sense of self as a moral agent. Although this view is factually incorrect insofar as there are examples of controlled heroin use without such negative effects (cf. Zinberg, 1984), the image of the addiction career as a necessarily downward spiral is represented in the literature as well. The clearest example is the medical model of addiction, in which the addiction career is described as a process of inevitable social deterioration: the drug addict becomes more and more involved in deviant and illegal behavior. The addiction career can be terminated only by therapy or death. Other literature, however, describes the course of addiction as a process of "maturing out" (Prins, 1995), in which a considerable number of addicts are able to kick the habit by themselves, step by step (Winick, 1962). The latter implies that addicts are able to control their career to a certain extent. The two approaches can be represented by different metaphors: downward spiral and controlled descent.
This article, which is based on 48 interviews, discusses how heroin addicts portray their careers and the extent to which they control the downward process. It is supposed that information of this kind will enhance our knowledge of addicts' methods of controlling their situation, which can be relevant for policy and therapy. Our main question, therefore, is whether addicts portray themselves as victims of forces beyond their control or, at least partially, as capable of regulating their situation.
In the frame of a more extensive study of differences between heroin addicts in and outside treatment settings in the city of The Hague (The Netherlands), interviews were conducted with 48 addicts who had been using heroin regularly (three days a week or more) for at least two years. Among the respondents were eight women. The sample consisted of 21 heroin addicts who had not been in contact with drug treatment agencies for at least two years, five clients of an outpatient methadone program, 11 participants in a clinical detoxification center, and 11 addicts staying in a drug-free therapeutic community. The 21 non-treatment respondents were selected by a snowball sampling method (see ElandGoossensen et al., in press). The treatment group were interviewed between two and four weeks after admission.
Respondents were invited to tell about how heroin use was embedded in their lives. Experiences with treatment and, if relevant, reasons for rejecting and quitting treatment were also explored. In the interviews we used a topic list corresponding to the life areas that are distinguished in the Addiction Severity Index (McLellan et al., 1981; Hendriks et al., 1993); these include chemical abuse, medical, psychological, legal, family/social, employment/support. Housing was added as a topic. Obviously, in the respondents' stories the different life areas were not so clearly separated. Interviews took approximately one hour each and were audio-taped. The interviews were transcribed.
Results are presented in three sections. First we discuss to what extent respondents portray their careers as dominated by forces beyond their control. Next we present data on respondents' descriptions of controlling behaviors. Finally we show how personal values are related to control and, consequently, are of influence on the addiction career.
In response to the request to tell about how heroin use was embedded in their lives, all respondents spontaneously described aspects of their careers as (part of) a downward spiral. The following extract from the interview with a respondent in the detox group is an example:
I: Our first question is . . . What has been the meaning of heroin use in your life, what has been its influence?
R: In order to suppress my feelings, diffculties. It is terrible, being hooked, for I never got a kick out of it. I just landed up in it. [part omitted]
I: What happened just before asking for help?
R: I knew it got worse and worse, you know, I mean I was just sliding down. It gets worse. I had no house anymore, I lost everything, I lived on the street, you know, my life was a misery. I used to live on my own, I had beautiful houses. I lost my friends, my relatives, I turned my back on them. I thought I must stop this, it is going too far. [man, age 28, detox]
This is a clear description of a downward spiral. The addict's course of life is experienced as an inescapable "sliding down" to a situation in which one "just lands up." Many life areas are involved in this process, such as social contacts, family life, and housing in particular. Another example is presented by the following respondent:
R: In the beginning I could handle the situation. I had a very good job, I was manager of a sandwich bar, I had a good salary, and so on. First I ate up this business. My relationship deteriorated, she left me. I stayed in the apartment, but I started dealing drugs and I didn't pay the rent. I sold the furniture, and in the end there was nothing left. I went really, really low. Then I had nothing left and was removed from the flat . . . I lost really everything. [part omitted]
R: I was really back in the cellar, though I had been at the top with having that house, spending my holidays in Morocco, and having completed school. But now I am back in the cellar. I have to climb up again.
[man, age 30, detox]
Respondents differ in terms of how they describe the process of sliding down. There are differences as well regarding the life areas that are involved in this process and, therefore, regarding the lowest point that is reached. This is illustrated in the following by presenting quotations from the interviews regarding different life areas.
In the fragments presented above, the loss of one's home was prominent. Due to heroin use bills may not be paid, including electricity, water, gas or rent. Sometimes neighbors complain about nuisance. These factors may result in being forced to leave the house.
R: For heaven's sake how could things go so far? I had everything I wanted, I earned money. Although I was alone with my children, it went very well. And then at a certain moment more and more people came into my house, and you cannot control it when you fall asleep. There is always someone around who opens the door for another, and once they are in they do not go anymore, it became full. [part omitted]
R: Then I was evicted from my home. I received a letter, and I had the money but it was too late. I could not undo it. I didn't know what had happened, but it appeared that neighbors had complained. I didn't know because I was working whole days. And the eviction came. [woman, age 39, non-treatment]
Another reason for losing one's home can be that relatives or the partner force the heroin user to leave as a result of quarrels. In most cases losing one's home means also losing one's possessions. In those cases users must turn to relatives, friends and acquaintances for housing. However, relations with relatives and friends will become stressed as well.
In the area of social relations the downward spiral is characterized by an estrangement from former friends, resulting in isolation. Money is considered more important than friendship:
R: And the friends in the drug subculture, one cannot call them friends. They betray you all the time.
I: Did you have friends before you started using dope?
R: At that time I had very good friends indeed. We did a lot together. Due to my dope use these friendships got neglected. People find out, and you start fooling them. I neglected them and since that time I have no good friends any more.
I: So that estrangement was caused by the dope?
R: Because of the dope, when with other persons one is constantly watching out for money. What can I remove here, what there? And at a certain moment one starts manipulating them. And when they figure it out, then it is over. That is how I lost many friends.
[man, age 29, non-treatment]
For almost all addicts it is this change of interest-from an interest in the person to dope and money for dope-that thwarts the ability to have satisfying social relationships. Contacts with non-using friends are replaced by contacts with other heroin users. Friendships in the drug subculture are not equal to relations with non-users ("one cannot call them friends"). They are more oriented to money and material advantage.
A similar process of estrangement may occur with respect to family members, though the ties are often stronger. When the relationship with the family is good, it can be a source of accommodation, meals, hygiene and money. Although several respondents reported being cared for by their mother during a large part of their addiction career, family contacts worsened as a result of lying about drug use, spending less time with the family, and manipulating behavior with the aim of getting money. Respondents told of arguments with parents and even of physical abuse of their mother. On the one hand, taking away valuable objects, cheques or jewelry was for several respondents a reason to stay away from home, because they felt ashamed. On the other hand, a few respondents reported that relatives initiated severing contact. In some cases relatives searched for the addict in the drug scene when the latter had broken all contact with the family:
R: Finally things were going so bad, you know, that my mother even searched for me. She wanted to know whether I was still alive. My brother searched for me several times and found out that I was sleeping in a squat, with ten blankets or five coats or whatever.
[man, age 35, therapeutic community]
Similarly, the relationship with a partner may suffer from the addict's lying, manipulating, indifference and "borrowing" of money, and from the disappearance of sexual desire. Aggression as a result of cocaine use was reported as well:
Did you become aggressive because of the coke?
R: Yes, one becomes a different person by using coke. For instance, first I could live together with my girlfriend, but later I began battering her. I was using, say, 10 to 15 grams of coke, and I could not avoid beating her. So I was thrown out. That was four years ago, but it still bothers me. [man, age 36, non-treatment]
Some respondents with children were deprived of their parental rights:
I: How did your heroin use affect your relationship with your family?
R: Yes, it spoiled the atmosphere totally. My children were removed because I did not pay attention anymore, because of my drug use. That is why they were taken away, but I always had enough food for them, they had no shortage of that. [man, age unknown, methadone]
Some made an arrangement with relatives-for example, a sister took care of the children. Others lost all contact and voluntarily or involuntarily relinquished their right to visit their children:
R: I have two children with another girlfriend. Twins, I love them. Two girls, 16 years old, so beautiful.
I: Do you still see them?
R: No, I watch them with my binoculars, in secret. They live in another city, with their mother. [man, age 41, non-treatment]
Losing contact with one's children is the most painful of all losses. The desire to establish contact with her children again is the only remaining wish of the following respondent, a sorrowful, unkempt woman in a filthy, empty house whose door could not even be locked.
I: Did you ever want to kick the habit?
