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G L E N D A Y . KOUTROULIS
Turning Point Alcohol and Drug Centre, Fitzroy, Victoria, Australia
ABSTRACT
Much of the drug research literature has concerned itself with quantifjring aspects
of drug use and drug users lives, paying little attention to the social processes that underlie drug
use and withdrawal therefrom. This paper highlights the value of the sociology of the body for
understanding the issue of withdrawal from injecting heroin use. Based on interviews with nine
women and seven men, the approach involves focusing on these clients accounts of their
experiences of (now-methadone) withdrawal from heroin, tracing the social processes that invoke
them to thematize the body as they position themselves as dirty or clean, and resist
construction of the self as junkie or slave.
Introduction
Despite the large body of literature surrounding drug use there is little that
conveys a sense of a persons embodied experience of drug use and withdrawal
therefrom. This could be explained by the selective character of the research.
What is significant about the drug and alcohol research literature is its
intellectual provincialism and isolation and a peculiar repetitiveness. This
repetitiveness relates to bias in the literature reviews2 and that extends to
research methodology2i3and reporting of findings.2 Such representations of
knowledge have gained their plausibility and normative status from assumptions about what is important to know and the superiority of certain forms of
kn~wledge.~
The narrow terms in which drug and alcohol research is defined3 and the
overshadowing of drug-related sociological research by medicine and psychology5 was highlighted in a special issue of the Australian journal Drug and
Alcohol Review, dedicated to social sciences and the addictions. This edition
testifies not only to the past pre-eminence of quantitatively oriented works, but
to the continuing diminution of the contribution of qualitative social scientific
research particularly with regard to that which seeks to understand subjective
meaning^.^ This is not to say that there is no qualitative research of this kind,
just that comparatively it is thin on the ground, and has difficulty being heard
when policy, funding and treatment decisions are made.
~
Correspondence to: Dr Glenda Koutroulis, 75 Henry Street, Windsor, Victoria 3 181, Australia.
0958-1 596/98/030207-18 0 1998 Carfax Publishing Ltd
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These items were then factor analysed. Three studies l 8 utilized a number of
questionnaires to find out why drug users sought help. One questionnaire,
employed by all three studies, itemized 54 possible reasons for coming for
treatment, asking respondents if they had experienced any of the listed reasons
and if so, whether this was an important reason for coming for treatment. Items
spanned such topics as: the availability of drugs, subjective experience of the
dependence on drugs, the physical health implications of drug misuse, problems
experienced in relation to money, accommodation, employment and the legal
system, appraisal of own emotional state, and relationships. Oppenheimer et al.
conclude that it does seem to be a combination of trigger events and a
subjective re-evaluation of the meaning of these events that precede helpseeking17 (p. 645).
How do these authors know, through respondents standardized responses to
highly structured questions, that a subjective re-evaluation of the meaning of
trigger events that precede help-seeking has taken place? Mishler takes the view
that instruments, where questions have been standardized and the technology of
coding and statistical analysis is used to make sense of the data, have the effect
of suppressing discourse and obscuring, even quashing the social and personal
contexts of meaning-expressing and meaning-understanding. l9 Thus, the conclusion of Oppenheimer et al., I argue, is debatable. From a poststructuralist
stance, Reekie points out that without attention to language and the processes
by which meanings and categories are constituted, we perpetuate conventional
and over-simplified understandings of the world, rather than opening up new
interpretative possibilities (p. 462). A case, therefore, can be made for some
displacement of what has come to be the traditional, customary well-worn way
of tackling research around withdrawal treatment. The replacing of quantitative
instruments with a more sustained focus on client experience and the discourses
through which clients are positioned, then, would promise illumination of
neglected aspects of withdrawal and the many ways withdrawal is experienced
and managed within given social structures. Social categories that include age,
class and gender are tied to how we experience our bodies. Contributions that
focus on the body and embodied experience could bring us closer to those
whom we are trying to study.21
This paper is an empirical contribution to drub research about withdrawal. I
focus on the meaning and significance of injecting heroin use within the context
of withdrawal as experienced in everyday life. This is understood within some
cultural interpretations of heroin use and withdrawal from heroin. My aim is to
contribute to the development of an understanding of the embodied experience
of heroin use and of heroin withdrawal and how this might influence clinical
practice around withdrawal. I do this by producing a record of interviews with
injecting heroin users about their impetus for withdrawal that are treated as a
narrative account embedded in complex issues of subjectivity; and through
providing a distinctive analysis of the withdrawal accounts by interfacing these
data with the sociology of the body perspective. This approach has an agenda
of fleshing out relations among subjectivity, embodied experience and the social
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G. Y.Koutroulis
and enjoyment.29In sum, the literature suggests that through the body meaning
is expressed. It follows, then, that how heroin use, or withdrawal from it, is
experienced is dependent on the social ascription of meaning.
