“Who Am I?”
Self-Transformations Among Recovering Heroin Addicts
Who Become Peer Educator
Master Thesis:
Milena Bussink
Student number:
10366571
Medical Anthropology and Sociology
Supervisor: Bregje de Kok
Acknowledgements
Foremost I would like to thank all peer educators and service beneficiaries who were so generous to share their experiences and wisdoms with me, and welcomed me in their family. You are beautiful and taught me incredibly much. I will forever treasure you and your stories I my heart. Thank you to the Organisation for inviting me to do my research.
Thank you to Pim, Margreet, Norbert, Sander and Doris for your endless belief and support and advise. I express gratitude to all my classmates who enabled me to become an anthropologist—and for the fun. Thank you Tom for teaching me LaTeX—and so much more.
Last but not least, thank you Bregje, for your dedicated guidance, your continuous honest attention for my work, for caring about my safety, and for the most insightful, thorough, and intelligent feedback I will ever receive.
Summary
This thesis examines how being a peer educator on Methadone Maintenance Treatment (MMT) in a harm reduction programme works upon peoples self-transformation pro-cesses which characterize their fight against heroin. Findings are based on three months of ethnographic fieldwork at a young, peer-led harm reduction programme in a large city in South Africa. Data was predominantly collected through participant observation and interviews and analysed using grounded theory and elements of narrative analysis. Find-ings show processes which link peer educating and MMT to the realization of a narrative self; telling the story of a human being leaving heroin addiction and becoming a ‘good person’, fighting for the righteous well-being of their peers and eager to (re)connect with the world, reality and people around him. The programme offered a platform to conceive new stories to their lives, which not only attempted to form a sense of self, but the narrat-ing of which appeared to serve many functions. Although various tensions arose between the role as recovering addict and being a peer educator, MMT and being peer educator gave my participants an opportunity to disconnect their selves from heroin and develop a reflective self, in which they reinterpret their past and tell their envisioned future.
Contents
Acknowledgements i
Summary ii
List of Figures vii
1 Introduction 1
1.1 Problem Statement . . . 1
1.2 Literature Review . . . 4
1.2.1 Perspectives on Addiction and Recovery . . . 4
1.2.2 Methadone Maintenance Treatment . . . 5
1.2.3 Self-transformation and MMT . . . 6 1.2.4 Peer Educator . . . 7 1.2.5 Gaps in Literature . . . 9 1.3 Methods . . . 10 1.3.1 Participant Observation . . . 10 1.3.2 Participants . . . 14 1.3.3 Interviews . . . 15 1.3.4 Data Analysis . . . 16 1.3.5 Positionality . . . 17 1.3.6 Local Background . . . 19 1.4 Ethical Considerations . . . 20
CONTENTS CONTENTS
2 The Narrative Self 23
2.1 The Addicted Self . . . 23
2.1.1 The Path Towards Addiction . . . 24
2.1.2 Life on Nyaope . . . 25
2.1.3 Leaving Nyaope . . . 27
2.2 A New Chapter . . . 28
2.3 I Share My Story . . . 33
2.4 Keeping Busy . . . 34
2.5 “Truth in Endless Error Hurled” . . . 36
3 The Moral Self 40 3.1 Becoming Human . . . 40
3.2 Purpose . . . 45
3.3 Make Amends with Past . . . 46
4 The Connected Self 50 4.1 Team . . . 52
4.2 Service Beneficiaries . . . 54
4.3 Family . . . 56
5 Discussion and Conclusion 59 5.1 Discussion . . . 59
5.1.1 Contribution to Literature and Practical Implications . . . 63
5.1.2 Limitations of the Study and Recommendations for Further Research 64 5.2 Conclusion . . . 67
Bibliography 77 A Field Note and Interview Excerpts 78 A.1 . . . 80
A.2 . . . 81
A.3 . . . 82
CONTENTS CONTENTS A.5 . . . 82 A.6 . . . 83 A.7 . . . 83 A.8 . . . 84 A.9 . . . 84 A.10 . . . 85 A.11 . . . 86 A.12 . . . 87 A.13 . . . 88 A.14 . . . 88 A.15 . . . 90 A.16 . . . 90 A.17 . . . 91 A.18 . . . 91 A.19 . . . 93 A.20 . . . 94 A.21 . . . 95 A.22 . . . 96 A.23 . . . 96 A.24 . . . 97 A.25 . . . 97 B Abbreviations 99
List of Figures
1.1 Outreach. The team spends some time with service beneficiaries (6 on this photo) who are burning garbage, while used syringes are collected in the yellow bin. “We meet them where they are at,” as the peer educators say. 13 1.2 Sleeping spot of one of my participants. A waterproof tent built in between
two trees, one of which he decorated with all kinds of treasures collected
from the streets. . . 15
1.3 Poem by Jeremiah: Mama Afrika. . . 21
2.1 Poem by Jeremiah: The Artist. . . 23
2.2 Nyaope is the local street drug my participants use(d). It is a crude mixture of low-grade heroin with anything from antiretroviral drugs to rat-poison or chlorine. The white powdery substance is usually packaged in a tiny scrap of beige coloured plastic, torn off a shopping bag. It can be both smoked—usually as a joint, mixed with dagga (cannabis)—or injected. . 26
2.3 Poem by Jeremiah: Who am I? . . . 29
2.4 Poem by Jeremiah: The Drug. . . 32
2.5 Poem by Jeremiah: On my way. . . 39
4.1 Poem by Jeremiah: Alone. . . 51
LIST OF FIGURES LIST OF FIGURES
A.1 Artworks of Jeremiah. Upper left: ”Black Jesus”. Upper right: salaman-der skins. Lower left: ”In case of emergency break glass”, a collection of heroin injecting utensils and a condom. Lower right: a parody on the stories drug users tell to get money. . . 79
Chapter 1
Introduction
“But if you take charge over your life, you will control your destiny. That’s what Daniel and the Organisation gave me. They gave me a sense of being. A sense of being who I am. You understand? Because for the past eleven years my life was on hold. My life was drugs.”
Thabo, peer educator
1.1
Problem Statement
Thabo succinctly introduces the central argument of this study, which expounds how being a peer educator on Methadone Maintenance Treatment (MMT) in a South African harm reduction project works upon peoples self-transformation processes which charac-terize their fight against heroin. In the course of creating a sense of self that both builds upon their addicted past, and disconnects from it, they find purpose as a peer educator: fighting for the rights and well-being of members of an outcast community of heroin users, including their past selves. A future which is in many aspects the opposite of who they were before, yet intrinsically linked to who they were.