R: Yes, for my children. I would like to quit at once, you know, for my children. I love my children very much. [woman, age 34, non-treatment]
Most respondents, however, do not report a decrease of substance abuse, but rather an increase.
Many respondents describe how the use of cocaine, certainly when it is boiled and used in a base pipe, often leads to loss of control. An extreme form is loss of consciousness.
R: Before applying for treatment I was completely out of control because of cocaine. I was entirely tired because of using. [part omitted]
R: I'll never forget . . . The other day I awoke on the floor with a bump on my head. I had not noticed it at all. Another time I found myself lying in the bathroom, totally unconscious. [woman, age 37, therapeutic community]
A clear signal of losing control of drug use is when a user does not decide for himself anymore the amount of use but is limited by the available money.
R: Money influences the amount of use. If you have more money, you use more.
[man, 29, non-treatment]
Few users are able to avoid this situation. Usually they will need more dope and therefore more money.
Sooner or later almost all users experience a shortage of money. Different solutions are found, among them the manipulation of relatives and acquaintances, and criminal activities. Mentioned by the respondents were forging cheques, shoplifting, stealing car radios or cars, burglary, drug trafficking, and bank robbery. Many respondents described the experience of the need to shift to more and more serious crimes. This is illustrated by the following fragment from a user who can be considered a hard-core addict:
And, for instance, getting money for dope . . . perhaps this brought you in contact with the police. That will influence your life as well.
R: Sure, it had a lot of influence, I was long periods in jail several times. One becomes more violent. Little things do not help enough, and then you start to do more serious things. One begins organizing something such as robbing a bank. Things get out of hand. And if one gets caught for that, one gets a long-term jail sentence. That happened to me once. [man, age 29, non-treatment]
However, the escalation described by this respondent does not apply to all. Another respondent described losing control within only one type of criminal activity, stealing car radios.
I: Can you tell more about how you financed your habit, and how that developed?
R: In the beginning I used to swindle my grandma, who had quite a lot of money, for thousands of guilders. That went on for quite a long time, about two years. I had not yet lost my job at that time. Where I worked, there was always money around, in the cash register. It was there for the taking. But later, it couldn't go on. My grandma is no tree that you can keep on shaking. I began to realize that. Yes, I used to do criminal things. But I was not one of those guys who open cars very easily. But then a boy came to stay with me, and he could drive cars away or open cars very quickly. So that's what I have done also, not burglary or those kind of things, though I have done it a few times, but predominantly stealing car radios. You learn something from the guy. In the beginning one just watches, but later one does it oneself. In the beginning one has fear, but one needs money and becomes bolder and bolder. One starts with cars on street corners in the dark. One ends not caring anymore, taking them just across from the police office, or with people around it. You become even more bold. That boldness has killed me. In the last year when I started using again, I stole car radios again. And at a certain moment a guy caught me and then it ended in a bad way, because I stabbed him with a screwdriver. That was the limit.
I: Did you often use weapons?
R: No, it was a reaction out of fear. [man, age 30, detox]
This is an example of a downward spiral within a confined domain, stealing car radios. Within this domain the addict's behavior becomes more indifferent and bold. A similar development is described in the following fragment in the domain of burglary.
I: Did you stretch your rules-for instance, your principles? What about stealing from an old lady?
R: In the beginning it was always gambling machines, in clubs and chapter houses and the like. Later it became distant snack bars. But at a certain moment I had burglarized almost every distant place. And one needs money. So I took the snack bar across from the main police office in The Hague. Hop inside and then immediately run away. Then I began to take many risks, breaking windows in crowded shopping streets, hup, with a lot of noise. I didn't care. In the beginning I was almost never at the police station, but that increased because I took more risks. I was hiding ever shorter periods after a burglary. And I did housebreaking by day, I didn't want to go out at night anymore. The next day one wakes up again, sick again, and one needs money, so one goes again. [man, age 19, detox]
Common to these stories is that an ever-increasing need for money results in an escalation in terms of seriousness of crime.
Psychological and medical
As a result of heroin use a process of alienation took place in many respondents. Feelings are suppressed under the influence of heroin. Some illegal drugs arouse psychopathological symptoms-for example, cocaine use may lead to uncontrolled aggression, a persecution complex or depression. When psychological problems occur it is not always clear whether they are a result of the drug use itself or of the changed living conditions. Sometimes the psychopathological symptoms appeared before the illegal drug use.