Setting
This study was carried out at a public non-residential alcohol and drug centre
located in an inner suburb of Melbourne, Australia. T h e location of this centre
was more eloquently described by one participant as being right in the heart of
Smacksville. Drug users come to the centre for withdrawal treatment and
other interventions, after a lengthy series of assessment procedures. T h e initial
assessment occurs when the drug or alcohol user first requests treatment, and
this may take place over the telephone. Provided certain criteria are met, for
example, the exclusion of some medical and psychiatric disorders, then the
client is invited to attend a more general assessment. At this assessment a
detailed psychosocial history is recorded. This is followed by a medical examination and the conducting of medical tests. For some, interventions (counselling,
and prescription drugs such as Valium and Doloxene) may begin at this
assessment. For others, interventions are initiated at subsequent withdrawal
appointments. The assessment determines the clients acceptance into the
withdrawal programme; if accepted, the person signs a contract agreeing to
the conditions of the withdrawal programme and so becomes a client.
Method
Fieldwork took place over a three month period during 1996. This involved
tape-recorded, semi-structured interviews with 16 clients who, following a
detailed explanation of the project and an assurance of confidentiality, agreed to
participate in the study. There were seven men (aged from 24 to 31 years) and
nine women (aged from 21 to 37 years). All were Melbourne residents
and Anglo-Australian in origin. Pseudonyms have been used throughout the
data analysis to protect client identity. Fourteen clients were injecting heroin
users, one was an alcohol user and one was primarily a cannabis user, although
this person was also an occasional heroin user. It is the accounts of the heroin
users that are represented here. I have used italics to distinguish the voice of the
research participants in an endeavour to signal their text as the primary
data.
The first interview, generally of 20 to 30 minutes duration, took place
following the clients agreement to participate. This interview explored the main
reasons influencing the clients decision to seek entry into the withdrawal
programme and how she or he anticipated that treatment might address these
issues. A second and third follow-up interview was conducted where possible.
When these follow-up interviews did occur, they were conducted with a slightly
different schedule of questions, but the focus was directed toward what the
client felt she or he might have achieved by participating in the withdrawal
Results
In what follows I shall examine some dominant features of the body themes that
emerged from the withdrawal narratives; and offer my own analysis of these
accounts. These narratives and the accompanying analysis highlight the role that
bodily experience has in shaping identity. I begin by introducing heroin users
talk and discussing symbolic meanings of this talk. Next, I examine how these
heroin users make sense of their withdrawal experience in the context of junkie
and as slave. Finally, I consider the subjective experience of withdrawal as a
gendered embodiment of social life.
I have to be clean
It is through illicit drug use that a person acquires certain meanings and
becomes a vehicle of signs, indeed a sign in their own right. T h e heroin user is
spoken of as dirty, junkie, scummy, untrustworthy. They may look dirty
on the outside, or even clean on the outside, but be dirty on the inside. Drug
users are constructed as dirty when their urine is found to contain evidence of
illicit drugs; they are clean when their urine indicates this to be so. These
categories of clean and dirty are an expression of symbolic systems.24
T o voice their own (im)purity through describing themselves as clean or dirty
is part of the common parlance of drug users, and this came through in a
number of interviews. T o get clean; stay clean as long as possible; clean u p
altogether; ty to get clean again, show that clean is a milestone to the pathway
of withdrawal. These, and the comment: I have to be clean .. . for practical reasons,
demonstrate how non-drug use is re-named or overlaid by the notion of
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cleanliness, a value through which the drug user is interpellated as one who
must keep his or her insides clean. This is required not only for the subjective
self but for reparation of the social fabric in which the drug users life is
entwined to take place.