The relation between peer educators, MMT and self-transformation in South Africa is an important field to study, for heroin addiction is a large and increasing problem. There are many different ways in which the concept of addiction is approached, framing it diversely as a choice, a moral failing, a crime, a sign of structural inequality, or a
1.1 Problem Statement Chapter 1. Introduction
disease (Garriott and Raikhel, 2015). The way of framing the concept of heroin addiction has implications for its treatment and policies. For instance, one of such treatments is MMT. MMT is an example of an opioid substitute therapy, in which heroin is clinically substituted with a different opioid, in this case methadone. When administered in the right dosage, methadone prevents the body from withdrawing from heroin, yet it does not cause a similar ‘high’. It needs to be taken once or twice a day and many clinics require clients to collect each dosage in person, instead of allowing clients take-home dosages. Methadone can be used as a detoxification regimen, in which case it is gradually phased out within three weeks. MMT is long-term substitution, with treatment duration ranging between six months and lifelong. In medical trials the treatment has proven to be effective in decreasing heroin use (Mattick et al., 2009). Some literature examining people’s experiences of MMT shows the treatment helped them to enter the workforce and feel more ‘normal’ (Doukas, 2011) whereas others argue the opposite, nicknaming methadone ‘methadeath’, referring to regulations of the MMT clinics as a constraint on autonomous change and freedom, causing people to feel ‘trapped’ and as if they are not moving forward (Koester et al., 1999). The literature highlights that MMT involves self-transformation, in various possible ways (Doukas, 2011; Gibson et al., 2004). Yet a detailed account of the processes how self-transformation occurs, has not been extensively researched (Doukas, 2011). Besides treatment possibilities, harm reduction interventions1 are a relatively new social policy in which peer education and outreach play a large role (Medley et al., 2009). Most literature focuses on efficacy or clients’ experience of such programmes, but the limited studies on the educators’ experiences suggest substantial benefits and challenges, such as support, empathy and shared experience, but also relapse, burnout and peer pressure (Broadhead et al., 1998; Col ´On et al., 2010). However, the role the job plays in peer educators’ own processes of recovery and possible changes in sense of self is largely ignored. Subsequently the following research question was formulated: How does being a peer educator, which involves MMT, change people’s sense of self ?
1Harm reduction interventions, such as needle exchange programs or safe injection education, aim to
decrease the negative consequences of drug use for the individual. In some contexts (for example South Africa) the emphasis on the purpose of harm reduction lies in reduction of HIV incidence in the wider population (Addictioninfo.org, 2017).
1.1 Problem Statement Chapter 1. Introduction
In addition to theoretical relevance of this study, three practical pertinencies are rec-ognized. First, peer education projects gain increasing popularity (McKeganey, 2000), therefore more attention and knowledge about the implications of this job for peer edu-cators themselves is needed. Second, inferences made from this study can yield insights about challenges and necessities in people’s processes of recovery from heroin addiction in general and may improve treatment approaches. Furthermore, in communities across South Africa there is an increasing concern about the rapid growth of heroin dependence, which places a heavy burden on the social, psychological and biological well-being of individuals, their social network and society as a whole (dos Santos et al., 2011). From a public health perspective it is even more troubling since it takes place in a context of three ‘epidemics’: TB and HIV, injury and violence, and maternal and child mortality, thus aggravating existing health and social vulnerabilities. People who suffer from heroin addiction in South Africa face substantial barriers to treatment for a number of reasons, including the predominant abstinence approach, war on drugs, paucity of treatment ser-vices, poor treatment literacy, costs and social stigma (Foundations, 2017; Scheibe et al., 2014). Against this background, investigating an alternative and more humane approach of responding to this issue is desired.
I spent three months doing fieldwork at a South African organisation (which I will further address as the Organisation to secure anonymity of my participants) based in a metropolis, undertaking an entirely peer-led harm reduction project. Detailed descrip-tions of study location and methods used follow in next secdescrip-tions, followed by a review of the literature on MMT, peer education and the relations of both with self-transformation. A section on the theoretical framework used will not be provided, instead discussion of theory will be interweaved throughout the chapters, in this way facilitating that ethno-graphic data will be the starting point and will not be forcefully moulded into existing theories. The first empirical chapter will provide insight in people’s addicted life and sense of self and their motives to leave this life and the role narratives play in people’s (re)creation of sense of self, followed by a chapter on the constitution of a moral self as peer educator. Chapter 4 includes an account of an emerging sense of self as connected to other human beings. Contexts and links between these different aspects of peer educator’s changing sense of self will be presented in the discussion/conclusion chapter.
1.2 Literature Review Chapter 1. Introduction
1.2
Literature Review
This section provides a literature overview on the concepts of addiction (a basic under-standing of which is needed in order to study its recovery), MMT, peer education, and people’s sense of self in relation to these topics. I conclude by presenting identified gaps in literature.
1.2.1
Perspectives on Addiction and Recovery
The way of framing the concept of heroin addiction and its ontological status has im-plications for its treatment and policies (Garriot and Raikhel, 2015). From a prevailing medical perspective addiction is understood as a (chronic) brain disease, which discards notions as free choice, moral failing, and responsibility and countermines the complexity of this phenomenon (Buchman et al., 2010). Some say that taking drugs inadvertently leads to a loss of control, whereas others reason that drugs might be taken in order to lose control (Gibson, Acquah and Robinson, 2004). In this light, addiction might be seen as self-treatment for coping with social oppression and structural violence (Farmer et al., 2004), because social conditions can come to the expression at the individual level in terms of emotional and psychological harm, self-blame, and crucially, risk behaviour (Rhodes, 2009). Similar to the variety in conceptions about the nature of addiction, also ideas about recovery from addiction found in literature show diversity. Seen from the perspective of addiction as a chronic illness for example, recovery is not deemed possible. Furthermore, a question is: from what is the addict believed to recover? If one assumes the consumption of drugs is the main concern, abstinence might be regarded as the way to recovery. Instead, one could also define the process of recovery with respect to re-covery of the self, rather than rere-covery from addiction (Gibson, Acquah and Robinson, 2004). In this light, some claim that the relationship with drugs should be replaced by reconnecting with the self—by creating a ‘new’ self or re-finding the old (Gibson, Acquah and Robinson, 2004)—with emotions (Solerio and Consigliere, 2015), or with love (Zigon, 2013).