In terms of health, first the conditions for maintaining health, such as nutritious food and hygiene, are often neglected because of the fixation on heroin. Neglecting food may also be caused by cocaine, which is known for its appetite-restricting influence.
I: What about your health and your eating habits? Do you care or do you neglect it?
R: In the beginning it was okay, when I lived with my father, when I used heroin in secret. At that time I didn't change my eating habits. But when I started using coke, I couldn't eat anymore. I remember that my father said to me: "You don't eat much recently. You only eat light things like custard, cookies and chocolate." Then I had to make up an excuse, such as I do not like potatoes anymore or something like that. I do not have a meal anymore at, say, twelve and six o'clock like I used to do. I don't care anymore since I've been using drugs. In the past I did care. Drug use has influenced my eating habits and my clothing as well. [man, age 28, non-treatment]
Second, some users are indifferent to injuries or infections when these occur. Insufficient attention may result in complications or a slowed recovery.
R: The other day I was pushed off some stairs that were set on fire. And this made scratches on my legs. Look, I still have scars from it. At that moment I didn't realize, just scratches, but a week later, when I wanted to walk, I couldn't stand up because of abscesses on my legs. I was two weeks in the hospital, nearly had a leg amputation. [woman, age 37, therapeutic community]
When one is capable of looking clean and tidy, this may prevent sliding down in other life areas, such as employment.
In the beginning of their career, users are often able to reduce negative influences on their work situation. In later stages, when they must use heroin daily in order to function well, the financing of the habit may become a problem, since time is needed for getting money. Respondents report losing their job because of, for example, coming late in the morning, or because of stealing from their employer. An example:
I: How did you find that job, just by applying?
R: Yes, simply by applying. I always took care that I looked good. Later I could not do that anymore, but in the first six years of my drug use I could still present myself properly. They could not see that I was a junkie. So I got that job. But I was often too stoned, which they could see. And I stole money from the cash register, which they knew, though they did not tell me. But then they said: "We've hired someone else" or whatever excuse they used. They said that I had been substituting for someone who came back to work. [man, age 35, therapeutic community]
Summarizing this section, it can be concluded that these heroin addicts perceive their career as a downward spiral characterized by a loss of control in different areas of life. This could be documented by examples in which respondents describe the downward movement in specific areas. It cannot be concluded, however, that this process has the same character and the same pace for each respondent in each life area, nor that respondents provide only examples of descent. We now focus on a very different kind of talking about the downward process by presenting fragments in which respondents talk about periods of being in a more or less stable situation, at least temporarily, or even describe stages of an upward movement.
The metaphor of the downward spiral fits the process of heroin addiction as illustrated in the previous section. There are, however, fragments in the interviews that do not fit this picture. First descriptions of climbing upwards after having "hit the bottom" were given. The following respondent, an older user who had been in a really bad situation, had climbed up to a more controlled situation after he had decided to nurse his father, an Alzheimer's patient. During this period he used drugs in a very controlled way. Looking back at the time before, he says:
R: I used to be like most junkies. I was lying, cheating, stealing and robbing, and I sold everything I had, the craziest things. If I could have sold the toilet seat, I would have done it. When I think about it now, I feel deeply ashamed, but it happened. [man, age 42, methadone]
He could escape this state of affairs and stay in a stable "higher" situation because he could not leave his father for longer stretches of time. Another example of a more or less stable situation in which a downward movement was halted was given by a respondent who had been working as a sailor on transatlantic cargo ships. During the long journeys on the boat he was forced to become clean and stay clean each time. Although he started using dope again as soon as he was on leave, he was always able to stop when a new trip began. This equilibrium was disturbed when he was forced to stop working because of an injury:
R: When I had sick pay because of my leg and fingers, I could not join my friends on the ship anymore. I started to see the boys who used heroin and I joined them. Then I started smoking as well. I have never again worked on a ship. [man, age 38, methadone]
Although this respondent did not work on a ship again, he is clear in stating that working on the ship would help him control his habit. Another frequently mentioned way of stopping the downward movement is seeking professional help. An example:
R: Then I came to the detoxification center. I restored in nearly six months what I had destroyed in all those previous years. I got friends again, I saw my parents again, the relationship with my girlfriend got better. My mother started to trust me again, my other relatives also a little bit. I was able again to live together with my girlfriend. I had furniture again. I could rebuild everything.
