Research paper
Trauma, damage and pleasure: Rethinking problematic drug use

https://doi.org/10.1016/j.drugpo.2007.08.001Get rights and content

Abstract

Background

While the pleasures of drug use are sometimes acknowledged, they are normally limited to those who are socially privileged. The drug use of those who are impoverished and marginalised is linked instead to crime, social misery and addiction. Studying poverty in connection with drug use enriches our understanding of both poverty and drugs, but there are limitations to these connections, including their neglect of pleasure.

Method

This paper draws on 85 qualitative interviews with service providers and clients, conducted for a project entitled ‘Comparing the role of takeaways in methadone maintenance treatment in New South Wales and Victoria’. Critical readings of psychoanalysis are used as a conceptual frame.

Results

Although pleasurable and problematic drug use are often thought to be mutually exclusive, pleasure is reported from both the effects of drugs such as heroin and methadone, and from the social worlds of methadone maintenance treatment. Attention to drug users’ narratives of pleasure has the potential for new understandings of drug use and social disadvantage.

Conclusion

Common distinctions between kinds of drug use, such as problematic and recreational, are less useful than is normally thought.

Introduction

In September 2005 the London tabloid The Daily Mirror published front page photographs of fashion model Kate Moss lining up and snorting cocaine. Media coverage of celebrity drug-taking is nothing new, but there was something a little peculiar about this incident. Kate Moss entered rehabilitation only briefly, and lost a few job contracts before winning them (and more) back. The trajectory of detection, confession, remorse and rehabilitation that has become typical was absent and so too were accounts of addiction and its terrible cost. Perhaps for this reason, coverage in the conservative London broadsheet Daily Mail was even less restrained than usual in its condemnation. Consider, for example, the following editorial:

[M]ake no mistake. There is a connection between the middle-class professionals who believe they can control their “recreational” cocaine use and the hopeless and helpless junkies in countless housing estates who are destroying their lives through such drugs. (Editorial, 2005)

Although this kind of name-calling is both familiar and intellectually bereft, it does gesture towards a serious and well-established phenomenon: drug use and its harms among those who are impoverished and socially marginalised. In this paper, we aim to explore the strengths and limitations of this approach to drugs and propose ways that it can be developed. We are especially concerned to unpack the constructions of drugs and users that (sometimes) allow pleasurable use to ‘middle-class professionals’ but inevitably connect drug use by the poor to crime, social misery and addiction. These constructions do not exhaust the ways in which drug-taking is understood, of course, nor the ways in which the pleasure of drugs can be examined. Our purpose here is to scrutinise a particular analysis of drugs as ameliorating pain rather than causing pleasure. The binaries that connect pleasurable drug use to class privilege – and problematic drug use to poverty – deserve more attention than they often receive.

In order to do this, we look to classical psychoanalysis. This is not because we wish to use a theoretical psychoanalytic framework to explain contemporary culture, nor because we aim to contribute to the longstanding clinical psychoanalytic tradition of theorising the causes and treatment of drug use (Rado, 1933). We are, rather, interested in the intellectual influence of psychoanalysis, and especially in two strands of this influence. The first is the importance of pleasure to human development, and the connection between pleasure and trauma. Psychoanalysis has been massively influential to psychology, philosophy and social movements and much of this influence comes from analytic models of human development, pleasure and trauma. It is thanks in large part to psychoanalytic thought that questions being answered by contemporary research can be asked, viz. what are the causal relationships between early trauma and later distress or disordered behaviour? What are the sequelae of childhood sexual abuse? Psychoanalysis gave rise to and corresponds with many contemporary areas of multidisciplinary research into disadvantage and trauma. The second is the importance of narrative and speaking the self. Psychoanalysis is famous as the ‘talking cure’, and classical psychoanalysis was produced through narratives of self and distress by people who, until that time, had for the most part not been heard. In the section that follows we briefly review the literature on social disadvantage and drug use, before turning to the theoretical framework of psychoanalysis to explore pleasure and trauma in different ways.

There is a growing body of work on the social dimensions and political contexts of problematic and dependent drug use: in particular the prevalence of poverty and social marginalisation among drug users (Advisory Council on the Misuse of Drugs, 1998; Fountain, Howles, Marsden, Taylor, & Strang, 2003; Najavits, Weiss, & Shaw, 1997; Spooner & Hetherington, 2004). These studies, indebted to the disciplinary traditions of public health, anthropology and sociology, emphasise that diagnostic categories like ‘addiction’ can mask the social gradient of health (Marmot, 2003) and the material circumstances in which health problems are both formed and treated. Rather than connecting addiction only to individual pathology, this body of research has been crucial in demonstrating the complex ecological relationships between problematic drug use and social structures.