1.2 Literature Review Chapter 1. Introduction
1.2.2
Methadone Maintenance Treatment
MMT is presented with abilities to reduce heroin addiction itself and certain problems related to heroin addiction, such as drug-related crime and blood borne virus transmission (Bell et al., 2002). Furthermore, literature presents testimonials in favour of MMT, stating that this treatment helped them to enter the workforce, to take up hobbies and to pursue education, which allowed them to feel more ‘normal’ (Doukas, 2011). Others, on the other hand, depict the regulations of the MMT clinics as limiting autonomous change and freedom (Koester et al., 1999). The most noteworthy debate in literature focuses on MMT as a means to control clients or a means for clients to take control.
Control Over Clients
Some authors write about MMT as a unidirectional oppressive force, where clients feel trapped and controlled in treatment (Fischer, 2000; Fraser, 2006; Friedman and Alicea, 2001; Gelpi-Acosta, 2015). Bourgois (2000), using Foucault’s concept of biopower (Fou-cault, 1982), argues that MMT is an effort of the state to produce ‘docile’ bodies. A different view on MMT is presented by authors who see MMT as a form of governmental-ity aimed at restoring a neoliberal lifestyle (Bjerge and Nielsen, 2014; Bergschmidt, 2004; Campbell and Shaw, 2008; Harris, 2015). Foucault used the concept of governmentality to describe a political notion that encourages and allows for various ways of surveillance in order to govern and regulate populations and individuals ‘at a distance’ (Foucault, 1979).
Besides shaping clients into docile, obedient and economically productive citizens, an-other purpose of MMT is believed to be making addicts socially acceptable, to normalise them (Weppner, 1979).
Literature also indicates that clients on MMT are often ‘under-occupied’, which means they are often hindered to engage in various fulfilling activities that could improve well-being, and they experienced a change from chaos to boredom, in which they often feel bored and segregated (Warren et al., 2016). Before starting MMT, clients often had a limited routine, consisting mainly of getting drugs and finding money to get drugs. While on MMT, again a limited routine is described, comprised mainly of visits to the pharmacy and the clinic. Helbig and McKay (2003) noted boredom as a contributing factor to the
1.2 Literature Review Chapter 1. Introduction
cycle of addiction. This can explain the success of peer education programmes.
Constraints Produce
Ning (2005) writes about how MMT clients do not always follow the rules, even if they say they do. While some present addicts as liars whose manipulative behaviour is caused by a loss of self-control (Roberts et al., 2009), Ning explains this on the contrary as a sign of clients in control who pursue their own ends in MMT, a treatment that holds multiple perspectives and interpretations. As such, in contrast to Foucault, the client is not a passive victim of the rules but a (re)active agent. Hence, the lived experiences of people on MMT have to be explored, because they cannot be predicted.
1.2.3
Self-transformation and MMT
In order to show the significance of identity work in MMT, I draw on Lock and Nguyen (2010) who stated that all medical treatments require a degree of self-transformation and on Waldorf and Biernacki (1981) who characterised the recovery process from dependent drug use as to managing a spoiled identity, to underpin the significance of the transforming sense of self during MMT. According to Gibson, Acquah and Robinson (2004), MMT users’ experience ‘entangled identities’ where an addict and a non-addict identity exist at the same time. In the process of ‘entangling’ or transforming from a user identity to a non-user identity, it is argued that narratives play an important role (Giddens, 1991). Although this can be disputed (McIntosh and McKeganey, 2000), it does appear an important component of the process of identity formation for MMT users, who might not necessarily (want to) identify with their behaviour, bringing the importance of narrative for their sense of self to the forth.
In this process of self-transformation, MMT is both described in literature as a facili-tating and impeding factor. Nguyen et al. (2007) propose that therapeutic citizenship is “both a political claim to belonging to a global community that offers access to treatment for the ill, as well as a personal engagement that requires self-transformation” (Nguyen et al., 2007, 34). Although Nguyen studied HIV-positive people, the concept can be transferred to drug users: They are a stigmatized community as well, often regarded as
1.2 Literature Review Chapter 1. Introduction
being irresponsible and deprived of their rights. Prescription-hood to a certain treat-ment can be regarded as a set of responsibilities and rights (Nguyen et al., 2007) and prescription-hood can lead to social commitment, empowerment and responsibility, which can lead to a sense of accomplishment and a positive transformation in identity (Robins, 2005). Furthermore, MMT is claimed to account for changes in lifestyle from a chaotic and unpredictable lifestyle to a peaceful and stable one which enabled clients to get a job or take up hobbies (Doukas, 2011). On the other hand, the dependence-forming character of MMT may prevent clients from identifying themselves as former addicts, for they are still addicted to something (Murphy and Irwin, 1992). In addition, the societal, profes-sional and internalized stigma associated with MMT forces some clients to not disclose their methadone status, which makes it difficult to cultivate a new identity (McIntosh and McKeganey, 2000). Peer education projects can be a way to approach drug users without stigmatizing them.
1.2.4
Peer Educator
The Peer Education Model
Naturalistically occurring peer education among heroin users is described by Dhand (2009), who describes street ‘doctory’: peer based medical care involving processes of peer learning. Novices’ learned about all kinds of illnesses through participation and ob-servation of ‘experts’ and both participated in discussions, in which they co-constructed meanings about remedies, symptoms and causes. By exchanging stories, ‘new’ under-standing are created that exist as a ‘social product’ (Blumer, 1969), different from indi-vidual meaning.
Formalised peer education and outreach is a cornerstone of harm reduction programs with high-risk populations such as injecting drug users (Broadhead et al., 1998; Friedman et al., 2007; Medley et al., 2009). The peer education model resides on the relationship and supposed similarity between peer educators and clients (Moorthi, 2014). According to Dhand (2009), peer education programs may however re-construct peer relationships to be disempowering and hierarchical, as opposed to naturalistically occurring peer learning. Furthermore it is critiqued that harm reduction programs typically focus on individual
1.2 Literature Review Chapter 1. Introduction
behaviour change—such as drug abuse or needle sharing—thereby ignoring social deter-minants of risk behaviours (Rhodes and Hartnoll, 1996) and focusing on the deficits of the community rather than its strengths. Such programs can fail because the rest of life is characterised by hopelessness and deprivation by their clients, making it difficult to convince people to avoid infection with a virus (HIV, hepatitis) that might not kill them for the next 15 years. Therefore, the most important and difficult part of harm reduction interventions is to convince people that they do have a future (Page, 1997; Dickson-G´omez et al., 2004), instead of merely conveying knowledge -which is, according to some authors, often how peer education is conducted (Goto et al., 2010). Other chal-lenges and implications of peer education showed in literature will be discussed in the remains of this section.
Challenges and Implications for Peer Educators
Some authors suggest that peer educators can be seen as “expert patients’ who, when trained in medical background knowledge, are able to understand clients not only medi-cally but also socially and emotionally (De Bruyn and Paxton, 2005; Dapaah and Moyer, 2013; Kober and Van Damme, 2006). In these studies, as expert HIV patients, peer educators become models of recovery for clients (Moorthi, 2014). For peer educators themselves, this role as an ‘expert patient’ or role model is described to have several (dis)advantages. On a positive note, some authors describe increasing feelings of compe-tence and increased self-confidence. This in itself can motivate peer educators to continue changing their own lives (Dickson-G´omez et al., 2004). This finding can be transferred to drug users becoming peer educators, who used to be refused by the bigger community because they looked dirty and smelled. Furthermore, their experience as a drug user, which would be considered a handicap in other jobs, gives them respect and credibility in this one. On the other hand, being a peer educator and a role model, comes with certain expectations: While harm reduction for them is a ‘lived experience’, still trying to recover themselves, they are expected by their clients to be a model patient and there-fore are forced to mask their struggles (Moorthi, 2014). Furthermore, being an expert can also create a barrier between the clients and them. Clients come to perceive them as ‘other’ instead of one of them or envy the benefits that come with their job, causing
1.2 Literature Review Chapter 1. Introduction
peer educators to feel excluded (Moorthi, 2014).
Some literature approaches peer educators less as expert patients or role models and more as ‘peers’, combating the same concerns about recovery as their clients, describing the relationship between them as both productive and problematic. On the on hand, the relationship is characterized by support, empathy, identification, camaraderie and shared experience, while on the other hand by re-engagement with high risk behaviour, relapse, burnout, peer pressure and conflict (Col ´On et al., 2010; Dickson-Gomez, 2010; Needle et al., 2005). Whereas some claim becoming peer educator is detrimental for their own process of recovery, others advocate contrarily that it gives them a sense of meaning and purpose; or that it gives them something to do and distract them from craving drugs (Dickson-Gomez et al., 2004). However, many of these positive effects have only been studied short term (within a month postintervention) and long term data are limited (Guarino et al., 2010).
1.2.5
Gaps in Literature
The literature review has identified three gaps which this study will address. First, although it has been suggested that MMT involves self-transformation, how clients’ lived experience of MMT relates to how they come to see themselves, has not been extensively researched (Doukas, 2011). Second, hardly any anthropological research on MMT has been conducted on the African continent. Third, the majority of the literature about peer education focuses on the efficacy of the peer educated programs (for example: reduction in HIV infections) or on the experiences of service users. Although limited research on educators’ own experience suggests substantial challenges and benefits, the role the job plays in peer educators’ own processes of recovery and possible changes in sense of self is largely ignored, especially for individuals who deliberately combine a career as peer educator with an attempt to ‘leave’ (local way of expressing) heroin addiction assisted by MMT. From this literature review, the following research question emerged: How does being a peer educator, which involves MMT, change people’s sense of self ? And the following subquestions: A: How do people’s senses of self change after becoming peer educator? What is people’s lived experience of B: MMT and C: becoming peer educator?
1.3 Methods Chapter 1. Introduction
1.3
Methods
Data was collected by doing participant observation and conducting interviews, and I have used a phenomenological approach, which is concerned with the issue of how individuals make sense of the world surrounding them and how in particular the researcher should bracket out prejudices concerning his/her grasp of that world (Bryman, 2015). Therefore, I tried to be as non-directive as possible in my instruction, but I did encourage my participants to share a (full) description of their experience, including feelings, thoughts, and memories. ‘Data’ was considered any way in which the participants could describe their lived experience, including through poetry or other art works (see Figure A.1 in Appendix A for some art works), the music they listened to, the books they read, the movies they watched, or their interpretation of graffiti.
1.3.1
Participant Observation
Participant observation has been the primary method of gathering information during the approximately three-month period of fieldwork. This method was suitable to gain insight into peoples lived experience of being peer educator and MMT, because it is more likely to reveal the ‘taken for granted’: the implicit features in social life which seem too obvious for interviewees to talk about in interviews (Bryman, 2015). Encountering the unexpected through participant observation can yield new topics to talk about more extensively in interviews. In addition, this method creates sensitivity to context, because extensive contact with a social setting can expose the links between context and behaviour (Bryman, 2015). By talking informally with participants, listening to conversations, observing (inter)actions, and attending consultations and meetings I collected most of my ethnographic data. People talked predominantly in English and Afrikaans—which I fortunately was able to follow quite well—and only scarcely in other languages. Although South Africa counts eleven official languages (Lehohla, 2012), in this city English (and to a lesser extent Afrikaans) is presumed to be understood by people from all ethnic groups and is therefore used in inter-ethnic conversations or with strangers. People were very willing talking about their lives. However, in order to ensure I would not be dragging information out of people which they were trying to keep to themselves, I usually did
1.3 Methods Chapter 1. Introduction
not inquire after a conversation I in a different language, what people talked about. My participant observation schedule followed the working schedule of the team. Every morning, we started at 8:00, when everyone gathered at the office. Some peer educators had a shower (predominantly the ones still sleeping on the streets), others had (free) breakfast, coffee and shared cigarettes. We had small talk and deep talk (for example about feelings or memories), prepared for the day and connected with each other. When I got the chance, I accompanied the ones who were on MMT to the clinical associate’s office to collect their daily dose, where I would take a seat in the corner. At 9:00, I left with the team on outreach: different routes on different days, which I alternately joined, see Figure 1.1. Some days we covered distances by car, pausing regularly to provide harm reduction services (needle exchange and education about safe sex and drugs behaviour) to service beneficiaries from the trunk of the car. Other days consisted of long walks with a team of three, on which we visited service beneficiaries at the sites where they sleep or zula2, carrying backpacks with harm reduction packs, including syringes, sterile water, alcohol pads, a cooking pot and a wad of cotton wool, and a sharps container for used needles. Those sites could be long abandoned buildings, now occupied by drug users, reached by climbing fences and clambering through bushes, in small slum-like communities right in the middle or on the edges of the city, an occasional township, a deserted bridge or tunnel, but often right on busy streets, amidst of ‘normal’ city life. Although the factual harm reduction service the project provides can be regarded as distribution of clean syringes, the team holds the idea that this is not the most important: besides educating how to use safely, the project aims to show heroin users on the streets that they matter and are cared about. This results in interesting and touching conversations of the team with the service beneficiaries. Wary not to intrude too much, I kept myself at a distance after introducing myself and my research, until service beneficiaries started talking with
2According to my respondents, literally translated ‘zula’ means: go up and down, move around
without destination. In the context of my study, zula refers to the ways in which people who live on the streets make money. People zula in diverging ways: some beg or tell made-up stories, some steal, some have a job, some recycle. People whose zula is to recycle roam the streets with huge self-made carriages to collect metal or paper from the streets. They burn wires, in order to collect copper for example. It is a tough zula: In order to get two shots (which is few) one has to collect at least 50 kg of metal in one day
1.3 Methods Chapter 1. Introduction
me-which was usually quickly. On Wednesdays, there was no outreach scheduled and all of us spent the day at the drop-in center, located in a basement. It consists of an office/storage room for the team, a kitchen, a movie room, a bathroom with sinks and showers, and a patio. Usually around 40 service beneficiaries3 gather here for the day or just a few hours, to have some rest, a shower, food, coffee, wash their clothes and watch a movie. Tagging along and hanging out with my colleagues (usually 7 to 10 people) and the service beneficiaries, both provided me with in-depth accounts of the lifeworld of people who use heroin, and the peer educators’ process out of this world.
Two phases can be distinguished with regard to participant observation. An orien-tation period, in which I tried to let people talk as freely as possible, and let relevant topics emerge by itself. During this time, I also spend three days observing at a sister organisation located in a different city doing the same project (yet fairly different), which underlined particularities about the contexts. In a later phase I would ask additional direction-giving questions about the earlier emerged topics of importance. Occasional ‘focus groups’ emerged when I asked something and a group (of peer educators and sometimes service beneficiaries) started to debate it together.
When participants told me personal stories, or when interacting with service benefi-ciaries on the street, it felt inappropriate to pull out my notebook in front of them and write as they spoke. So I would wait until the conversation ended—which was usually fairly fast in these dynamic situations—and find a more secluded spot to jot down my observations. Sometimes people encouraged me to write down what they said (often when explaining why drug users should be treated better and not be judged), which enabled me to keep track of the conversation in a more detailed way. In the evening at home I
3I use the term ‘service beneficiary’ to refer to people accessing the services of the Organisation
because it is the term practiced by the Organisation. Although it could be considered an interesting choice of words, people did not seem to know the rationale behind them. On my question why this term was used and not another, people responded “they just do”. Additionally, my participants do not appear to contemplate about the choice of words, which came to the forth in a group conversation. Everyone just came back from outreach and we were chatting and drinking coffee until it was time to go home. Lesego had to blow off some steam from the day, expressing a complaint about the service beneficiaries being greedy and selfish. “All they do is... they just want to benefit, and benefit more. They don’t even think about us.” I jokingly respond what I though was obvious: “That is why we call them service
1.3 Methods Chapter 1. Introduction
Figure 1.1: Outreach. The team spends some time with service beneficiaries (6 on this photo) who are burning garbage, while used syringes are collected in the yellow bin. “We meet them where they are at,” as the peer educators say.
typed out my field notes and reflections in as much detail as possible.
Although I positioned myself as a visitor of the Organisation, a student conducting research, the line between observing and participating was often crossed. I felt welcome and accepted from the first day on, and the relationship between us advanced. On outreach, I would sometimes be treated as a colleague and oftentimes the peer educators expressed our friendship. Every now and then one would trust me with a story he did not want to tell others. I also did not see them merely as research participants, but began to care for them as I got to know them better. Although this closeness and empathy could sometimes make it difficult to witness the hardships they were going through, I do not reckon this to be an obstacle to my research. Contrarily, it motivated me to understand their experiences and life worlds to the fullest extent possible and ‘see through the eyes
1.3 Methods Chapter 1. Introduction
of the beholder’.
1.3.2
Participants
Although I learned a lot from service beneficiaries about the lifeworld of heroin addicts, which provided me the necessary background knowledge for my study focus, I do not refer to them as my ‘participants’. When I mention participants, by name or in general, I refer to peer educators. For the selection of my peer educator informants I beforehand decided to use a purposive sampling approach. This non-probability sampling approach limits generalizability, yet it allows me to address ethical considerations (Bryman, 2015) and it allows for getting variation of participants in terms of age, gender and ethnicity. The population of heroin addicts can be considered a vulnerable group4 and it is important to select individuals who are least vulnerable in relation to my research. Before the start of fieldwork I therefore designed the following exclusion criteria. First of all, respondents have to be able to provide informed consent, therefore I excluded individuals below the age of 18-years-old, individuals who are (visibly) high on drugs, and individuals with severe mental health problems. Aforementioned exclusion criteria are not conclusive, therefore, selection of informants occurred on close consultation with the project manager, who knows the peer educators better than me. It turned out all fourteen peer educators were eligible and also consented to inclusion. The average age of my participants is around 40, ranging from late twenties to late sixties. To the extent I know, none of them completed a higher educational level than primary school and they are all male, except for one lady who started her training to become peer educator in the last two weeks before my departure. The gender imbalance is similar to the gender ratio found among street-based heroin users. Seven of them live in a house, seven still sleep on the streets as is illustrated in Figure 1.2. Six of them are whites, three are coloureds and five are blacks (terms originating from the apartheid regime and still used). One is a migrant from Malawi. Due to the large variety of backgrounds, I could not find patterns nor generalize about
4Although people who inject heroin and live on the streets can be considered vulnerable in some
extents, I want to stress that this cannot be confused with ‘weak’ or ‘defenseless’. The peer educators as well as the service beneficiaries are some of the most strong, courageous and resilient people I have ever met.
1.3 Methods Chapter 1. Introduction
differences in experiences directly linked to ethnicity. In order to ensure anonymity, their names were changed and I will not provide individual profiles of my participants.
Figure 1.2: Sleeping spot of one of my participants. A waterproof tent built in between two trees, one of which he decorated with all kinds of treasures collected from the streets.