[man, age unknown, detox]
Another respondent, who had lived on the street from a very young age, described how the army had provided structure for his life and compliments regarding his behavior, which he had missed in his youth.
R: At age 18 I went in the army. I did very well, used no dope, did not drink, nothing. When I left the army, there was that big empty space again, into which I fell. And I started using three times as much as previously. If I got the chance to return to the army, I would do it. [man, age 28, detox]
Some respondents mentioned examples of specific controlling behaviors concerning drug use and criminal activities. A frequently mentioned example was saving some dope for suppressing dope illness in the morning. The following respondent tried to control his heroin use all day long.
R: For a few years now I've really tried to control myself. I smoke only little amounts at a time. I try to become disciplined. I try to save it for when I become dope-ill, try to use it only when I really need it. [man, age 30, detox]
Forms of control can also be found regarding social relationships. Some users visit relatives and friends only when they are sober. Others avoid dope-using friends and thereby using (more) dope. Most users have a sense of need for control, but the aims of their controlling behaviors differ widely. Some users talk about becoming clean again, and others are satisfied when they have a house or a room to live in. Most respondents know how the negative effects of their use could be managed or even controlled, but many are not able to realize this in their behavior.
Because the interviews were not focused on gathering detailed information about controlling behavior, we do not know exactly which controlling strategies are applied by heroin addicts in practice. By asking respondents to describe the way their heroin use is embedded in their lives, we incidentally gathered information about how they present themselves in terms of knowledge about controlling behavior and of trying to act according to this knowledge. Some examples were given-for example, saving dope for the next morning. But no detailed information was gathered. Such information may provide important practical information on which therapists and outreach workers can base their approaches.
The examples in this section do not fit the model of a spiral in which addicts are pulled downward by forces beyond their control. They rather fit the model of controlled descent, in which they are at least partially capable of regulating their situation. We have described some examples of being in control, such as returning to the parental home in order to care for a sick father, or entering the army, or being a sailor on transatlantic journeys. There is, however, another factor that we have not mentioned above, which we introduce here with the following example:
R: I can control my drug use.
I: What do you mean by control?
R: I do no crazy things for dope. I am not going to burglarize, for instance, or rob people. I would never do such things just for getting heroin. If I cannot work and I have no money for dope, that's it. Maybe it is laziness, but I do not run everywhere to ask on my knees for a little bit of dope. I do not do these things.
[man, age 43, non-treatment]
What is clear from this fragment is that certain personal values can play a role. In this case, the respondent exhibits a kind of pride that effectively prevents him from "running everywhere to ask on his knees for a little bit of dope." One can identify a clear sense of morality as well, which is quite incompatible with the model of the downward spin in which the addict is supposed to lose any sense of self as a moral agent.
Addicts as moral agents
Although it was not our initial intention to focus on moral values, they were so prominent in the interviews that we could not ignore them. Moral values showed up in two ways. First they appeared as an area in which the process of uncontrollable sliding down took place. An example:
R: The influence of drug use on my life? Both positive and negative. What I experienced as positive is that I dared a lot more because of drugs. I did things that I wouldn't do so easily otherwise. Negative sides of my drug use are that certain limits were overstepped-for instance, regarding criminality. I am no criminal. Normally I wouldn't think about doing the nasty tricks that I have done. But due to hard drugs I overstepped my limits so far that I did things of which I think now: How could I ever do that?
[man, age unknown, detox]
I: So you overstepped your limits in the area of criminal activities as a result of drug use?
R: Yes, I do not think that I really am that way, but I was caught several times, was in jail several times. I do believe that drugs can make you overstep your limits. I am convinced of that. You start doing things that you would never do. Even dangerous things.
[man, age unknown, methadone]
At the end of such a process of blurring of moral principles, users may arrive at a state of psychological numbness in which indifference to all values is described:
I: But you are able to control?
R: Sometimes, only some moments. It is very strong in me that if I suffer misfortune, I sink away and nothing interests me anymore. I just sit and smoke. So deep one can go, without values and norms.
[man, age 29, non-treatment]
I: What did you do in order not to slide down?
R: Well, actually nothing. It did not interest me, I didn't care.
I: You didn't care that you were sliding down?
R: No, not really, the deeper I went the better it was.
I: Yes? Why?
