MATURING out an Empirical Study of Personal Histories and Processes in Hard-Drug Addiction
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MATURING OUT An empirical study of personal histories and processes in hard-drug addiction ER UIT GROEIEN Een empirische studie van levensbeschrijvingen en processen in harddrugverslaving mijn maeder is mijn naam vergeten, mijn kind weet nag niet hoe ik heet. hoe maet ik mij gebargen welen? no em mij, bevestig mijn beslaan, laat mijn naam zijn als een kelen. naem lIIij, naem fIIij, spreek mij aan, 0, naem mij bij mijn diepste naam. vaal' wie ik liejheb, wi! ik helen. Neeltje Maria Min. Maturing out An empirical study of personal histories and processes in hard-drug addiction Er uit groeien Een empirische studie van levensbeschrijvingen en processen in harddrugverslaving PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof. Dr. P. W.C. Akkermans M.A. en volgens het beslnit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woensdag 25 jannari 1995 om 15.45 nnr. door ENGEL HENDRICUS PRINS geboren te Amsterdam Promotiecommissie Promotor: Prof.Dr. W.J. Schudel Promotor: Prof.Dr. F. Schutze Overige leden: Prof.Dr. H.F.L. Gat'l'etsen Prof.Dr. F.e. Verhulst Contents Preface VIII 1 History of the study 1.1 Introduction I 2 Framen'ork 5 2.1 The setting of the project 5 2.2 The aims 6 2.3 The relevant literature 6 2.4 Changes in the environment since Winick's study 9 2.4.1 The availability of drugs 9 2.4.2 The variaty of drugs 9 2.4.3 Attitude of society 10 2.4.4 AIDS 10 3 Methodology II 3.1 The Design II 3.1.1 The sample criteria 12 3.1.2 The Interviews 12 3.2 The Autobiographical narrative interview method 12 3.2.1 The theory 12 3.2.2 The techniquc 15 3.3 The Execution 19 3.3.1 Locating study participants 19 3.3.2 Privacy protection and approaching the parlicipants 19 3.3.3 Non-cooperation and non-response 20 3.3.4 Response 21 3.3.5 The actual contacts 21 4 Quantitative analysis 23 4.1 Introduction 23 4.2 Representativeness of the sample 24 4.2.1 Male/Female distribution 25 4.2.2 Age distribution 26 4.2.3 Duration of the addiction course 26 4.2.4 Ethnicity 26 4.2.5 Educational level 27 4.3 The demographic characteristics of our sample 28 4.3.1 Sample size 28 4.3.2 Years since last addiction period 28 4.3.3 Age when stopped 29 4.4 Family relations 29 4.4.1 Parental structure 29 4.4.2 Brothers and sisters 30 4.4.3 Child ranking 30 VI 4.4.4 Relations with parents 30 4.5 Social economic background 32 4.6 Addiction history 33 4.6.1 Addiction starting age 33 4.6.2 Kinds of drugs used 34 4.6.3 Duration of the addiction course 34 4.6.4 Present state of the addiction course 35 4.6.5 Interruptions in the addiction course (Kicking off) 36 4.6.6 Health 38 4.6.7 Overdoses 40 4.6.8 Suicidal behaviour 40 4.6.9 Intravenous use of drugs 41 4.7 Ways of administering drugs 42 4.8 Family use of dmgs 43 5 Qualitative analysis 45 5.1 Introduction 45 5.2 Theoretical Framework 45 5.2.1 The drug career as a process of social deterioration ("VerelendungsprozeB") 45 5.2.2 The drugs career as a maturing process 46 5.2.3 The drugs career as an identity development and socialization process 47 5.3 Trajectory 50 5.3.1 Description of the steps of analysis 51 • The selection of the first interview 51 • Structural description 51 • Analytical abstraction 52 • The selection of the second interview 52 6 Conceptual framework 53 6.1 Introduction 53 6.2 Survey of the range of population groups in which drug addiction occurs 54 6.3 The distribution of dmg addicts within the population groups 54 6.3.1 Gender 54 6.3.2 Age 54 6.3.3 Socioeconomic status 55 6.3.4 Education 55 6.3.5 Intelligence 56 6.3.6 Religion 57 6.3.7 Psychopathology 57 6.4 A conceptual framework of a drug addiction course 58 6.4.1 Introduction 58 6.4.2 The societal setting 59 6.4.2.1 The technological development 59 6.4.2.2 Growing individualism 61 6.4.2.3 The dangers of emotional neglect 66 VII 6.5 The origins of the gender differences within the drug addicted population 67 6.6 The development of a personal and social identity in two theories 68 6.7 The different phases of a drug addiction trajectory 70 6.7.1 The introductory phase 70 • Description of the three cases 73 6.7.2 The unrecognized signals of the first trajectory 77 • Description of the three cases 77 6.7.3 The entrance 80 • Description