Chapter 1
An enquiry into psychological aspects of recovery from dependence on psychoactive substances
Mary Addenbrooke
My study is based on the qualitative analysis of a set of tape recorded interviews of twenty-seven ex-patients of a local substance misuse service formerly treated for dependence on alcohol or injectable drugs, primarily heroin. In the majority of cases, abstinence had lasted between five and twenty-four years whereas six informants, who were originally treated in the 1970s were still addicted, providing a comparison group.
I reflected upon the significance of Jungās link with the founding of Alcoholics Anonymous and examined precursors to the cessation of drug and alcohol use and the mode of their quitting and both the short and long-term challenges of living without alcohol or drugs.
Methodology
The theoretical perspective of the enquiry developed through the study of psychoanalytic literature, recall of patientsā material in my own analytic practice, and through contact with colleagues in the hospital team. Recently, questions of legitimation have been raised as to whether it is actually possible for researchers to capture lived experience directly, or whether such experience is created in the text written by the researcher. This can be seen to arise partly from the debate over the possibility of obtaining an objective view of experiences which are subjective in character, that is, between a positivist and a constructivist perspective. As Denzin claims, āWe create the persons we write about, just as they create themselves when they engage in storytelling practicesā (Denzin 1989 82). This question is a difficult but important one for a psychoanalyst and my interpretations of the words of my informants speak from that perspective, rather than from a sociological or behavioural one. As an analyst I am continually in touch with the quality of mutuality in forming or discovering interpretations of patientsā states of mind, in a setting where analyst and patient are joint creators in the enterprise. My aim in this study has been to try to enter imaginatively the world my informants inhabit as I listen to their words. Yet I am aware that it is not my own world. When informants speak of recovery, or, conversely, of a turgid entrapment in their addictions, I may empathise with the struggles they describe, but the empathy derives from imagination rather than memory. Some aspects of the challenge to build a different life after addiction are universal and would not be unfamiliar to the experiences of, for example, displaced people in a new land, or of the bereaved or of the terminally ill, all of whom find themselves metaphorically in a new landscape. Thus, as a researcher, I grapple continually with the challenge of trying to understand the world of the āotherā, while being aware of the presence of the āotherā, the unconscious, within myself.
The sources of the methodology are:
ā¢Grounded theory, a branch of qualitative research, which rests upon field work employing observation and recording of words and actions of a sample selected for its applicability to the phenomenon in question.
ā¢Psychoanalytic research based upon single or cross-case reporting from a series of sessions in the consulting room, observed and reported upon, usually, though not invariably, by the analyst. Its focus is the psychological development and functioning of the individual in depth.
Still addicted after 25ā30 years
The interviews of six individuals still addicted to drugs and/or alcohol were studied. The overriding factor remains their relationship with the drug. This is no longer seen as pleasure-giving or life-enhancing. Their predominant attitude is dissatisfaction and ambivalence towards their drug dependence. There is a striking preoccupation with a balancing act between how much they need, how much they want, and how much they wish to jettison their drug dependence completely. Methadone is used as something to be boosted from other illicit sources or as a salve to the conscience. It is as if they can tell themselves that they are doing something. Here four people speak about their situations:
There is little evidence of a sense of confidence in being able to spring the trap of dependence or indeed to affect what happens in any way in their lives. Well-known sources of self-help are mostly regarded with scorn as useless and there is equally little sense of a hopeful outcome of treatment within the statutory services. In general, outside sources of help are criticised as inadequate or failing. A passive, fatalistic attitude prevails. In some people this extends to a sense of despair, blame or angry bravado. Yet all except one have had periods of abstinence, sometimes extending over several years. They have proved that they can quit and can exist without drugs. The reasons for their relapses in the past are not uniform or consistent, but are as varied as their personalities.
All have deviated far from the flow of mainstream society in their aspirations and their thinking. Those who are drawn to deviance and live on the brink of the criminal world express no hope of enjoying the fruits of the materialistic culture. Experimenting with drugs which started as exploratory and part of a varied picture of deviance has overtaken them and grown to be an all-pervasive influence in their lives, dictating their actions and aspirations. No part of their lives is untouched by this now. The imperious lure of āmust haveā rules their lives, so that they have come to live within an archetypal tyranny. Several of them speak of drug use as an escape, especially from emotional problems, but what has happened is that having escaped up a particular track, they now feel demoralised and imprisoned there. No longer is drug-taking an activity that brings a sense of belonging to, and identifying with, a chosen group as it was at the start. On the other hand, now each person has one āaccompliceā. The quality of life of these people is not only poor, but diminishing in terms of health, morale and relationships. None have any legitimate employment or any significant interests beyond the chemicals on which they are dependent, although at the time of the interviews the amounts involved were not vast. All illustrate a lack of mutually satisfying relationships, either being isolated in ways they regret or being unhappily dependent on the aid and support of others.
Quitting
There are invariably multiple factors which drive drug-dependent people to change. Fears, even of death, are only a part of what motivates change, as can been seen in some of the informants still addicted. They seem able to deny or ignore their fears. It is when a level of desperation is reached that the time comes. The persuasion of others had little effect in many cases, which accords with the Alcoholics Anonymous belief that the decision has to come from within. Informants recall their experiences of cessation in vivid detail, however many years ago this took place. The experience had great significance in the flow of their lives and the descriptions resemble those of survivors of wars speaking about the battles and personal escapes which colour their perception of the world for ever after. This informantās story illustrates the power of narrative:
The A.A. approach fitted the needs of this man who had had many detoxifications in private hospitals at great expense, all of which had resulted in a rapid return to drinking. At one point he fell downstairs drunk, and broke his neck ā even this didnāt cause him to stop drinking. His employers had offered him every chance of help and support. His description of the A.A. response to his call demonstrates the power of narrative, which he is recalling many years later with great clarity. The words have a magic quality for him. He himself is metaphorically a āprize fighterā, left in an orphanage at an early age with his brother because his parents were destitute. In an intuitive way, his A.A. phone respondent tuned in to this. The juxtaposition of the fighter, lord of the battle in the ring, with the Korsakoffās sufferer with a āwet brainā totally abject and childishly helpless, is a dramatic tour de force. His respondent uses narrative to bring him into tune with his vulnerability. He had had a long affair with alcohol, the mistress, and was loath to let go, but he tuned in to the terror of the threat of the helplessness he had experienced as a little boy, deserted by his parents. The A.A. member told him that he should know when to retire gracefully from the ring, because his life was more important than his audienceās entertainment. Just as his parents gave him and his brother up for the sake of their survival in the face of destitution, so he has given up something he loved ā alcohol ā so that he can survive and flourish.
His life story illustrates several enantiodromia. From being left in a childrenās home, he pulled himself up, first to look after his younger brother and to win the support of his school teachers by his feisty style, and then went on to lead an exciting and challenging life as a soldier. At the crisis point he reached with the destructiveness of his alcoholism, he was able to listen and accept and act on the advice from a recovering alcoholic who recognised his omnipotence. He became an avid member of A.A. and said of his current situation,
The first five years of abstinence
Here two people describe their state when they stopped using drugs, heroin in the first case, and alcohol in the second:
