heroin addict

8/13/2019 heroin addict

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American Journal of Community Psychology VoL 2 No. 1

Fie ld Ob serv at ion s o f a Her oin A ddictA Case S t ud yPatric ia B Sutk er 2Medical University of South CarolinaVeterans Administration Hospital Charleston South Carolina

Observations of the ongoing activities of a heroin addict were recorded in com-plete narrative sty le on 15 separate occasions spanning a period of 3 weeks in aneffort to describe and identify key stimuli in the daily repertoire or environ-mental milieu o f the addict-client predictably related to drug or other antisocialactivities. It was noted that the chance meeting o f another addict whether in arehabilitation center or on the street was the most frequent stimulus to heroinuse in a client attempt ing to achieve a goal o f drug abstinence. Though difficultto obtain for most clients behavioral observations are fo un d to be an interestingand highly relevant source o f data to improve the formulation and evaluation o ftreatment strategies on an individual basis.

Chief among problems in the treatment of urban narcotic addiction is a paucityof definitive research regarding the determinants of heroin abuse and the ante-cedents of drug abstinence in once addicted individuals. Theoretical explanati onsof the origin of addic tive behavior are as varied as one might imagine, rangingfrom Fenichel s (1945) des cription of addicts as those who display an inordina teneed to satisfy archaic oral longings to Prebel and Casey s (1969) formul ationthat addicts are actively involved in an adventurous, challenging, and rewarding

This investigation was supported in part by the National Institute of Mental Health, HealthServices and Mental Health Administration, U.S. Department of Health, Education, andWelfare, through contract PH-43-68-1520 administered through the Department of Psychi-atry and Neurology, Tulane University School of Medicine. Appreciation is expressed toChester B. Scrignar and Gary H. Cohen, past and present directors of the Narcotic AddictRehabilitation Act (NARA) Program, which provided the subject for observation, and toSandra H. Gil and Rickie S. Gilliard for their assistance in data collection.2Requests for reprints should be sent to Patricia B. Sutker, Psychology Service, VeteransAdministration Hospital, 109 Bee Street, Charleston, South Carolina 29403.

35 1 9 7 4 P l e n u m P u b l is h i n g C o r p o r a t i o n 2 2 7 W es t 1 7 t h S t r ee t N e w Y o r k N . Y . 1 0 0 1 1 . N op a r t o f t h i s p u b l i c a t i o n m a y b e r e p r o d u c e d s t o r e d i n a r e t r ie v a l s y s t e m o r t r a n s m i t t e d i na n y f o r m o r b y a n y m e a ns e l e c t r on i c m e c h a n i c a l p h o t o c o p y i n g m i c r o f i l m i n g r e c o r d in go r o t h e r w i s e w i t h o u t w r i t t e n p e r m i s s io n o f t h e P u b l is h e r .


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6 ~ t ~ r

l i fes ty le . Research a t tempts to i so la te poss ib le causal fac tors f rom almost over-whe lming co m plex i t y have been l a rge ly pos td i c t ive i n the i r focus on desc r ip t i onof personal i ty character i s t i cs of a l ready addic ted indiv iduals (Ast in , 1959;Gi lber t Lo m bard i , 1967; G end reau G end reau , 1971 ; Sutker , 1971 ; Sutke rM oan, 1972; Sutker Al la in , 1973) , m etabol ic theor ies of phys io logical depen-dence (Do le Ny swande r , 1967) , and psychosoc i a l exp l ana t i ons o f add i c t be -havior (Ausu bel , 1961; Akers , Burgess , Joh nso n, 1969). S imi lar ly , ef fo r t s toiden t i fy c r it ica l f ac to r s a s soc i a ted w i th d rug abs t i nence o r , converse ly , d rugrelapse (V ai l lan t , 1966) are incom plete in descr ib ing the ,env i ron m en tal , t rea t -m en t , and soc ia l cond i t i ons under w h ich abs t i nence is m os t l i ke ly to occ u r andas ye t i n ne ed o f r ep l ica t ion .

In ad voca t i ng t he unob t rus ive obse rva t ion o f behav io r i n na tu ra l s e t t ings ,Barker (1963 , 1965) fo s t e red an ap proach t o t he co l l ec t ion o f da t a t ha t d i f f e r sf r o m t h e m o r e p r e d o m i n a n t o r i e n t a t io n s o f c o n t e m p o r a r y p s y c h ol o g ic a l re -sea rch . Bor rowing t echn iques t yp i ca l l y em ploye d by e tho log i st s and p f imato lo -g is t s in thei r f i e ld s tudies of an imal behavior , he sought to descr ibe the ongoings t ream o f ch i l d ren ' s behav io r a s i t occu r red i n t ac t i n t he i r na tu ra l su r round ingsw i th em phas is on t he spa t ia l and t em pora l d i s t r i bu t i on o f eve ryday ac ti v it ie s .More recen t l y P a t t e r son and C obb (1970) desc ribed a ca re fu l ly des igned sys t em fo rapply ing observ at ional t echn iques to th e dya dic analys i s of in t rafa m i ly aggressionin w hich s igni f icant variab les , ca l led fac i l i ta t ing or inhib i t ing s t imul i , were ident i -f ied b y changes p rod uce d in response proba bi l it i es for par t icu lar typ es of aggres-sion.

S uch t echn iques have ra re ly been app l ied t o an unders t and ing o f t he m oreser ious ly deviant adul t groups , such as cr iminals or hero in addic t s . As ear ly as1963 , how ever , Becker em phas i zed t he fu t i l i t y o f exp l ana t i ons o f dev i an t be-hav io r wi thou t t he co l l ec t i on o f de t a i l ed accoun t s o f ongo ing da i l y ac t i v i t i e sw i th in the env i ronm ental mi l ieu in such groups (B ecker , 1963) . Spec i f ica l ly , hepo in t ed t o t he sub cu l tu re i den t i f ica t i on as a pow er fu l , t hou gh poo r ly under -s too d, inf luenc e on ant i socia l ac t iv i ti es . P rob ably the greates t h indranc e to be-hav io r change wi th in t he t yp i ca l ou tpa t i e n t t r ea tme n t cen t e r i s t he l ack o fcon t ro l over t he env i ronmen ta l m i l i eu and t he r e l a t i ve i n f requency o f con t ac t swi th the addic t -c l ien t . Cer ta in ly , weekly or b iweekly sess ions , whether in asso-c i a t i on wi th methadone main t enance o r d rug abs t i nence goa l s , p rov ide on lyscan ty , ir re levant , o r de l ibera te ly fa l s i fied info rm at io n regard ing the ongo ingbehav io r i n t he l i fe o f t he add i c t . I f i t is a s sumed tha t a p rom inen t goa l o ft r ea tm en t is a wi thd rawa l o f i n t e res t, t ime , and m on ey i nves ted i n d rugs and anul t im ate s ta te of drug abs t inen ce, as wel l as ade qua te socia l iza tion , the n ident i f i -ca t i on o f ke y s t imu l i in t he da i l y r eper to i re o f t he c l ien t wh ich a re p red i c tab lyre l a t ed t o d rug ac t i v i t i e s wou ld be o f p r ime impor t ance . In a p i l o t a t t empt t oiden t i fy t he s t imu lus c ond i t i ons m os t o f t e n as soc ia t ed w i th a dec i s ion t o s eekthe he ro in co nnec t i on and t o und ers t and be t t e r t he m o t iva t i ona l fo rces opera t -


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F i e l d O b s e r v a t io n s o f a H e r o i n A d d i c t 7

i ng t o s u s t a i n s uc h be ha v i o r , t he da l l y a c t i v i t i e s o f a n i nd i v i dua l a dd i c t - c l i e n tw e r e s a m p l e d .

M E T H O D

Sub ject BackgroundT he S r e f e r r e d t o a s J . , w a s a 31 - ye a r - o l d w h i t e m a r r i e d m a l e w i t h a

14 - ye a r h i s t o r y o f he r o i n a dd i c t i on . H e w a s s e pa r a t e d f r om h i s w i f e a nd 11 - yea r -o l d s on . T he s i x t h o f s e ve n c h i l d r e n , he w a s ra i se d b y h i s m o t h e r i n t he a bs e nc e o fh is f a t h e r. T h e o t h e r c h i ld r e n i n th e f a m i l y - w i t h t h e e x c e p t i o n o f t h e s e c o n do l de s t b r o t he r , w ho w a s i nc a r c e r a t e d f o r t he t h i r d t i m e i n t he s t a t ep e n i t e n t i a r y - w e r e f re e o f c r im i n a l r e c o rd s o r i n v o l v e m e n t . A l t h o u g h h e r o i n w a sh is d r u g o f c h o i ce , J . h a d s m o k e d m a r i ju a n a f r e q u e n t l y w h i le i g n or in g a m p h e t -a m i ne s a nd ba r b i t u r a t e s e xc e p t i n t he a do l e s c e n t ye a r s . H e w a s a l so a ha b i t ua lt h i ef ; h o w e v e r , h e h a d o n l y b e e n a p p r e h e n d e d o n c e f o r a t h e f t -r e l a te d c h a r g e ,t he f t o f a c r e d i t c a r d . A c a d e m i c a l l y , J . w a s uns o ph i s t i c a t e d w i t h a s i x th - g r a dee duc a t i on . H e d i d no t e n j oy r e a d i ng a nd t o t a l l y r e f u s e d t o w r i t e l e t t e r s . S c o r e son severa l IQ t e s t s (Wechs le r Adul t In t e l l igence Sca le ; Sh ip ley Har t ford In te l l i -gence Sca le ; Po r t eus M azes ) c l a s si f ied h i m in the ave rage range . Voca t iona l ly heh a d c o m p l e t e d n o a d v a n c e d t r a i n in g a n d w a s q u a l if ie d f o r o n l y l a b o r e r - t y p ew o r k . A t t h e t i m e o f o b s e r v a ti o n , t h e c l ie n t h a d b e e n o n t h e N A R A P r o g r a m f o rove r a ye a r . H e ha d s pe n t 6 m o n t h s a t t he H os p i t a l in F o r t W o r t h a n d r e tu r n e dt o da i ly u s e o f he r o i n l e ss t ha n 1 m on t h a f t e r h i s re l ea s e i n A pr i l 1970 . Cons e -q u e n t l y , t h e t r e a t m e n t t e a m r e q u e s te d h is p a r t i c ip a t i o n in t h e m e t h a d o n e m a i n -t e n a n c e p r o g r a m e a r ly i n M a y . W h e n o b s e r v a t io n s b e g a n , J . h a d b e e n a t t e n d i n gm e t h a d on e c l in i c r e gu l a rl y f o r 2 w e e ks a nd w a s a c t i ve l y l ook i ng f o r a j ob t oc o m p l y w i t h p r o g r a m e x p e c ta t io n s .

ProcedureT he S w a s s e l e c te d on t he ba s i s o f h is w il li ngnes s t o a l l ow obs e r va t i on a nd

t o g ive a c om pl e t e a c c o un t o f a c t i v i ti e s du r i ng pe r i ods w he n he w a s a l one .O bs e r va t i ons w e r e r e c o r d e d i n c om pl e t e na r r a t i ve s t y l e on 15 s e pa r a t e oc c a s ionss p a n n in g a p e r io d o f a p p r o x i m a t e l y 3 w e e k s f o r a to t a l o f 4 9 h o u r s . F e m a l eo b s e rv e r s, d i s p a tc h e d i n t e a m s o f t w o , a t t e m p t e d t o r e c o r d a r u n n i n g a c c o u n t o fbe ha v i o r s , ve r ba l a nd o t he r w i s e , a s t he y oc c u r r e d a nd a t the s a m e t i m e t o in f l u -e nc e w h a t t r a ns p i r e d a s li t t le a s pos s i b le . O bs e r ve r s a c c o m pa n i e d t he a dd i c t -c l i e n t w he r e ve r he w e n t , i n t he c a r , i n t he hom e , o r on f oo t . I t i s r e c ogn i z e d ,h o w e v e r , t h a t t h e r e w e r e s o m e p l a c e s w h e r e t h e p r e s e n c e o f o b s e rv e r s w o u l dres t r i c t J . s ac t iv i t ie s , and thus h e d id n o t f req ue nt a fu l l range o f poss ib i l it i e s .