Heroin is surrounded by prohibitions, moral regulations and more recently
with the advent of AIDS, rules of hygiene. The layers of meaning built up
around heroin, and through heroin use, as well as the myths and fantasies that
accompany it, seem to form part of a dynamic of socialization which is
understood as a relation of crossing boundaries; moving from outside the body
inwards, heroin is lived from inside the body outwards, including in its association with urine: heroin, when inside the body, becomes dirt. This magical
of the
reconstitution of heroin can be understood within K u b i e ~ framework
~
body as a dirt factory, thus explaining the reference to the (human) container as
dirty or even junk.
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slaves have interpreted their drug use through what Bell calls a subtle conceptual
framework whereby the drug (heroin) is seen as the causal agent in the
p r ~ b l e m . ~T h e drug is conceptualized as an evil essence that has invaded
the person. Thus, American theories of drug and alcohol abuse convey the belief
that the essence of the abuse lies in the chemical substance rather than in
personal or social factors. This ignores the social relations in which drug use
takes place, that is, the drug is isolated from its context of use and is cast as the
demon, the menace, the problem.
T o be a slave is to occupy a hallowed space as the object of another;
participation in the reinforcement of a subordinate status can be called slavish
b e h a ~ i o u r Drug-taking
.~~
does not automatically place someone in the position
of slave, So, how do drug users construct themselves as slaves? Blackwel13
reports that a slave-like sense is more likely professed by those who are
powerfully compelled to heroin and other opiate narcotic use than b y those
whose compulsion is less powerhl. In the present study, slave language
showed up in a number of the interviews. I have used excerpts from these
interviews to illustrate what informs a slave identity. Although differences are
apparent in the choice and frequency of this slave language, the excerpts are all
remarkable for these drug users recognition of their position as slave and for
their expression of resistance which, through the desire for withdrawal, is
directed against the dictates of the body. In the following account, Jims sense
of being a slave is linked with multiple elements (feelings, money, control).
(J =Jim; I = interviewer).
If we didnt get it [smack] wed stop for a day and then if we didnt get
it the day after that Id start feeling really horrible and shitty; ... then I
realized I had to get a grip because it was costing me a lot of money. Like
I want to control the drug not the drug control me ... . Money was another
big factor, like Im in debt a bit.
J:
I:
J:
I:
J:
T h e stories clients told explaining why they wanted to withdraw were linked
with loss of control and revolved almost without exception around finances.
Eland-Goossensen et al. have written that a sure sign of losing control of drug
use is when the user ceases to decide the amount of use but is limited by the
available money. T h e image of slave allows us to grasp the relation of
structural domination within which the heroin user is subordinated to the drug,
and at the same time to portray the heroin user as active, albeit in the context
of given constraints. T o Jim, heroin has lost its function of pure pleasure in
which its usefulness was defined in relation to how it made him feel. Instead, it
has become a symbol of domination, and of potency not only in its pharmacological characteristics but in its association with his lack of money.
I was realizing that I was becoming the slave and it was becoming the master
and I dont like those sort of relationships, so yeah, thats the main reason
why.
Zoes use of the term slave allows her to describe the behaviour of herself-a
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heroin user-in a way that showed her to be both subordinate and active; she
is subordinate to the master, explicitly named as the drug, yet through entering
a withdrawal programme she is working actively toward displacing the positioning of herself within the master-slave relationship.
I do want to stop [using heroin] ... I want to get off ... I just want to clean
up altogether, implored Joan at her first interview. Seven weeks later
having: stayed clean for 21 days, Joan remarks: at the moment its
maintaining itself in a controlled manner.
Having rethought her usage, she adds:
Also I think I dont want it totally out of my lije, I still get a lot of pleasure
from it. But I do have a control problem with it. Its a battle to maintain it
just as a recreational pleasure and not let it swallow nze up ... . It does get
to a point where all of a sudden Im using e v e y day again and then Ill
decide I cant afford this, Im in debt up to my eyeballs, Ive got to stop using
and I have to come in here again. ... I suppose I do have an addiction
though I dont know. What else could there be?
In the words of medicine, Joan does have an addiction or dependency. Joans
question, though, suggests an awareness of the narrow repertoire available to her
to help explain her experience. Her references to having difficulties controlling
her heroin use, not letting heroin swallow her, and not being able to afford to
use every day, make visible the slavish relation whereby through addiction or
structural domination, Joan constructs herself as subordinated to heroin. At the
same time, her entrance into a treatment centre portrays her as actively stepping
outside this relation to have control(1ed use).
Subjective experience
There is a widespread belief, says Stein, in the inherent powerfulness of drugs
that it leads to reasonings like she is not really herself, it is the drug speaking.