1.3.3
Interviews
I conducted eight semi-structured interviews. I was able to conduct interviews with eight out of fourteen of them, because the others were not available towards the end of my fieldwork period when I conducted the interviews. Some relapsed and left the Organisation, others were in prison (for carrying drugs) and one person seemed hesitant for the interview and kept postponing the arrangement until there was no time for the interview left. Semi-structured interviews are able to address issues that are resistant to observation such as inferences and motivations or to talk retrospectively about situations
1.3 Methods Chapter 1. Introduction
that were considered unethical for me to attend and observe, like criminal practices or their lives on the streets after work (Bryman, 2015). I made an interview guide, partially based on the topics that originated from observations, which I assessed and adjusted after each interview. Not the interview guide, but the people guided the interview. Length, questions and the way in which I phrased questions depended on the person and the state they were in. Interviews took between 0,5 to 1,5 hours and were all conducted informally on a quiet spot on the parking lot next to the drop-in center. It was not possible to plan interviews in advance, because the peer educators did not feel the same way every day and evidently I did not want to interview someone who was not feeling well. Therefore, they originated in a somewhat spontaneous way, and I kept it informal by bringing cake, drinks, and by taking time first to make them feel at ease. They daily worked with informed consent forms for new service beneficiaries, therefore the signing of a consent form did not cause an awkwardly formal ambiance and did not surprise them. I transcribed the interviews as soon as possible after the interview, so I could ask for clarification if needed.
The initial plan to ask participants to keep a diary was discarded in consultation with the project leader, because it did not feel ethical to ask them. I was concerned about privacy matters, for half of the team sleeps on the streets and has no means to keep the diary in a private place. Furthermore I did not want to burden them with such a sensitive and reflective exercise in the environments and moments they are most vulnerable: when they are not at work.
1.3.4
Data Analysis
I draw on principles of narrative analysis (although I do not conduct a full narrative anal-ysis). With this approach, the focus of attention changes from ‘what actually happened’ to ‘how do individuals make sense of what happened, and to what effect? ’, because stories are almost always told with a purpose (Bryman, 2015). In other words, I do not merely focus on the content of people’s stories, but also on their function. Whereas most data collection and analysis approaches disregard the fact that people discern their lives in terms of process and continuity, narrative analysis does pay attention to this and enabled me to heed the perspective of those studied. In this thesis it becomes clear that there
1.3 Methods Chapter 1. Introduction
are various ways of making sense of stories: what the stories are about and the purposes they can be claimed to serve interactively (Bamberg, 2012).
Furthermore I used both deductive and inductive coding and I incorporated principles of grounded theory such as writing memo’s, axial coding (“a set of procedures whereby data are put back together in new ways after open coding, by making connections be-tween categories” (Corbin and Strauss, 1990, 96)) and constant comparison (constantly comparing new data with existing concepts and data) (Silverman, 2015). My analysis was not guided by a pre-existing theoretical framework, instead I let it emerge from the data. During my fieldwork, I started transcribing interviews and field notes. Aided by the software Atlas.ti., I coded, categorised and analysed the data and these preliminary findings had a guiding role for the rest of the fieldwork. Furthermore I am reflexive of my cultural background and of my unfamiliarity with the research site, which will have an influence on how I conduct research and interpret data (see next section on position-ality). I collected a wealth of rich material which cannot all be included in the main text. Additional excerpts of observations and interviews, which are illustrative and engaging but not essential to comprehend the analysis, are included in the appendix.
1.3.5
Positionality
Research symbolizes a shared space, shaped by both participants and researcher. As such, identities of both participants and researcher have the ability to impact the research pro-cess (England, 1994). Before, during and after entering the field I asked myself the follow-ing questions: What role did my positionality as a white/young/Dutch/European/healthy/ rich/not suffering from substance abuse/ religiously agnostic/heterosexual/Dutch- and English speaking/non-homeless/non-marginalized/never imprisoned/high educated/medical student/anthropology student/woman play in my research? How did I use my positional-ity in various spaces? And how did it influence interactions I had with my participants? I cannot discuss the full list of subject positions mentioned, but I will give some illustrative examples. I focus on the main aspects which appeared to matter, though not always in ways one would expect. My experience shows that how one’s positionality matters cannot be determined in advance, hence continuous reflexivity needed.
1.3 Methods Chapter 1. Introduction
proximity and familiarity in me. My gender presumably played a role in their attitude. Service beneficiaries, on the other hand, flirted with me sometimes. Although I never felt unsafe or assaulted, I got irritated sometimes, because it made me feel disrespected and it disturbed my ability to listen to them and not judge them for it. I dealt with it by systematically ignoring those remarks, or naively continuing the conversation as if they said something more abstract. Oddly, this often worked. For example when someone called me beautiful and expressed how much he loved me, I acknowledged that love can play a very important role in people’s lives and we ended up in an interesting conversation about his family relations. Furthermore I dressed as plainly as possible in dark trousers and a t-shirt, wore my hair tied in a bun and never wore any make-up, in order to present myself in the least provocative way.
Beforehand, I was afraid that my highly privileged and powerful status would build a wall between my participants and me or even making them feel angry or inferior. On the contrary, they told me they felt proud that “This white European comes all the way to Africa to learn from us!”. Which, however, made me feel uneasy as well, for it still presupposes unequal power relations. My white skin color did not seem to render differences in interactions with white or black peer educators, but on the streets on outreach, where we often walked in places where I was the only white person, it was more conspicuous. Once Jeremiah and Thabo took me to a very remote spot on the route, where drug users reside who ‘hate whites’ (because they are often raided by white police officers). Hence, the white peer educators are not allowed to go there. “No, but you can come,” the two peer educators assured me. “Just tell them you are a student from the Netherlands and chat with them, I’m sure they won’t mind,” implying that I was so much of an outsider, such an exotic case, I was not a danger.
Another way in which I consciously presented myself, was as an anthropology stu-dent, disregarding of my bachelor’s degree in medicine. I did not disclose my medical background, because I did not want to be perceived as a doctor, who are treated with respect and humility, but are on the other hand known to stigmatized drug users.
To my surprise, no one seemed to relate my Dutch background to South Africa’s colonial history; They said it was too long ago to matter. On the contrary, my participants liked the fact I am Dutch, because through the Organisation they know the Netherlands
1.3 Methods Chapter 1. Introduction
as a progressive country regarding drug use policies and treatments.