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Field Observat ions of a Heroin Addi ct 9

whatever was available at his sister's house. He was not particularly interested infood in the evening, unless immediately following heroin injection.

Thefts No thefts were directly observed, but the client offered a verbalreport of all articles stolen and the dates on which the event occurred. Eightthefts were described, ranging from sunglasses on the seat of a truck to eighttires stolen in one evening from the place where J. played cards with the nightwatchman. In addition, it is interesting to note that J. stole on two occasionsfrom his newly acquired employer and quit that job after having his car searchedby the police at his employer's request.

Heroin Use J. reported heroin use on 5 observation days. On each occa-sion, the effects of the drug were obvious, although J. complained that metha-done made it necessary for him to shoot at least two papers of heroin to feel theeffects. Drug intake occurred after the chance meeting of an addict acquain-tance, either on methadone or not, who may have suggested obtaining the drugor had already purchased it. On the one remaining occasion, J. bought twopapers of heroin after receiving his first full paycheck and took observers withhim to inject the drug. On this particular weekend, he spent over hal f his moneyfor heroin.

Viewing the observation periods as a whole, it became obvious that J. wasrarely motivated by concrete plans regarding a destination. Though his dailyroutine included several possible alternatives, most of which were designed pri-marily to pass the time, he was easily swayed by the chance meeting of a familiarpasserby. Further, he. had few close friends, and no girlfriends, to whom hemight turn in his boredom or need for social contact. Sure to find his friend C.working at the service station, he spent more time with him than anyone else. Healso sought out G., a nonaddict who was not really considered a friend, when hewished to go drinking at night. Assorted addict acquaintances, of whom therewere many, were encountered accidentally, and their meeting usually precip-itated drug intake. In short, daily activities when J. was unemployed mightinclude the following sequence of events:

Eat breakfast at a 24-hour restaurant. Go to sister's house to shave and tochange clothes. Wander around the city. Drive to C.'s service station. Getmethadone by 1 p.m. Go to sister's house and watch TV. Snack over there.Search out acquaintances who might be hanging around the streets. Find G.about 7 p.m., drink beer, sit in bar until after 12 p.m. Go to warehouse andplay cards, or execute a theft. Finish the day at C.'s service station, rest, orpump gas until morning.The territory covered on such a day included well-traveled paths throughout thecity with occasional detours prompted by the chance meeting of a police car. J.also avoided certain sites, particularly night spots where he expected to meetpeople who might wish to repay him for his having beaten them out ofdope.


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4 Sutker

D I S C U S S I O NR e pr e se n ta t ive o f t he s t r e e t a dd ic t , J . wa s poo r ly e duc a t e d , voc a t iona l ly

unski l led , an d no s t r anger to c r im ina l pursu i t s . He was a t ho m e in an envi ron-m e n t wh ic h a f f o r de d e a sy a va i la b i li ty t o i ll ic i t d r ugs , a m in im um o f opp or tu n i tyfor ach ievem ent of soc ia l ly acceptab le goals, and a h igh degree of co m m un i tyto l e r a nc e f o r de v ia n t be h a v io r o f a l l t ype s . Ea s i ly l i ke ne d to Ausube l 's ( 1961 )

