Key research highlighting the social exclusion that dependent drug users experience, and the difficulties they face in trying to reintegrate. Julian Buchanan describes a model for integrating problematic drug users back into mainstream society. (2,756 words)
Every now and again, I read a book or research paper which has a huge impact on me. This was the case with Julian Buchanan’s key 2004 paper Tackling Problem Drug Use: A New Conceptual Framework [1], which describes important research conducted by Julian and colleagues on dependent drug users in Liverpool which started in the late 1980s.
Sadly, and somewhat embarrassingly, I never saw the paper until May 2022. I’ve always read a great deal about addiction and recovery, so it’s all the more frustrating that I missed the paper earlier. Anyway, the research and accompanying ideas are so important that I decided to write some blog posts in May 2022 and then this article on Julian’s work.
In his paper, Julian describes findings from three separate qualitative research studies that involved semi-structured interviews with 200 known problem drug users. The studies sought to ascertain:
the views, suggestions and experiences of drug users in respect of what was helping or hindering them from giving up a drug-dominated lifestyle.
The paper highlights:
the debilitating nature of marginalisation and social exclusion that many long term problem drug users have experienced. It concludes by suggesting a new social model to understand and conceptualise the process of recovery from drug dependence, one that incorporates social reintegration, anti-discrimination and traditional social work values.
Before looking at this research in more detail, it is important to consider the wider social context in which this research took place. Two major social factors need to be highlighted, as described in Julian Buchanan’s excellent paper Understanding Problematic Drug Use: A Medical Matter or a Social Issue. [2] The first factor concerns the impact of mass unemployment in parts of the UK and the second relates to the impact of drug laws.
The economic recession of the early 1980s, exacerbated by Thatcherist monetarist policies and deindustrialisation, left many working class areas severely blighted by mass unemployment. McGregor (1989) noted that badly affected cities like Liverpool and Glasgow that once had a strong manufacturing base, became symbols of economic decline. [3]
In the mid 1980s, a study by Pearson of young people and heroin use in the North of England found unemployment rates in excess of 40%. [4] The extent and longevity of unemployment was unprecedented. Pearson suggested unemployment became so ‘scandalously high’ and access to housing so difficult, that it made it extremely difficult for young working class people to ‘fashion meaningful identities’. [5]
A study carried out by Buchanan and Wyke in Sefton, Merseyside to understand the extent and nature of drug use amongst probation ‘clients’ and make recommendations for drug policy and practice, identified long-term unemployment and limited job prospects for young people as key factors. [6]
The three research studies described by Julian Buchanan involved listening to problem drug users about the barriers that hindered their capacity to regain control of their drug habit, and to the suggestions they had about improving services to enable social reintegration.
The first two studies led to the establishment of Day Centre provision (Bootle, Merseyside) and a Structured Day Programme (Liverpool, Merseyside). The third study involved action research interviewing the drug users who attended the Structured Day Programme, listening and recording their experiences.
A number of common themes emerged from the participants in the three studies: their social dislocation; their poor experiences of education and employment; their lack of realistic opportunities and hope; their isolation from a non-drug using population; and, a sense of stigma and low self-esteem.
The study participants revealed that the social exclusion and discrimination they experienced had a profound effect on them. Many participants who sought social reintegration had been unable to achieve it. This was not always due ‘to their own inability to become stable or drug free, but by a ‘wall of exclusion’, that has ghettoised problem drug users.
The research illustrated how many drug users on Merseyside felt socially stranded, largely forgotten, with little hope or alternatives. Once a drug using identity is ascribed, no matter how much progress, it became clear that it is extremely difficult, if not impossible, to overcome the hostile levels of discrimination.’
Most of the participants described heroin as the drug they were most dependent upon. The most common period of drug use was 7 – 13 years. Just over 50% had no qualifications whatsoever, and all apart from two people were currently unemployed. One in seven had never had an ‘official’ job at any point in their life.
The study participants had few legitimate options available to them and for many of them, drug-taking was an alternative to unemployment, boredom and monotony. As one person stated:
No prospects for someone like me I gave up years ago thinking I could get a job, I might as well reach for the moon.
Many felt that a drug-centred existence was all that was available to them, recognising that it offered an all-consuming alternative. Each and every day involved the same demanding routine:
- Wake up anxious, with concerns about generating funds to buy heroin.
- If no drug available, start to experience withdrawal symptoms.
- Make plans for the day to acquire funds to purchase heroin.
- Carry out plans, generally involving shoplifting.
- Stolen items sold at a fraction of their true value.
- Use this money to purchase some decent quality heroin.