I can conclude that I was a complete outsider in many aspects, yet this did not prevent me and my participants from getting close to each other. This closeness does not imply objectivity, but my participants’ non-judgmental and accepting attitude allowed me to quickly discard many of my own preconceptions and judgmental attitudes an sich.
1.3.6
Local Background
Since the democratization 1994, South Africa showed a steady increase in heroin use (Pasche and Myers, 2012) and is now known for the largest illicit drug market of sub-Saharan Africa. Because of its geographical location, South Africa became a useful trans-fer shipment point for heroin and cocaine, after it became member of the international community again. The so-called HIV/AIDS epidemic in South Africa also complicates the situation (Dos Santos et al., 2010). The group most affected by heroin use are black African communities, especially men (dos Santos et al., 2011) whereas most individuals in treatment are white 21- to 24-year-old males, who rather tend to smoke the substance than to inject. However, this profile seems to be changing with injection use gaining importance and users becoming younger (Parry et al., 2005; Van Schoor, 2015). It is suggested that the increased prominence of heroin use is a way of adjusting to the “new” South Africa, which is a society in transition (for Drug Control and Prevention, 2002). It has been argued that changes in the social, economic and political structures before and after Apartheid have made the country more sensitive to drug use. For example high unemployment rates are contributing to drug use: 27,7% in general in 2017 and 48% amongst youth (15-34 years old) (Trading Economics, 2017). Drug use and availabil-ity are likely to correlate with social pressures because of a decline in traditional forms of family structures and social relationships (Peltzer et al., 2010). As an illustration, Ruthven (2016) describes that the current public health policy aims for health seeking subjects as neoliberal, self-interested, enterprising, responsible and rational individuals. This is considerably different from Ubuntu, which is an important national philosophy in South Africa and holds the idea that humanity is gained through relationship with others (Metz and Gaie, 2010). Despite the neoliberal social structures and policies, over two decades later, many of the practices of apartheid are continuing today: classification
1.4 Ethical Considerations Chapter 1. Introduction
of citizens is still based on skin color (Vahed and Desai, 2010).
Until recently, many rehabilitation services were not coordinated by the Department of Social Development (DoSD) or the Department of Health (DoH) (Dos Santos, 2010). Various unregistered centres still exist and numerous human rights violations have been revealed (Bateman, 2006). In the meantime, the state is reducing subsidies and closing down various long-established centres. Additionally, rehabilitation and detoxification can be highly expensive, and a large divergence between services of the public and private health and welfare sector persists (Dewing et al., 2006). Furthermore, the stigmatization of heroin use disorders is suggested in the white Afrikaner Calvinistic community, con-tributing to delays in developing appropriate medical interventions: it was perceived as a non-white and (considering the Calvinistic culture of South Africa) a moral issue. In other words: There is not yet an adequate response for the so-called ‘heroin epidemic’ that addresses the complexities of heroin addiction and there is growing attention for im-plementation and investigation of treatment options in South Africa (Dos Santos et al,. 2010). A poem of Jeremiah, see Figure 1.3, expresses the situation from his perspective.
1.4
Ethical Considerations
In the methods section I discussed how ethical consideration was at the heart of, amongst others: the design of inclusion and exclusion criteria for participation; when and where I took notes during participant observation; a non-intrusive attitude but open to be approached; and the decision to not use the diary-method. Not only in the research design phase did ethics play an important role (including a bureaucratically difficult process of obtaining permission from the South African ethics committee) but also in the field I daily weighed the ethical dimensions and consequences of the choices I made—both by action or inaction.
1.4 Ethical Considerations Chapter 1. Introduction
1.4 Ethical Considerations Chapter 1. Introduction
The American Anthropological Association designed six core principles to guide an-thropologists (Association, 2012). The principle to obtain informed consent and necessary permissions made me question whether or not to obtain informed consent from every ser-vice beneficiary I talked to, which I decided not to. I felt it was not necessary because my interactions with service beneficiaries were not the main focus of my research, very informal, short, and guided by themselves. Asking signatures for these casual chats and jokes, would make them more formal and heavy and could make beneficiaries feel ill at ease. I did however make sure to introduce me to everyone and explain my role.
The principle that raised the most difficult ethical considerations was to do no harm to material and bodily well-being and harm to dignity. As an example, I describe a situation where a service beneficiary overdoses in front of us on outreach, and I wonder whether I should assist in saving the man’s life or to trust on the peer educators’ and bystanders’ expertise (see Appendix A.1). I was hesitant to interfere in the process of keeping the man alive, because the peer educators and by standers saved many people before from overdose and for me it was the first time I encountered such a situation. I wanted to prevent questioning their expertise and possibly insulting them, by interfering with my ‘book knowledge’ about life support. However, in this chaotic situation, no one but me seemed to notice that the man’s condition was deteriorating because of the position he was laying in. I decided the most ethical response would be to change the position of the man’s head myself without focusing too much attention on myself, and without taking over control of the process. Luckily, the man kept breathing an no one seemed to be offended by my short interference. (see also Appendix A.2 for another example)
Chapter 2
The Narrative Self
Figure 2.1: Poem by Jeremiah: The Artist.
2.1
The Addicted Self
In order to understand people’s experience of leaving heroin addiction and whether and how they rebuild a sense of self, this chapter will first build up a sense of how the peer
2.1 The Addicted Self Chapter 2. The Narrative Self
educators in the South African MMT programme started using drugs, how it affected their sense of self and what motivates them to quit the drugs.
