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Article Excerpt
It goes without saying that the preferences, wishes, beliefs, and attitudes of people that consume licit and illicit substances influence their acts. The notion that addicts are slaves to substances who only and at any cost try to satisfy their craving has been rejected empirically (e.g. Mello & Mendelson 1966; Petry 2000). Furthermore, it seems intuitively fallacious since quite a few substance abusers manage to quit by their own decision, and since--like everyone else--they naturally have more concerns in life than one single activity. Addiction is nowadays often perceived as a multi-faceted phenomenon best described and explained by use of a combination of neurobiological, psychological, and sociocultural factors (Elster & Skog 1999).
A general characteristic of addiction is ambivalence towards the problematic activity, i.e. the feeling of both wanting and not wanting to consume substances. This may explain why people who suffer from it do not always and unconditionally try to quit and/or seek help for their problems. Another common attribute is that the use of substances by habit has become a central activity in the person's life, indicating that by and large everything circles around it (Fingarette 1988). Even if recurring "bad" decisions (such as continuing a self-destructive pattern of consumption) appear repetitive, compulsive and uncontrolled, people who display addictive behaviors are according to this understanding viewed as subjects able to choose between alternative acts.
Responding to these features of addiction, practitioners and researchers have discussed and analyzed extensively the concept of motivation for treatment and lifestyle change during the last 20 years (e.g. Miller 1985; Prochaska, DiClemente & Norcross 1992; West 2005). It is now widely acknowledged that substance abusers' attitudes--their problem recognition and desire for help for example--are associated with treatment entrance and retention (Simpson 2001). Several studies have demonstrated that dynamic variables of that kind often predict treatment outcomes more efficiently than static variables such as demographics, level of consumption and objective harm (e.g. Babor & Del Boca 2003; Joe, Simpson & Broome 1998).
Studies on "natural recovery" from addiction (i.e. quitting without the aid of formal treatment) show that a wide range of individual, social and structural factors may promote and facilitate lifestyle change. As stated by Cloud & Granfield (2004), personal change takes place in a social context, and the amount of "recovery capital" (i.e. contextual conditions that favor change) influences to what extent an individual is successful in trying to exit an addiction. The process of change is apparently characterized by experiencing negative consequences and triggering events that increase the perceived importance of change, utilizing various personal strategies that assist abstinence, being aware of benefits related to abstinence and immersing oneself in positive relationships and activities that provide life with meaning (Cloud & Granfield 2004; see also Blomqvist 2002).
Orford, Hodgson, Copello, John, Smith, Black, Fryer, et al. (2006) draw similar conclusions and discuss treatment in terms of a "complex system of parts, facilitating a nexus of cognitive, social and behavioral changes, embedded within a broader system of events and processes catalyzing change" (p. 60). It therefore seems as if treatment as such--if the patient enters at the "right" time and is satisfied with its form and content--may be an important complement to natural circumstances and events that support rehabilitation. This idea is confirmed by the absence of between-treatment outcome differences in large-scale studies on the effects of substance abuse treatment (see e.g. Babor & Del Boca 2003; Orford et al. 2006). Examining the similarity in outcomes between different treatment programs found in Project MATCH, Cooney, Babor, DiClemente & Del Boca (2003) assert that the decision to enter treatment allows clients to mobilize skill, motivation and support for abstinence, and that one key treatment ingredient may be the ability to convince clients that they will benefit from it.
Nevertheless, studies on substance abusers' attitudes towards substance consumption, treatment participation and lifestyle change generally place focus on those who have decided to and/or managed to quit already. Notwithstanding the significance of findings from such research, it can be asserted that the accounts of persons who are in the midst of addiction, and the "street life" often associated with it, may reveal a different and complementary picture of the pros and cons of substance use and the prospects for and procedures of lifestyle change.
In previous articles (e.g. Ekendahl 2006a & 2006b), the attitudes towards lifestyle change and treatment of three groups--untreated, compulsorily treated, and voluntarily treated--have been described and analyzed. Results show large between group differences and that willingness to change correlated with different attitudinal characteristics in the three groups. It was, for instance, associated with perceiving external pressures to enter treatment and experiencing substance abuse-related negative consequences in the non abstinent untreated group. A guiding interpretative frame has been that substance abusers are more or less attitudinally, spatially and temporally distant to the treatment system, and that this distance influence willingness to engage in treatment and to change lifestyle.
The present study analyzes in more detail some substance abusers' accounts of their lifestyles, living conditions and efforts to change. The objective is to inductively identify the qualitative characteristics of the distance to the treatment system that may be articulated in the data. Analyses and interpretations of the respondents' statements focus how their self presentations and descriptions of reality relate to their views on treatment and lifestyle change.
Sample and collection of data
Intravenous amphetamine abuse has been common in Sweden since the 1960s (Boekhout van Solinge 1997; CAN 2005). In 1998 the number of people in Sweden with "heavy drug abuse" (as defined by the authorities at the time) was estimated at 26,000. Thirty-two percent used amphetamine as main drug of choice (CAN 2005). In the present study eight middle-aged amphetamine using men that resided in Stockholm, Sweden, were interviewed during May-September 2004.
A research assistant recruited respondents by means of visiting their regular localities and inquiring about their willingness to be interviewed. Criteria for inclusion were prior participation in the research project, no obvious mental health problems, willingness to contribute with audio-taped personal information and daily consumption of amphetamine alone or in combination with other substances including alcohol. Females willing to be interviewed could not be found. The research assistant who conducted the interviews had previously worked as an ambulating social worker in Stockholm and was therefore somewhat acquainted with the target group. This probably contributed to the respondents' willingness to talk about their lives. Interviews were carried out in a private setting and lasted for about an hour each. An interview schedule with questions on social situation, substance abuse, motivation/treatment and time perspectives was used in the semistructured interviews. All respondents were by and large asked the same questions, but attendant questions and requests for clarifications were tailored to fit each interview.
Research participation was voluntary under informed consent....
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