THE ROLE OF PERSONAL RULES AND ACCEPTED BELIEFS IN THE SELF-REGULATION OF DRUG TAKING

Do illicit drug users have rules and values? Michael George presents the facts about an individual drug user in a discussion on characteristics of opiate users.

Long-term recreational opiate use presents a significant challenge to accepted anti-drug dogma. Political and legal responses to drug use are largely underpinned by the ubiquitous belief that opiates generate dependence which, in turn, creates chaos. This philosophy implies the necessity of denying the existence of personality and environmental characteristics which exert sustained control over the use of drugs. For many, the assertion that this sustained control cannot and does not happen may promote a self-fulfilling prophesy. If it were widely held and believed that alcohol use led irresistibly to alcohol dependence, might there not be a higher percentage of problematic drinkers? Balancing the view that drugs lead to loss of control is the observation that drug users (within which I include alcohol drinkers and cigarette smokers) make, and often observe, rules by which their drug use is controlled. Everyone develops, to a greater or lesser extent, rules that govern their behaviour. These may be identical, similar or radically different from those imposed upon the individual by society, the legal orpolitical systemor religous organisations.

In my experience, illicit drug users rarely have rule books or value systems which are co-terminous with societal law and norms. Nevertheless, they do exist. Anecdotal examples arise from assessment interviews with clients contacting a community drug team:

'I would never steal from an individual, but large chain-stores are different.'

'I would never introduce another person to heroin.'

'I wouldn't give anyone their first fix.

'I only deal to people 1 know.'

'I'd never see a friend hang out.'

Slightly more obscure, though of more therapeutic value, are the rules which the user applies knowingly or unknowingly to the extent and frequency of their drug taking.

Examples of these rules include

'I only use at weekends.

'I stop when my money runs out and leave it alone till my next giro comes through.'

'I couldn't use a needle - they have always scared me.'

'I'd stop if 1 felt the children were starting to suffer.'

Even harder to define are the vague ideas which users report of drug use 'getting out of control'- of their lives becoming unacceptably chaotic. Some users don't identify their rules until they have violated them. One client injured a child while driving in an intoxicated state. Another, while under the influence of hallucinogenics, stole a motorcycle and took it home where he found it the next morning in his first-floor bedroom. Some female users find themselves unable to continue using when they discover that they are pregnant, although they had made no previous conscious decision to stop when they fell pregnant.

In a sense, the average drug clinic attender is a victim of his or her failure to make, identify or obey adequate personal rules which govern problematic drugrelated behaviour.

Haynes and Ayliffe (199 1) used a locus of control questionnaire to support the proposal that'clients need to believe they have a significant degree of control over theirbehaviour if they are going to make progress...'. It is logical to suppose that the internal locus of control, which provides a positive prognostic variable in treatMerit outcome, also reduces the risk of drug use becoming dependent or problematic in the first place.

Blackwell (1983) in an elegant and carefully constructed paperstudied the characteristics of opiate users who avoided becoming chronically dependent. Trackingdown long-term recreational opiate users is the ultimate challenge to outreach research. In her paper, Blackwell identifies 51 such users and divides them into three groups according to the method they employ to control theirdrug consumption:

Drifters'
Casual users, relatively unimpressed with the psychotropic effects of narcotics for whom other aspects of life compete strongly for time and resources).

'Controllers'
Those who respond to their strong attraction to opiates by making even stronger rules governing their use and by being aware of the effect of drug use both on themselves and other users.

'Overcomers'
Those who allow the process of habituation and/or dependence to develop but become past masters or mistresses at the art of ending dependent episodes.