R: Well, I keep on asking myself. I do not understand. That is why I had to see those psychiatrists and so on. [woman, age 18, therapeutic community]
Several other respondents stated that their overstepping of moral limits was related to the boldness induced by heroin use. This boldness may contribute to a continuous stretching of rules that can be considered a downward moral career.
Second, moral values are a constant background, a criterion against which the downward career is described. The respondents refer to this criterion only implicitly, by expressing feelings of guilt and shame. In the interviews, often a tension was expressed between actual behavior (e.g., criminal activity) and moral values. The following respondent reported tension because of a conflict between his actual behavior and his religious values.
R: It influenced everything, food, my clothes.
I: And what about your religious life?
R: I was born and raised as a Moslem, which I will stay forever. But I know what the Koran means and I know what I do now. I actually got lost from religion. I ended up at a side track. I ran away from the belief because, for instance, the Bible says also: thou shall not steal. But I do steal. And thou shall not drink alcohol, which is forbidden. Okay, I drink a little alcohol-I can't combine it with drugs, but sometimes I do drink, which is not allowed by the Koran. And one must pray, which I don't do. One has to wash oneself five times a day and pray. I take a shower every day, but washing and praying five times a day, that I don't. And everything as a result of heroin.
I: Does this bring you in conflict with yourself?
R: Yes, sure, sometimes I think eh, why don't I pray five times a day? Why don't I wash myself? It is healthy and clean if you wash yourself five times a day, but I don't do it. Then I start feeling dissatisfied. I get angry at myself, and I think: why? [male, age 28, non-treatment]
Several strategies were reported to cope with this tension between values and actual behavior, and to restore psychological equilibrium: (a) quitting the morally rejected behavior; (b) using more drugs in order not to feel the tension; or, (c) accommodating the values downward to the level of the actual behavior. (a) quitting the behavior
Some heroin users realize that their behavior contradicts their values and are able to stop the behavior:
R: I have been smoking drugs for a long time, and then I started injecting now and then, very rarely. Well, and there was one period in which I became hooked to the injecting itself. When I realized that, I thought never again.
I: You quit injecting?
[man, age 29, non-treatment] (b) using more drugs
The next respondent is not able to stop his behavior of accepting that his girlfriend works as a prostitute but doesn't want to adjust his values. He suppresses the negative tension by using more drugs:
R: What really hurt me had to do with my girlfriend, who worked as a prostitute before I met her. When we had been together for a while she started doing prostitution work again. I blamed myself for it, and her too. We both were very wrong in that. That was for me the most important limit that I overstepped in my life, emotionally. I could have stopped her doing it. It was not a dope relationship such as one often hears about it. I still love her very much, and I loved her then very much. The idea of her doing that work demanded a lot of energy and emotions, which I suppressed by using heroin. [man, age 28, detox] (c) accommodating values
Many heroin users are not able to quit the morally rejected behavior. Therefore they adjust their values in order to balance the situation, at a lower level on the downward spiral. For many addicts such repeated adjustments of values result in another experience of "self."
I: Have we forgotten anything about the influence of drugs on your life?
R: Well, the influence of drugs on my life was that I became a real bastard. So inhumane that people feared me. [woman, age 37, therapeutic community]
This self has to cope with many "failures" in terms of personal and societal moral values. The changed self-concept is difficult to reverse, which is illustrated by a user who experienced a confrontation with his "old self" after becoming drug free:
R: What has been pushed away for twenty years comes to the fore again with a bang when one becomes drug free. I have never been so overwhelmed as at that time. Many times I could not endure it. I locked myself in, I couldn't handle it.
I: Did you lock yourself in your house?
R: Yes, I really couldn't handle it, becoming drug free. It was such a horrible mirror for me, having to cope with my true self. I couldn't handle it. I locked myself in for several days until 1 was okay again. It's an enormous task, you have to learn how to handle yourself again, to accept yourself again, and many times people don't remember how they were. At least I didn't. [man, age 42, methadone]
The feelings of guilt and shame that were recognizable in a number of respondents' stories reflect the presence of central values of society in heroin addicts. Addicts are not the amoral persons that they often are believed to be. They have moral values, but they are not able to behave according to their values.
In this study we have collected data on how heroin users talk about their past, present, and future lives through in-depth interviews with 48 heroin users in The Hague (The Netherlands). Our main question was whether heroin addicts portray themselves as victims of forces beyond their control (downward spiral) or at least partially as persons capable of regulating their situation (controlled descent). They do both.