These understandings of problematic drug use as both socially mediated and associated with deprivation have a number of uses beyond the greater richness they add to the field. They emphasise the need to move away from individualist and pathologising models of addiction. They identify the importance of material inequalities in the emergence and treatment of problematic drug use, and the need for holistic approaches to preventing harm. However, there are limitations to understanding drug use only in social or structural terms and we will very briefly indicate four of the most important of these. First, when problematic drug use is considered as an indicator or correlate of other ‘social problems’ like crime, the specificity of each is lost. This can work to reify the categories of both drug dependence (Moore, 1992) and crime (Marston & Watts, 2003). Second, these approaches risk emphasising social determinants at the expense of individual agency and choice. Choice and agency are always constituted socially, and are always constrained. Socially marginalised people who use drugs in harmful ways are much more constrained than others. However, it is possible to recognise constraints on agency while also recognising people's inherent capacity for agency: to do otherwise is to risk further marginalising them. Third, and similarly, social explanations of drug use can be exceptionalising, making drug users a special case. As Moore and Fraser (2006) argue, neo-liberal formulations of the subject demand resources that many drug users do not have, but this does not mean that neo-liberal models of subjectivity are useful for everyone except drug users. Instead, critiques of the neo-liberal subject can be productively extended to all citizens. Finally, deterministic arguments about drug use can work teleologically, so the incapacity of drug users and the givenness of their drug use is confirmed rather than questioned in treatment sites. Associating problematic drug use with trauma and a fractured self can easily shift to a reinscription of users as deficient; where problematic drug use represents proof of trauma and nothing else. Ethnographic and other qualitative research emphasises the importance of the interplay between agency, discourses and social environments (Bourgois, 1995), but there are also influential trends in research that downplay taking account of users’ self-understandings. A recent editorial in Addiction worries that the ‘brain disease’ model of addiction has led bioethicists to argue that people addicted to drugs lack the capacity to give informed consent (Hall, 2006). While this development is considered to be worrying only in terms of its possible impact on research, it also speaks to broader concerns, such as the rights of drug users to represent their own interests and be heard.

Contemporary research then tends to concentrate on the link between deprivation, trauma and drug use, and these links are well established. Drug use is understood as both an indicator of social marginalisation and a result of it. A consideration of pleasure may require a different vantage point from which to view deprivation and drugs.

The question may be asked: why, given its lack of currency in the research cited above, do we need psychoanalysis at all in any discussion of pleasure and drugs? What does psychoanalytic thinking add? There are two answers. The first answer is that research into the causal effects of disadvantage on drugs rarely addresses directly the question of pleasure. Psychoanalytic accounts of development and trauma offer an alternative. Pleasure, according to psychoanalysis, is central to all development, whether normative or abnormal. Pleasure is never absent, even where it has been repressed or re-routed towards inappropriate objects. Whereas non-analytic thought around trauma tends to focus on self-medication and the mitigation of pain, reserving pleasure for those who are not traumatised, a psychoanalytic schema confirms the importance of pleasure for everyone. For all its heteronormative and otherwise problematic vocabulary, classical psychoanalytic thought embeds pleasure where those systems of thought that are indebted to psychoanalysis, and have supplanted it, treat pleasure as marginal. The second answer is that psychoanalysis emphasises the importance of narrative and people's accounts of themselves. In its focus on the sense of symptoms and its operations as a talking cure, psychoanalytic modes of thinking rely on what people say. These modes are therefore a counter to increasingly important approaches to explaining drug use that disregard or even discount the legitimacy of users’ accounts of their use, pleasures, constraints and choices.

It is necessary to very briefly rehearse a couple of the central tenets of psychoanalytic thought that are relevant here. In the early essays on sexuality, Freud described infantile development in terms of the derivation of satisfaction during oral, genital and anal stages. Pleasure has an evolutionary purpose: actions that are necessary to survival are pleasurable, in order that they will be sought and repeated. In earliest infancy, for example, the taking in of milk is pleasurable because the lips ‘behave like an erotogenic zone’ (Freud, 1977, p. 98). This means that the infant will continue to seek out the activity of sucking vital to their existence. As children grow into adults the seeking of immediate pleasure matures into sublimation, ‘phantasy’ and day-dreaming, but pleasure remains vital. Later works such as Beyond the Pleasure Principle (Freud, 1961) and Civilisation and its Discontents (Freud, 1994) describe the tension within individuals between the pleasure principle and the death drive. This is a tension necessary for people to live together in social worlds but one that also drives societies towards their end.

Pleasure, then, is critical to the development of individuals from infancy to maturity, and for the development of civilisations in drawing people together to live cooperatively. Pleasure also, famously, has the potential to be re-routed in the course of infantile or later development, and this re-routing or perversion can produce neuroses, psychoses or other abnormalities (Freud, 1985a; Lapanche & Pontalis, 1988). Psychiatric distress has its origin in the misuse or detouring of pleasure and its development from the infantile search for instant gratification to a more mature deferred gratification. Freud argues that symptoms of distress make a kind of sense, indicate the disruption to the mind that caused them, are not simply indicators of physical decay or degeneracy (Freud, 1985b). Symptoms are substitutes and satisfactions for what has not happened in real life. Pleasure is not just important to normal development; it can also be found, distorted, in the explanations of abnormal development.