All three groups in her study displayed a degree of selfmotivation and introspection greater than that usually attributed to dependent users first entering treatment. Indeed, the main thrust of'motivational interviewing' interventions (Miller, 1983) is to increase these aspects in the individual and thus combat denial and powerlessness. I attempted to contact non-addicted heroin users around West Sussex by extending invitations through clients attending the Community Drug Team. After many dead ends I came across Darren, the 30year-old brother of one of our female clients. He readily agreed to be interviewed. This brief report attempts to summarise the important case characteristics, within the framework suggested by Blackwell (1983), reinforce the importance of exploring rule-making and rule-breaking in the treatment of problematic drug users, and explore the dynamic interplay between drug user's rational isations and the commonplace beliefs of the wider society to which they belong.

Darren is a single man, aged 30, with two younger sisters. He lives with one of them and her long-term partner. Theyare both long-term injectingopiate users. The third sibling is not drug involved. His childhoood was marred by his father's violent behaviour and chronic heavy drinking. Darrenhad to'stand up tohim' and 'take responsibility for his mother and sisters from an early age'. His parents are still together. Age has modified his father's drinking and his rages. Mother is employed as a nurse, father as a manual worker. At school Darren achieved four CSEs and left aged 16. He is ambitious and regrets not having more qualifications. fie described himself as shy and introverted, not a risk taker by nature, quiet in social groups, and a loner, although he'likes to have people around'. His developed sense of responsibility has survived his childhood and he is both aware of his own actions and influenced by those of others. He made an early rule not to inject afterseeing afemale intravenous user:'I witnessed a girl injecting herself and trying to hold herbaby at the same time...' and not to develop physical addiction because of withdrawal states'they were pacing up and down and banging their heads against the walls'. Darren, on one occasion, had stomach cramps after smoking two E30 bags of heroin in 2 days: 'I was trying to see how far'l could go...'. Following calculated and pre-meditated experimentation, the boundaries were established and maintained.

Darren's drug use started with alcohol, drinking regularly and sometimes heavily since the age of 17. Two years ago he drove home while intoxicated. The next morning he found he had parked erratically, left the lights on, and doors and windows open on the car. As a result of this he had'had a good look'at himself. Since then he drinks only at weekends, 8-10 units. He never drinks and drives. He continues to smoke cannabis which he started at the age of 19. He has not identified harm resulting from this although he maintains strict controls on his financial outlay.

In his early twenties he experimented with amphetamine (he was unimpressed) and LSD. His use of acid discontinued after he was run over by a car while tripping. He went through the windscreen and lacerated his forehead. Both his LSD and alcohol experiences represent 'overcoming' (Blackwell, 1083) whereas his heroin experience fits more into the 'controlling' model of dependence avoidance. He first used heroin 10 years ago, aged 20. He was introduced to the drug by friends who themselves'only dabbled' providing an acceptable role-model. He used, and continues to use, only when he has enough money ('no dosh, no gear') usually smoking E 15-20 worth at a time, four or five times a month. This consumes (together with cannabis purchases) about 20% of his monthly income. To spend more than this proportion would be unacceptable eating into money allocated for alternative activities. He once used heroin intravenously. He fell asleep, his cigarette slipped from his grasp and burned the tip of his forefinger severely - he never injected again. He still carries the scar to remind him why. His initial use of heroin required 'overcoming' strategies before settling down. He started to use daily which he found unacceptable, so he took a job selling ice-cream in the south of France for 6 months, only returning when he was sure that his incipient addiction was mastered. He used no heroin for 6 months on his return to the UK before reintroducing its use within acceptable boundaries.

His senses of control and mastery are both highly valued. He studied the martial arts and passed his black belt at an early age. He is keen on active sports, especially football, reads widely and studies 'the paranormal'. He hates letting people down socially or professionally. He works at an estate agency where he is well liked and well respected. That means a lot to him and he would never willingly i eopardise his position of esteem. He said'I want to give them something back'. He denies fearing loss of control now. He claims a'sense of moral responsibility' and a horror of insolvency which both regulate his drug use. Like Blackwell's 'drifters', he has plenty of valued alternatives and'always likes to be doing something active'. Thus far he has had no contact with the police, nor has he had cause to approach any treatment agency. Although he claims to be uninflu, enced by the dependent heroin use of the couple with whom he lives, he feels that'... if everyone else stopped completely, then I could quite easily...'.