Such reasonings define the acts of the drug user as ego-alien. This conveys a
notion of a split subjectivity (self and other) which comes through in Blackwells30account of a man who toward the end of one using episode thought that
he was taking on an alien identity. These themes of disruption to the self
through injecting drug use come through in other ways. B l a ~ k w e l has
l ~ ~written
that 19 of her 51 participants found themselves in a situation whereby they
wanted to self-regulate their opiate use to improve health, psychological wellbeing and general appearance. Moores4 analysis of dependence gives insight
into some aspects of the emotional life associated with injecting drug use. He
tells of the tension, edginess, ugly arguments and emotional outbursts related to
coming down. And, a withdrawal from speed experienced by two of his study
participants (Vinnie and Laura) was marked with depression, extreme agitation,
mood swings, lethargy, irritability and paranoia.
In this section I describe some of the subjective, bodily existence of injecting
heroin users. Heroin is thought of as something added to the person-something that can be felt as disrupting an essence, the character, the emotions, the
physical being, even eclipsing the self-both buttressing and emphasizing subjective experience. In a cross-sectional analysis of the interviews with men and
women I found many points of similarity between their stories and this is
represented in the themes. I also found some points of difference between the
stories of these men and women; one difference manifests in the way in which
the subjective experience of heroin use is expressed. Reducing heroin use
(coming down) threatens body stability. The interviews speak of the emotional
and corporeal experience: women, more often than not, discussed the feeling in
terms of emotions-usually expressed negatively and as out of control; whereas
the men tended to discuss the feeling in terms of a bodily or corporeal
sensation-usually expressed negatively as a sickness.
Emotions are gendered, and therefore womens expression of emotions is
evaluated differently from mens expression of emotion^.^"^^ Understanding the
expression of feeling or emotion lies in understanding the social relations in
which such feelings and emotions are embedded.41First I turn to explore how
these womens expression of the self pertains to their emotions:
Judy: Ijust feel miserable, I rn not a person any more ... . Most of my friends
are straight-thank God I dont move in a circle of junkies or anything ... .
And having a girlfriend ringing me up in tears and saying to me: Wheres
Judy gone? ... Where is she?
When asked by the interviewer to prioritize her reasons for wanting to withdraw,
Judy said:
... getting me back ... . Having all my old energy and, you know, being
vivacious, ... being clever and stuff. And now Im just not until I have a hit
and then ... Im stoned and thats not the real me either ... . I dont want
to substitute for anything ... . I want to get a sense of myself back. Not just
a sense of myself, I want to get myself back because it is just such an insidious
drug it just takes you over.
Emotions are constructed with reference to the evaluation of other^.^',^* In
Judys self-reflection, and in subsequent appraisals and evaluations of her
behaviour by her friend, misery is constructed.
Judys story carries with it an awareness that heroin use threatens her sense of
self, even displaces the self. Her embodied experience (as a heroin user) is one
of otherness inhibiting her energy, vivacity and abilities, preventing her from
accomplishing her goals. The real or true self can only be realized with
the assertion of independence from heroin use. This expectation is further
illustrated in another womans reflections:
Zoe: I want to see the old me sort of showing through a bit because you forget
that there is another person underneath there, and I just want to see
her ... without being clouded by drugs. Emotionally I just cant cope with
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G. Y. Koutroulis
being on heroin all the time because I dont give my real emotions a chance
to peep out of the clouds. And when they do, they really do, they storm
down ... . A couple of times lately when Ive had it ... Ive got cranky on
it ... . I just thought Oh God, whats the point?
Zoe, as a drugged subject, experiences the self as eclipsed by a cloud brought
about through drug use which prevents expression of her real emotions. When
expressed, there is a sense that they are regarded as out of control. Relief from
the (storm of) emotions is constructed at the point of freedom from heroin use,
and is grounded in the recognition that there is another (more desirable) self to
be recalled.
For others, heroin use was also linked with control or stability of emotions:
Judy: M y temper has been completely out of control.
Anna: Coming down all the time means that Im not emotionally stable
enough to do anything.
So debilitating is Annas experience of emotions, she finds herself immobilized.
Following, there is a more globalized sense of bodily debilitation and a recognition of a decline in the symbolic value of the body:
Beth: M y looks are going down the gurgler a bit, ... [my] skin is not
wonderful, ... [Im] not dealing [with] anxiety; ... I dont think my body
can take it much longer.