In addition, there are alternative ways of looking at the narrative of abuse-trauma-damage than those that tend to dominate both analytic and non-analytic thought. The paradigmatic example of this narrative is child abuse. Judith Butler (1997, pp. 7–8) and Ian Hacking (1995, pp. 65–66) argue that the prevalence and harms of child abuse have been harnessed too closely to consequences, and that abuse should instead be recognised as an evil regardless of its long-term effects. Butler in particular uses a psychoanalytic framework to argue that children are not passive cyphers; indeed, the injustices that are done to them are abuses of the emotions and pleasures that are essential to their selfhood. Nor should the injustice done to them be understood only in terms of consequences, of the bad things that happen to them as a result of abuse.

In turn, this suggests alternatives to the thinking around trauma, disadvantage and drug use that currently dominate. Rather than thinking of trauma and problematic drug use only in terms of cause and effect, it is possible to acknowledge both the injustice of disadvantage and the agency of those who have been traumatised. That is, poverty and social marginalisation can be recognised as ills in themselves, regardless of their association with problematic drug use. People without resources will suffer different, and usually more severe, consequences of harmful drug use than people who have resources. This does not mean that people without resources have an inherently exceptional relationship to drugs, only that access to resources has an impact on the experience of both harms and treatment. Such a formulation has the potential to undo some of the more mechanistic links between poverty and drug use without losing sight of the importance of poverty to the harms done by drugs. It also involves the recognition that drug use is the result of agency as well as trauma, and may involve pleasure as well as, or as part of, the mitigation of pain. Rather than seeing those who use drugs in terms of passive victimhood, it is possible to acknowledge both the damage done to them and their capacity to respond and act in their own lives.

Methadone clients by definition use, or at least used, drugs problematically. Many are also socially marginalised or have suffered trauma, or both (Shand & Mattick, 2002). Methadone maintenance treatment is therefore a productive site from which to explore the connections between pleasure, agency and trauma in the light of this discussion. This paper is guided by two methodological principles: firstly, to be alert to the impact of disadvantage and trauma while declining to assume that people are determined by it, or that pleasure is absent; and, secondly, to recognise both clients’ capacity to speak and the importance of narrative in making sense of experience.

Section snippets

Method

The method has been described in detail elsewhere (Fraser, 2006; Treloar, Fraser, & valentine, 2007). This paper is based on 85 in-depth, semi-structured interviews gathered for an Australian National Health and Medical Research Council-funded project entitled ‘Comparing the role of takeaways in methadone maintenance treatment in New South Wales and Victoria’. Interview participants were methadone clients (n = 50); service providers including prescribing doctors, dosing pharmacists, and clinic

Traumatic origins

The figure of the drug user who is self-medicating, rather than consuming drugs for pleasure, has become relatively familiar. Our interviews, for example, suggest that in Australian drug treatment the prevalence of childhood trauma in client life histories, and the impact of that trauma on their lives, is quite widely recognised. Some clients refer to past trauma as an explanation for their drug dependence. For example Ed, a client from Sydney, reflects on his own history when asked for his

Acknowledgements

This study was funded by the National Health and Medical Research Council of Australia, and conducted at the National Centre in HIV Social Research, University of New South Wales. Thanks to the Chief Investigators and reference group: Carla Treloar, Susan Kippax, Alex Wodak, Max Hopwood, Catherine Waldby, Susan McGuckin, Andrew Byrne, Anne Lawrance, Denis Leahy and Sarah Lord. Thanks also to the anonymous reviewers and editors who commented on earlier versions of this paper.

References (25)

  • Freud, S. (1985b). The sense of symptoms (J. Strachey, Trans.). In Introductory lectures on psychoanalysis (Vol. 1)....
  • Freud, S. (1994). Civilisation and its discontents (J. Riviere, Trans.). London:...
  • Cited by (69)

    • Your diagnosis will not protect you (and neither will academia): Reckoning with education and Dis-Ease

      2021, International Journal of Drug Policy
      Citation Excerpt :

      Next, CDS challenges the assumption that poverty, homelessness, and other traumas produce use that is only ever malignant by highlighting that even highly marginalized “addicts” can derive pleasure from consuming (e.g. Dennis, 2017; MacLean, 2008). These interventions encourage us to imagine future research and policy directions where inequalities are treated as “ills unto themselves” (valentine & Fraser, 2008) that may complicate one's relationship with “addiction” but do not mechanistically cause or result from it (Ibid). That said, as useful as CDS is for interrogating “truths” about alcohol and drug use, existing scholarship does not expressly account for the additional “truth” that some “addicts” are Mad.

    View all citing articles on Scopus
    View full text