r e a c t ive a dd ic t , he ha d be e n de l inq ue n t w i th r e gar d to t he la w be f o r e ana dd ic t t o he r o in a nd d isp l a ye d a va r i e ty o f soc iop a th i c f e a tu r e s on theM inne so ta M ul tipha si c I nve n to r y ( MMP I ). Onc e c a ugh t i n t he sna re o f a dd ic t ionand the ac t iv i tie s w hich th is by na tu re involves , he m a in ta in ed a r e la t ive ly con-s t a n t u se o f op i a te s f o r 14 ye a r s . I t wa s on ly w he n a p p r e he nde d by the la w f o rposses s ion o f he r o in t ha t h e c a me to t he a t t e n t io n o f re ha b i l i t a t ion wor ke r s a ndbe ga n a t r e a tme n t p r og r a m tha t ha d a s i t s u l t ima te goa l d r ug a bs t ine nc e a nda de qua te soc i al i za t ion . S ix m on ths o f hosp i t a li z a t ion , f r e e dom f r o m phys i c alde pe n de nc e , a nd ve r bal a f f i rma t ions o f i n t e n t io ns t o f o r sa ke d r ugs we r e no t ,howe ve r , su f f i c i e n t t o p r e ve n t r e sum pt ion o f he r o in u se a f t e r on ly a f ew sho r tweeks fo l lowin g hospi ta l r e lease . W hat va r iab les se rved to re ins ta te and sus ta inth is be ha v io r de sp i te a lmos t da i ly c on ta c t s w i th h is NA R A c o unse lo r , m on ths o fc o n f i n e m e n t i n a h i g h ly r e g i m e n t e d e n v i r o n m e n t , a n d t h e t h r e a t o f i m p r is o n -m e n t shou ld r e ha b i l i ta t i on f a il is a ma t t e r f o r spe c u la tion .

Obse r va t ions o f t he ongo ing s t r e a m o f be ha v io r in t h i s sub je c t sugges tsevera l hypothe t ica l p rocesses , in addi t ion to poss ib le pe r sona l i ty d ispos i t ions ,wh ic h m a y in pa r t e xp la in r e la pse. S eve r al p r ob le m s be c a m e a ppa r e n t wh ic hin t e r f e r e d w i th t he e x t inc t ion o f d r ug - r e la t e d be ha v io r s . The f a c t t ha t p r e v iouse xpe r i e nc e s w i th he r o in ha d t a ugh t J . t he p ow e r f u l pos it ive r e in f o r c e m e n t o f t hed r ug i t s e l f wa s a n e ve r - p r e sen t r e a l it y . The imm e d ia t e e f f e c t s o f d r ug in t a ke we r er e m e m be r e d to be b o th p l e a sa n t a nd e upho r i c . F u r the r , pos sib le ne ga t ive c onse -que nc e s a r e t yp i c a l ly pos tp one d in time f r o m the a c t o f d r ug in t a ke . The e f f e c t so f he ro in w ere a lso re l iab ly assoc ia ted w i th soc ia l contac ts , i l lus tra t ing the poin ttha t be ha v io r doe s no t e x i s t e xc e p t i n f unc t io na l re l a t i onsh ip to i t s e nv i r o nm e n t ,a nd in t h i s c ase, t he soc ia l e nv i r on m e n t wh ic h ha d 14 ye a r s be e n a s soc i a te d w i thhe r o in a buse ( C he in , Ge r a r d , Le e , & R o se n f e ld , 1964 ) . S imi la r t o m a n y o the r a d -d i c t s f r e e d f r om e i the r p r i son t e r ms o r pe r iods o f e x t e nd e d hosp i t a l i z a tion , J . re -t u r n e d t o h i s f o r m e r s u r r o u n d i n g s - u n e m p l o y e d , s e p a r a te d f r o m h i s w i f e , a n dlone ly f o r c om pa n ionsh ip : I t i s no t su r p ri s ing th a t h i s cha nge wa s sho r t -l i ved .