- Find a safe place to enjoy the ‘reward’ for their hard work.
The participants’ isolating existence appeared to have a marked negative impact on their self-esteem. When asked how they felt about being with people who weren’t drug users, many expressed feelings of unworthiness and of being second-class citizens:
They look down on me as scum of the earth and as someone not to be associated with.
They experienced a growing sense of unease and anxiety. Their fear of rejection led some to feel they couldn’t risk being honest.
I feel I have to make up for being on drugs. I have to be at my best, I don’t want people to look down on me so I make everything look perfect.
The isolation and exclusion perpetuated drug use, preventing and hindering opportunities for social reintegration. When asked about the quality of their relationships, many users had little or no relationships that they would describe as friendships. Instead, they referred to having acquaintances with drug associates that were largely functional. Julian says:
This lonely and dehumanising experience ultimately undermines their ability to form relationships and tends to reinforce social isolation and subsequent dislocation. The harsh and demanding drug centred lifestyle is for many, all that is on offer. In the ‘normal’ world from which they have been excluded many feel vulnerable and lack confidence, and thus the cycle is perpetuated. When asked about why they used drugs it was clear that some used drugs to mask this sense of inadequacy.
Heroin killed the pain arising from the disconnection from normal society that study participants experienced.
When participants in the Bootle study [7] were asked to identify the main difficulties they faced as drug users, low self-esteem and poor confidence featured as a major factor (64% of respondents) followed closely by finances and relationship issues. The researchers were surprised to find that legal and health issues scored lowest. The qualitative data revealed that confidence and self-esteem are seen by drug users as a crucial factors for recovery.
I need my self-esteem back, it just affects everything.
The action research of the Structured Day Programme ‘Transit’ [3] findings highlighted the importance of social rehabilitation. When asked about the staff at the Structured Day Programme, drug users identified being able to develop trust in staff members, and staff being non-judgemental as key factors.
Most of them [the staff] I got on with. It surprised me. I don’t normally trust people.
A common theme that emerged from participants in this study was that many felt inferior and undeserving.
We’re very lucky to have somewhere like this and to be treated like equals.
Julian points out that:
… these findings suggest that the social dimension to drug use must be acknowledged, understood and integrated into policies and practices if rehabilitation and reintegration are to become realistic and achievable goals for long term problem drug users.
He describes a model for integrating problematic drug users back into mainstream society, one which is based in part on the Stages of Change Model developed by James Prochaska and Carlo DiClemente.
The Steps to Reintegration Model (see Figure below) views that problem drug users pass through a series of steps on their way to becoming rehabilitated and reintegrated into mainstream society. Users generally proceed forward through the steps one at a time, although they may also move backwards, sometimes through several steps.
It is crucial that treatment practitioners and others trying to help the person need to recognise where a drug user is on these steps, since it enables a more appropriate response to be made. Julian describes six phases, four of which occur before what he terms the ‘Wall of Exclusion’ and two afterwards. Julian says:
The Wall of Exclusion is not a phase but a barrier that makes it extremely difficult for recovering drug users to become accepted into the structures and networks of everyday life. The propaganda designed to deter people from trying illegal drugs by portraying drug users as a deviant enemy, has led to a war on drug users themselves. This has resulted in discrimination at every level.
For many drug users relapse is not attributable simply to the physical craving or a change in motivation, but as a consequence of their frustration at trying to break into mainstream community life and finding themselves constantly shunned and excluded. At the very time when recovering drug users need assistance and support from the non drug using population to establish alternative patterns of social and economic life they are often prevented by the wall of exclusion.’
At the chaotic phase, problem drug users do not see that they have a problem with drugs. If they do, they are usually unwilling or unable to contemplate change. This stage is often characterised by an all-consuming drug-centred existence in which satisfying the need or craving for drugs can override most other issues or concerns.
‘What is particularly important at this stage is to develop an honest and accepting relationship that gives the drug user permission to communicate what their intentions are in relation to drugs, without the fear of rejection or moralising from the agency worker. Within this relationship it is then possible to offer realistic strategies that may reduce the degree of risk or harm to the drug users, their family or wider community.
At the ambivalent phase, the problem drug user is periodically beginning to acknowledge negative aspects of being dependent on drugs, and these feelings cause shifts in their motivation when they are contemplating making changes.
The emphasis required at this stage is to enable the drug user to explore the pros and cons of their pattern of drug use and lifestyle in general. The worker needs to avoid projecting their own personal/professional thinking, values, choices or interpretations, but instead facilitate space for the drug user to explore these issues from their perspective.