of the three cases 80 6.7.4 Balancing 83 • Methadone 84 • Description of the three cases 87 6.7.5 Sliding deeper and suffering a breakdown of self-orientation 88 • Description of the three cases 89 6.7.6 Reaching a turning point 90 • Description of the three cases 92 6.7.7 Getting out 93 • Description of the three cases 94 6.8 Summary 98 Appendix I First interview with Alice on December 18, 1989 107 Appendix II Analysis of the first interview with Alice 131 11.1 Introduction 131 11.2 Analysis of the narrative 133 II. 3 Conclusions 151 11.3.1 Primary and secondary trajectories 151 11.3.2 Family environment and the building of an identity 155 II.3.3 The functions of some transcendent living conditions 155 11.3.4 The utility of treatment centres 156 11.3.5 Methadone as a substitution for heroin 157 II.3.6 Ways of learning to perform biographical work 159 Appendix III Second interview with Alice on June 9, 1993 161 Appendix IV Analysis of the second interview with Alice 179 IV.I Introduction 179 IV.2 The analysis of the narrative lSI Notes 189 References 199 Preface Ever since the fiftieth, the sixtieth and the seventieth, the time I worked and studied in the United States, I developed an interest in the fate of the many drug addicts I met there. What struck me particularly was the fact that these drug addicts were almost always quite young. In light of the long history of drug abuse in the United States, I wondered at that time where the older ones were and what had happened to them, but I did not have the possibility to carry the question any further. Only much later, in 1986, when I entered the department of epidemiology of the Municipal Health Service of Rotteraam as a qualitative researcher and was asked if I had a preference for a specific research topic, I saw a possibility to look into the question. When I put it forward, the answer was at first a somewhat surprised "Well, I suppose they are all dead", shortly followed however by "but if Il you want to be SlIre, write a research proposaJ • This I did, in the sense that I proposed to look into the whole course of a drug addiction. The proposal was accepted also because such a project could possibly provide suitable leads to improve the treatment of the addicts which has up till now a depressingly low success rate. The ensuing study is an attempt to construct a grounded theory about the course of hard-drug addiction. That is to say, the theory or rather the conceptual trame work of a theory which came out of the study is based on data, in this case personal histories of drug addicts and ex-drug addicts. These histories have been systematically obtained and analyzed as Glaser and Strauss suggested. The method they recommended is gratifying, but requires much labour and a very wide range of knowledge and interests on the part of the researcher. As usual in this kind of undcl1aking, one comes time and again upon fields of knowledge each of which require a lifetime to master, and an important problem is consequently where to draw the line. I hope I succeeded in drawing these lines in such a way as to leave a picture of the development of a drug addiction course in which roads are visible leading to improved treatment of the addicts and subsequently to a reduction of their suffering. A project like the one before you is, of course not entirely the product of one person. I want to thank all those who assisted me in one way or another during the years that I worked on it. [n the first place the Board of the Municipal Health Service Rotterdam area and the leadership of the Department of Epidemiology and Health Policy. They not only gave me the opportunity to perform the study while I was in their service, but also allowed me to continue the use of their facil ities for years after [ retired from the Service in order to finish the project. They sUPP0l1ed and encouraged me throughout. In the second place [ want to thank Rinus van Klaveren who, as the director of a treatment centre, saw the possibili ties of the project for improved treatment approaches and trusted me enough to write an invitation to his former clients to participate in the project. Without his support this project would have been practically impossible to carry out since al IX other treatment centres refused cooperation on the grounds of privacy protection.