What are the lessons to be learned from this? First, Blackwell's groups (drifters, controllers and overcomers) do not appear to be mutually exclusive. Darren shows features of all three regulatory mechanisms: 'drifting' with amphetamine and cannabis, 'overcoming'dependent trends in early opiate use and'control, ling' his current use. Secondly, it would appear that individual value systems can both survive and be more powerful than early parental and current environmental influence. Darren was brought up (like his addicted sister) in an environment of alcohol abuse and violence. He now lives with two addicted opiate users. Thirdly, sustained 'recreational' heroin use can be achieved, but remains an uncommon phenomenon. The influential characteristics of this recreational user appear to be:

1 . A valued sense of 'mastery' and control which manifests itself in the non-problematic use of both illicit and legal drugs and in Darren's choice of pastimes, i.e. expertise within the martial arts.

2. The availability of value alternatives to drug-centred behaviour, for example hobbies, work, sports etc.

3. A developed sense of responsbility to self and others which results in the ability to modify behaviour as a direct result of negative consequences of drug-taking - in other words, learning from one's mistakes.

It would be rash indeed to generalise widely on the basis of one case study. However, these ideas might be extrapolated to form hypotheses which could be tested on a larger cohort of non-dependent long-term opiate (or other addictive drug) users.

Therapeutically, the 'protective' characteristics which distinguish the survivors may be used productively in the treatment of the casualties using techniques such as motivational interviewing (Miller, 1983; Van Bilsen and Van Ernst, 1989) and relapse prevention training (Warnigaratne et al., 1990) which seek to increase mastery, generate valued alternatives and increase insight by challenging denial.

In conclusion controlled users of all types of drugs challenge the widely held belief that drug use tends inexorably towards loss of control. This belief has generated a myriad of 'ex terna F controls: religious, legislative and societal. The dependence on external controls has allowed or encouraged individuals to abdicate responsibility and espouse the view that drug use cannot be controlled and must therefore be abandoned entirely or discouraged by punishment. The widespread 'extemalisation'of control over drug use may have the effect of disempowering drug users, themselves members of the society which has adopted the'helpless victim'myth, and, by expecting loss of control over drug use, perpetuates the self-fulfilling prophesy of addiction. In a book which argues persuasively that there is more volition and choice in drug taking than socicty suspects or drug takers admit, Davies (1992, p. 15) comments that:

'.. the very act of explaining drug use in certain habitual ways might help to maintain and develop a problem in those terms.'

'the more we treat drug problems as if they were the domain of inadequate, sick or helpless people, the more people will present themselves within that framework, and the more we will produce and encounter drug users who fit that description' (p.23).

These hypotheses, if accepted, challenge the 'one hit and you're hooked' version of drug dependency which is the common currency of legislators, and have farreaching implications for the philosophy and implementation of drug services of the future.

Michael George, Chartered Clinical Pyschologist, Director, Options Project, West Sussex.

REFERENCES

Blackwell, J.S. (1983) Difting, controlling and overcoming: Opiate users who avoid becoming chronically dependent. Journal of Drug Issues, Spring, pp.219-235.

Davies, J.B. (1992) The Myth ofAddiction. Harwood Academic.

Haynes, F. and Ayliffe, G. (1991) Locus of control of behaviour: is high externality associated with substance misuse. British Journal of Addiction, 86, 1111-1117.

Miller, W, (1983) Motivational interviewing with problem drinkers. Behavioural Psychotherapy, ii, 147-172

Van Bilsen, H.J.P.G. and Van Emst, A.J. (1989) Motivating heroin users for change. In Treating Drug Abusers. Bennett, M. G. (ed.). Tavistock: Routledge.

Warnigaratne, S., Wallace, W., Pullin., Keaney, E and Farmer, R. (1990) Relapse Prevention for Addictive Behaviours. Oxford: Blackwell Scientific.