On the one hand, respondents report negative effects of heroin use that are beyond their control. They describe various kinds of material, social and emotional loss resulting from uncontrollable conditions. The image of a downward spiral is a very appropriate metaphor for this experience.
Respondents differ, however, in terms of the life areas in which the process of sliding down manifests itself. For some respondents the downward spiral is confined to the legal domain (criminal behavior), whereas others mention family relationships or housing as the main areas in which they have experienced a process of sliding down.
On the other hand, respondents speak about different types of regulating behaviors for which the image of controlled descent is an appropriate metaphor. This regulation can be aimed at preventing destructive behavior, or at restoring a "lost balance" by stopping behavior that is recognized as negative, or at kicking the habit completely. Although moral values were not a central theme in our initial analysis, we found that they are an important factor in understanding the mechanism of self-control. We found that many of our respondents express their adherence to general societal norms and exhibit feelings of shame and guilt in talking about their violations of such norms. The fact that heroin users often do not act according to these norms does not imply that they lack ethical integrity, but rather points to their inability to bring their behavior into accordance with their principles. The tension that originates from this discrepancy between accepted moral values and actual behavior can trigger forms of self-control. These findings support Faupel's view that [t]he failure of heroin addicts consistently to maintain ethical integrity is commonly understood to be evidence for a lack of any normative sensitivity whatsoever. . . Moreover as the addicts failed to maintain their ethical standards behaviorally, addicts acknowledged and asserted the legitimacy of the very norms they violated. . . . The regrets expressed, and the very necessity of offering excuses, rationalizations, and moral comparisons, all acknowledge the legitimacy of those norms that have been breached. Through these sorts of statements and reactions, then, addicts honor and reaffirm their own indigenous standards of conduct, even in pointing to and acknowledging their violation on particular occasions. (Faupel, 1987:415-16) Ethnographic studies of heroin users' subcultures (Grund, 1992; Ingold, 1992; Moore, 1992) illuminate heroin users' behavior and its (local) meaning but are less appropriate for discovering how heroin users evaluate their (heroin) career, different treatment options, and their chances to successfully kick the habit. However, in a study of 124 heroin users from "inner city" ghettos in Chicago, Philadelphia, Washington and New York, Hanson et al. (1985) describe material comparable to ours. They find ample evidence of heroin users' fear of getting caught in an uncontrollable downward spiral. One respondent describes his situation as being "at the bottom," where self-esteem is something of the past. Similarly to our findings, some of Hanson et al.'s respondents position themselves higher on the moral ladder than others and are proud of it:
I don't stick up. I don't snatch ladies' pocketbooks, man. My mother brought me up knowing better than that. (Hanson et al., 1985:36)
There is, however, a clear difference between Hanson et al.'s findings and ours. Whereas our respondents express shame and guilt, and hardly any pride, Hanson et al.'s respondents frequently demonstrate pride in their accomplishments. Related to this is that on the whole they feel themselves much more in control than our respondents. They proudly describe how they are continually and successfully engaged in a balancing act between the "straight" world and the heroin-using subculture. This difference between Hanson et al.'s respondents and ours can probably be explained by the very different societal positions of their respective social and ethnic groups. The position of poor black men in American ghettos is not such that they can easily feel in control of their lives. In this situation controlled heroin use is one of the few ways in which one can assert oneself. It shows that one is able to flirt with danger and still keep control. The two samples differ in the degree of addiction accordingly. Hanson et al.'s respondents seem to have slid downwards to a lesser degree than ours. An indication of this is that most of them still had a legal job.
In interpreting the way heroin users talk about "control," it is useful to look at the repertories that are available to them. It seems that these are much more restricted than regards addiction to other substances. Comparing current repertories of talk about heroin use with the way we talk about alcohol is illuminating. Similarly to the current image of heroin addiction, the metaphor of a downward spiral was an integral part of the social imagery of alcohol addiction from the middle of the l9th century onwards. In the propaganda of the temperance movement at the beginning of this century, the gradual physical, social and economic degradation due to alcohol consumption was graphically depicted as a downward ladder from "the first glass to the grave" (Lender and Karnachapee, 1977). The implied message was that by losing control over one's consumption of alcohol, one would lose control over one's life. Another example of this imagery is a graph by Jellinek (1952) that illustrates the phases of alcohol addiction: pre-alcoholic phase, prodromal phase, crucial phase (onset of loss of control), and chronic phase. Similarly to current ideas about heroin use, it was believed that the consumption of alcohol itself was the first step in an uncontrollable process of sliding down. The only acknowledged form of (self) control was total abstinence (see, e.g., Alasuutari, 1992). Presently we have, at least in Western societies, more sophisticated ideas about the relationship between alcohol consumption and control. As Takala (1989) has argued, the concept of "control" is used in many different ways in talk about alcohol use. One can lose control of a car in a case of drinking and driving, or lose one's "cool" by drinking too much, or lose control over one's life by being an alcoholic. These are different uses of the concept of control, and it is important when using the concept of control in a scientific context to acknowledge that it can be located at different general analytical levels (Room, 1973).