At the action phase, the problem drug user has decided what they want to do, and is beginning to make plans for what they will do and what support they will try to access. Action does not necessarily mean a decision to become drug-free; for example, it might involve a decision to access prescription methadone. It is important in this phase that the person:
… pursues assistance appropriate to their need and situation, and at a pace of change that is realistic and manageable. Mistakes can be made either by the drug user or the worker, rushing, enforcing or pushing change.
The control phase refers to that period when the dependent drug user has taken the planned action and has successfully regained control of their drug use. This is a time of change and uncertainty for the drug user; they need to begin thinking ahead to what new habits and interests are going to replace the old ones.
This is a vulnerable period in which the drug user can swing between confidence about staying in control and unpredictable anxiety about possible relapse. It is helpful at this stage to explore and rehearse both the drug users’ and agency workers’ response to relapse, and to seek to learn positively from it, if or when it occurs.
Gaining control of one’s drug consumption does not mean that a person has overcome their difficulties—control needs to be maintained long-term. The person now faces the Wall of Exclusion, which represents a significant barrier to establishing alternative patterns of social and economic life, and being accepted as normal by ‘normal’ society.
I’ll leave Julian to describe the two last stages of his Reintegration Model (NB. I have shortened the length of some of Julian’s paragraphs to facilitate ease of reading online):
The reorientation phase is a particularly challenging period when the drug user is in control of their habit and trying to actively re-orientate themselves with new activities, lifestyle patterns and habits away from the drug scene. It is important at that the goals and plans here are realistic, achievable and suitable for the drug user. For many problem drug users in the research mentioned earlier, sleeping patterns, finance, education, employment, fitness, diet and friendship networks had all been seriously undermined….
… Confidence and self-esteem are likely to be damaged leaving the drug user vulnerable and in need of regular support and encouragement. Many drug users felt uneasy and threatened in the company of non-drug users, yet this is the group of people whose support, friendship and integration is crucial.
Sheltered environments specifically designed to assist drug users such as Structured Day Programmes, day centres, befriending or buddying schemes are useful at this stage, but such services are scarce. For a drug user who hasn’t eaten three meals a day or slept through the night for the past 6 years (and this wasn’t unusual in our studies), the reorientation phase can take a significant amount of time.
The reintegration phase is the period when the dependent drug users begin to participate and join in mainstream activities. Due to negative experiences, many drug users feel anxious and afraid of judgmental attitudes from non drug using population, and understandably tend to lack confidence.
Normal day to day activities such as engaging in further education, doing voluntary work, attending school meeting, doing a vocational adult education course, joining the local gym can be very intimidating as many have been disconnected from mainstream activities. They face a dilemma of whether to disclose their drug history, knowing that, ironically, honesty is likely to lead to distrust and possible discrimination.
Acceptance and belonging within non drug using communities will enable the drug user to complete the break from a drug centred lifestyle. Unless ‘doors open’ and drug users are sufficiently integrated and purposefully occupied it will be hard to sustain, and the risk of relapse looms.
This reintegration phase is crucial if the drug user is to successfully make the transition and participate in the social and economic life of her/his local community.
Soon after I uploaded my three blog posts about his work, Julian recently contacted me from New Zealand, where he now lives, and sent me a revised figure to what I had shown in my blog post of his ‘Steps to Reintegration’ Model which includes an additional feature, details of the Bricks in the Wall of Exclusion—Government Voices, Community Voices, Media Voices, and Drug User Voices. The quotes are real! So here we go:
References:
[1] J. Buchanan, Tackling Problem Drug Use: A New Conceptual Framework, Social Work in Mental Health, Vol 2, No. 2/3, pp. 117-138, 2004.
[2] J. Buchanan, Understanding problematic drug use: A medical matter of social issue. British Journal of Community Justice, Vol 4, No. 2, 387-397, 2006.
[3] S. McGregor, (ed) Drugs and British Society Responses to Social Problems in the 1980s, Routledge Press, London, 1989.
[4] G. Pearson, Social deprivation, unemployment and patterns of heroin use, pp. 62-94 in N. Dorn and N. South (eds), A Land Fit for Heroin? Drug policies prevention and practice, MacMillan, London, 1987.
[5] G. Pearson, The New Heroin Users, Blackwell, London, 1987.
[6] J. Buchanan and G. Wyke, Drug Use and Its Implications: A Study of the Sefton Probation Area, Merseyside Probation Service, Waterloo, (unpublished research report), 1987.
[7] J. Buchanan and L. Young, Drug Relapse Prevention: Giving Users a Voice, Bootle Maritime City Challenge, Liverpool, 1996.