While noting the array of themes (e.g. looks, feelings) there is a generalized
relationship and a preconstructed social recognition of a standard by which the
self is measured. Heroin use is unbecoming, impeding Beths chances of
achieving the standard. Similarly, Bla~kwell~
makes reference to one woman, a
photographic model, who expresses worry that her unhealthy lifestyle (associated with opiate use) might adversely affect her appearance. These examples of
concern about decline in the symbolic value of the body through injecting drug
use contrast with some other findings. Dorn and
for example, assert
that for many groups of injecting drug users, looking somewhat wrecked is
viewed as more attractive. They invoke the term lookism and import a theory
of intersubjectivity to claim that in the cultures of many groups of injecting drug
users, damage to appearance and to health is worn with pride.
I now turn to explore how the men interviewed expressed their subjective
experience of heroin use. Heroin use brings an awareness of the body. Through
this use there is a noticeable change in bodily state signalling a disruption or
dysfunction that warrants attention. While health might not be the prime motive
for seeking withdrawal services for these men or women, it is a prompt and a
strong theme in many of their stories. What is of interest is that in these mens
stories there is an absence of emotional expression and a (re)focus on corporeal
sensation:
Eddy:
its
... [but] Z use too much; my livers starting to hurt and Z dont eat enough.
222 G. Y.Koutroulis
symbol, is linked with a positive self-identity. The most common example here
of withdrawal as a body project can be found in the attention given to the effort
not to become junk. The expression junkie recognizes the body as making a
personal statement about who and what she or he is; drug use and withdrawal
therefrom are tethered to expressions of self-identity and lifestyle: from dirty,
scummy junkie to clean and in control.
The (drugged) body is implicated in a system of domination and subordination. I have shown the body as a basis of oppression through, for example, its
location as a site for the construction of the junkie, and the slave. In addition
to the appearance of the body in these narrative accounts they also highlight the
social location to which the drugged body is subject. As importantly, however,
these accounts are a demonstration of the body as a phenomenon of options
and choices (p. 3)23 where drug users can exert control over their bodies by
injecting drugs or not injecting drugs.
Withdrawal is entertained at moments when the body (which otherwise has
receded from direct experience) becomes a focus of negative qualities.44 How
men and women reflect upon, and live their bodies might be seen as one of the
defining features of their experience of withdrawal.
Sociology of the body enables a clear understanding of the relationship
between heroin use and identity, so permitting such observations as the transformation from person to junk(ie); and the importance of self-identity, or the
experience of the self, to well-being. The problem with the typical approach of
the structured, standardized questionnaire outlined at the beginning of this
paper is that withdrawal is examined independently of its constitution by the
embodied social actor-the drug user. I am not suggesting a disregarding of
the insights gained from the scales and instruments or for them to be cast aside.
The propensity for examining withdrawal through these quantitative measures,
though, inhibits contextual understanding of how, when and under what circumstances the body becomes thematized. For example, Sheehan et a1.I6 cite
My life is out of control as the single most frequently claimed important reason
for coming for treatment. There is no sense, however, of how respondents give
meaning to this statement; and it is unlikely that this, among a long list of other
withdrawal items appearing in the questionnaire, is viewed as identical in
meaning by all respondents. Indeed, any number of meanings is possible and
these meanings, as Reekie2 notes, are determined by the political position of the
reader of the problem. Only when there is an opportunity to analyze meaning
can control-slave-body linkages be made. T o give credence to heroin users talk
about their withdrawal experience, in the way that credence has been given to
researchers instruments examining withdrawal, can help us to understand
better the sociopolitical dimensions of this bodily process.
In this discussion of withdrawal, I have attempted to draw attention to
withdrawal as a body project, a smaller project within the vaster project of
becoming a healthy, normal body. The emphasis is on becoming withdrawn-something constantly worked at-which is closely linked with self-regulation, self-responsibility and projecting an image of the self as clean. Injecting
Acknowledgements
This research was supported by funding received from the Victorian Government Department of Human Services. I am gratehl to the withdrawal research
team, particularly Peta Odgers and Allan Kellehear for their support in my
construction of this paper. Thanks are especially due to the clients who
contributed to this research. The helpful comments of Sue Goldman and the
two anonymouse referees on an earlier draft of this paper are appreciated.
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