Although Van de Wijngaart (1991) does not explicitly mention the concept of control, his description of four different approaches to drug use can be of help in distinguishing different meanings of control and self-control. In the moral model, of which the temperance movement is an example, the substance is seen as an agent that chooses its victims among those who are not able to resist. Victims are uninformed and weak-willed; therefore they must be protected and educated. In the medical model the drug is the agent, and the individual is mainly seen as the victim of an illness. In the sociocultural model the addict is a victim not only of the substance, but also of society's response to it. Finally, the psychosocial model emphasizes that the substance user is an active agent himself. The latter model allows that distinctions are made between different individuals (Van de Wijngaart, 1991:7880). Although the concept of self-control is important in both the first and the fourth model, it has not the same meaning. In the moral model only abstinence is seen as a form of selfcontrol; in the psychosocial model self-control is exhibited by the ability to make distinctions between different amounts, frequencies and patterns of drug use. Moore's (1992) study of amphetamine users demonstrates the usefulness of the psychosocial model. Moore describes, for example, how amphetamine users can deliberately suspend control of intravenous amphetamine use during a three-week holiday and regain control when they start studying or working again. This type of regaining control is very similar to how some of our respondents controlled their heroin use by going in the army, by sailing on transatlantic cargo ships, or by nursing a father with Alzheimer's disease. Moore's examples and ours demonstrate at the same time that maintaining and regaining control are not entirely individual matters but are related to factors such as having a job, having friends who do not use drugs, and having relatives who are dependent on the drug user. It is the social context that gives meaning to the drug user's life and thus allows some users to maintain control.
Our study thus highlights on the one hand the importance of social support (employment, friends, relatives) for maintaining and regaining control over one's heroin use and, on the other hand, the import of moral values and feelings of shame and guilt for therapy and prevention. However, our findings do not allow drawing conclusions about how therapy and prevention programs could make use of these factors. Further study should be directed at getting more detailed descriptions of actual self-regulation behavior and at investigating how moral emotions such as shame and guilt may play a role in the process of kicking the habit.
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BY ANNE ELAND-GOOSSENSEN, TONY HAK, AND LIESBETH VOLLEMANS
Anne Eland-Goossensen is a research fellow at the Addiction Research Institute (IVO, Essenlaan 4, 3062 NM Rotterdam, The Netherlands). Liesbeth Vollemans is a community field worker at the IVO. Tony Hak is a lecturer in medical sociology at the Department of Primary Care of the University of Liverpool (UK).
AUTHORS' NOTE: Research for this paper was supported by the Nationaal Fonds voor de Geestelijke Volksgezondheid (Utrecht), the Trustfonds of the Erasmus University Rotterdam, and the Municipality of The Hague. The research was performed in cooperation with Verslavingscircuit Bloemendaal and Centrum Verslavingszorg Zeestraat, both treatment modalities in The Hague. The authors wish to thank the heroin users in The Hague participating in this study. Correspondence address: Addiction Research Institute Rotterdam (IVO), Essenlaan 4, 3062 NM Rotterdam, The Netherlands. Fax 00 31 10 2122814; E-mail Eland@ivo.fgg.eur.nl.…
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Publication information: Article title: Heroin Addiction Careers: Downward Spiral or Controlled Descent?. Contributors: Eland-Goossensen, Anne - Author, Hak, Tony - Author, Vollemans, Liesbeth - Author. Journal title: Contemporary Drug Problems. Volume: 24. Issue: 2 Publication date: Summer 1997. Page number: 293+. © 2003 Federal Legal Publications, Inc. Provided by ProQuest LLC. All Rights Reserved.