I t wa s obse r ve d th a t t he c ha n c e me e t ing o f a no th e r a dd ic t , w he th e r in ar e ha b i l i t a t i on c e n te r o r on the s t r e e t , wa s t he mos t f r e que n t s t imu lus t o a n t i -soc ia l be ha v io r i . e ., d r ug in t a ke o r t he f t , t hou gh the l a t t e r wa s a s soc ia t e d l es sf r e qu e n t ly w i th t h i s s timu lus . As R a y ( 196 4) e m pha s i z e d , t r e a t e d a dd ic t s ar e no to f t e n r e wa r de d b y the i r pe e r s f o r d r ug a bs t ine nc e . I n fa c t , obse r va t ions de m on-s t ra te th a t the conv erse is t rue . Add ic ts , themse lves dep end en t on he ro in , are a ll


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Field Observations of a Heroin Addict 41

too wil ling to share their supply of drugs with a fr ien d who is at tem pting toremain clean, at least unt i l i t becomes obvious that h e too requires the drug.

Viewing the results as a w hole, th e fol lowing conclusions are offered ashypotheses w orthy of fur ther investigat ion:

(1) Habitual pat terns of ant isocial behavior, i .e. , s teal ing, which are presentbefor e addict ion require considerable t ime be fore disappearing from thebehavioral repertoire and may not in fact discontinue even with drugabstinence.

(2) Drug intake, part icularly in cl ients at tem pting to remain abst inent , ishighly associated with the chance meeting of ano ther addict .

(3) Sporadic gathering sites for addicts, whether for treatment or socializa-tion, may serve to reinforce drug-related activities and conversation rath-er than discourage such.

(4) A subst i tute for h eroin, such as frequen t or excessive drinking, thoughsocially disappro ved, m ay play a role in facilitating drug abstinence.

Behavioral observat ions, thoug h difficul t to obtain for most addict-clients,provide an interest ing and highly informa tive source of data w hich has been largelyignored by treatment specialists. Accounts of ongoing activities, emotional re-sponses, and react ions of significant others within the family structure quicklypinpoint problem areas and part icular weaknesses to sustain or prompt drugintake in cl ients at tempting to remain abst inent . Such may also provide anobject ive basis on which to formulate, execute, and evaluate t reatment planswith regard to each cl ient. In the case of the cl ient observed, the outc om eremains positive, despite a rather shaky beginning. After almost a full 3 years ofpart icipat ion in the NAR A pro gram and an addit ional period of hospital izat ion,J. has been steadi ly employed by the same employer for a period of 2 years. Heremains drug abst inent w ith th e exc eption o f singular and sporadic inject ions ofheroin. A t the t ime of last contac t , he maintained his habit of heavy drinkingalmost nightly, th ough this behavior occurre d in the set t ing of famil iar bars. Notyet married, he resided primari ly with a brother-in-law and wife, nei ther ofwh om had a history of drug abuse. He gave up associat ion with oth er addicts andsought out the com pany of a var ie ty of women, most of whom he encounteredin restaurants or bars. Male friends were those he m et on the job. In retrospect ,J . displayed few of the p redicto r variables that Vail lant (1966 ) associated withlater drug abst inence; yet he is beginning to represent a t reatment success todayafter a steady, uphil l cl imb o f 3 years.

R E F E R E N C E SAkers, R. I., Burgess, R. L., Joh nso n, W. T. Opia te use, add ictio n, and relapse. oe~lProblems 1968, 15. 459-469.


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4 2 u t k e rA s t i n , A . W . A f a c t o r s t u d y o f t h e M M P I P s y c h o p a t h i c D e v i a t e Sc ale . Journal of ConsultingPsychology 1 9 5 9 , 23 5 5 0 - 5 5 4 .A u s u b e l , D . P . C a us e s a n d t y p e s o f n a r c o t i c a d d i c t i o n : A p s y c h o s o c i a l v ie w . PsychiatricQuarterly 1 9 6 1 , 35 5 2 3 - 5 3 1 .Ba rke r , R . G. (Ed . ) The stream of behavior. N e w Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 6 3 .B a r k e r , R . G . E x p l o r a t i o n s i n e c o l o g i c a l p s y c h o l o g y . American Psychologist 1 9 6 5 , 20 1-14 .B e c k e r , H . Outsiders. C h i c a g o : T h e F r e e P r e ss , 1 9 6 3 .C h e i n , I ., G e r a r d , D . , L e e , R . , R o s e n f e l d , E . The road to heroin. N e w Y o r k : B a s ic B o o k s ,

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