2.1.1
The Path Towards Addiction
People’s accounts of why they started using heroin stress the “social creation of addiction” due to societal structures: During apartheid regime, blacks and whites were segregated: blacks were displaced and put in townships and homelands (SAHO (South African History Online), 2016). After abolishment of apartheid, circumstances in the townships remained abominable, according to my respondents. Black communities still had no chances for a wealthier life, but now they had easier access to drugs. In Daniel’s words: “And that’s why drug use is accepted in black communities now5. Because what choice do they have? They live in extreme poverty, they have to forget where they are. And even if that means they have to commit crime. Anything is better than the place where they are at. To make them fucking forget where they are. The system is still broken from apartheid.” Heroin seems to be the way to escape reality for many. Broken family structures, including absent fathers, also enhance drug use. Fathers left their families—because, according to my participants, they did not learn how to be responsible—they got into prison, or they went into the city to earn a living and provide for the family. Mothers try to look after the children but often do not know how to get food on the table and look for refuge in alcohol or drugs. Children of those families are born without bright future prospects. Daughters, according to my participants, who never received fatherly love, are often found to end up with the wrong husbands, thereby creating new cycles of disrupted family structures. Fatherless boys lack a role model and reach adultery without knowing how to be a responsible man. Children growing up in distorted families, grow up with confusion, which can turn into hatred and anger, especially when they see the cities and when they do not understand why they do not deserve good lives. Daniel phrased this as follows: “The lost-boy-syndrom: a bunch of lost boys, gather on the corner, trying to make sense of the world.” Although heroin does not necessarily provide answers, at least it distracts them from their questions. My participants’ account of distorted family
5This statement might be a bit strongly put: although drug use becomes more common, people who
2.1 The Addicted Self Chapter 2. The Narrative Self
structures is supported by literature, affirming that the legacy of apartheid disrupted family life, with consequences on care givers’ responsibility and capability to care for children (Budlender and Lund, 2011). Literature also constructs the absence of fathers in south Africa as problematic for children of both sexes, but predominantly boys (Ratele et al., 2012)6.
On a micro level, some of my respondents say that life on heroin and on the streets is attractive because there is “no stress”. Although their lives sound extremely stressful to me, what they mean is that they have no responsibilities: they do not ‘owe’ anything to anyone and no one tells them what to do. However, the majority asserts they did not choose this life: “No one used [heroin] to get hooked” (Thabo). Many individuals explain they started using as a way to escape ‘reality’: a reality which lacks hopeful future prospects. Or a reality filled with emotions they want to take away, for example because of an experienced war, an abusive youth or other trauma’s: Jeremiah: “I’ve experienced war crimes so bad... Everyone was send to psychiatrists after combat, but it did not really help. But now, I’ve dealt with this trauma.” “How?” I ask. “Just by itself. Well, by using drugs. After all the chaos and sounds, I just needed silence in my head.” Whereas some people become homeless after they start using heroin and their lives start to crumble, others resort to heroin because they live on the streets and it helps them to care less about their circumstances.
2.1.2
Life on Nyaope
Soon, the lives of people who use heroin on the streets change from “chasing the high” to an endless race against withdrawal: as tolerance builds up, nyaope, see Figure 2.2, does not render a large high anymore but without using, unbearable withdrawal symptoms appear. The fear of withdrawal does not only make people scared, but also resourceful
6Although the described local theory of addiction as a social construct deals with the black
(predom-inantly) male community, whites and women are also found using heroin and living on the streets, yet fewer. The heroin using community used to be dominated by white males, because, living in the cities, they had easier access to drugs than black men. After abolishment of apartheid this composition started to shift to young, black males, as explained above. Although I saw people of the same background often cluster together on the streets, class and skin color differences seemed to matter less in drug using communities on the streets than in the rest of society.
2.1 The Addicted Self Chapter 2. The Narrative Self
Figure 2.2: Nyaope is the local street drug my participants use(d). It is a crude mixture of low-grade heroin with anything from antiretroviral drugs to rat-poison or chlorine. The white powdery substance is usually packaged in a tiny scrap of beige coloured plastic, torn off a shopping bag. It can be both smoked—usually as a joint, mixed with dagga (cannabis)—or injected.
2.1 The Addicted Self Chapter 2. The Narrative Self
and determined: They will not give up until they have a solution, as Daniel explains (see also Appendix A.3). “All you think about is drugs and zula,” my participants say. There is no time to consider the future, no time to sit still: it is a constant living in the now. “Most of the time, heroin is acting, not the person. It takes them over. Heroin is in control,” (a service beneficiary). People express they are not themselves anymore because of heroin, or that they forgot who they are. In this tough life, heroin users often lack basic necessities, such as access to food, water, toothpaste, bathrooms, shelter; their things get stolen; there is a lot of violence and weapons on the streets; they are often mistreated by police and always risk getting in prison and face withdrawal (illustrated in Appendix A.4); they face many health problems because of injecting drug use, but my respondents told me that hospitals usually refuse to admit drug users because they look dirty and “they did it to themselves”. In order to survive on the streets, people group together in ‘street families’: They zula, sleep or hang out together.
2.1.3
Leaving Nyaope
Almost every service beneficiary I asked about their life told me they wished to leave nyaope, because they are “tired of this life”. Considering above described harsh living conditions that people who use drugs face on a daily basis, it is understandable that these circumstances become so unbearable at some point, that people decide to quit. However, although many say that “it needs to go very bad in order to want to quit”, the tough living situation does not seem to be the most important motivator for people to quit. People who claim they are tired of this life, are generally the ones who have not managed to leave heroin yet: although their lives may sound unbearable, most have lived that way for a decade and therefore (subconsciously) know they can bear it. Some say they want to change for their mother or child, but also these reasons and perceived responsibilities often seem to be not enough to actually try. My respondents emphasized an additional aspect in their motivation to leave heroin: they seem to realize that, although time appears to be standing still while living in an endless now where every day looks the same, that time does pass by and they are aging. As they consider their age, and reflect on their lifetime—from beginning to end—they realize that if nothing happens, they will die on the streets. Many come to the conclusion it is either live (off the streets) or die (on
2.2 A New Chapter Chapter 2. The Narrative Self
the streets, “like a heroin addict” or “like a dog”). “Is that really my way to die?” many questioned themselves, and by choosing for a different way to die, they simultaneously choose for a different way to live.
2.2
A New Chapter
Sifiso and I had a talk about his process to leave heroin: “There is a beginning, a middle, and an end. Everyone has a beginning, a home where they grew up. You have to go back to the moment you betrayed your parents and went the addict way, then do the middle, which is facing your feelings. And you should thrive for an end, where you want to be. It is like this book you are carrying [pointing at my
notebook]; it is like a story. Your story is your soul. Recovery starts with making a story. I make myself a dictionary in my mind”
Sifiso and I
Recovery does indeed seem to start with making a story. A story that starts with a beginning and extends beyond the present into the future, and which does not merely sum up what happened but ascribes subjective meaning to it as well—if that is the rationale behind Sifiso’s choice of the words ‘make myself a dictionary’ (which implies he puts things in an order, explaining what they mean to him). With ‘recovery starts with making a story’ I am not only implying that ‘narrating the self’ can be the expression of and a useful tool in leaving heroin and building up a new life. I also argue, referring to previous paragraph, that when heroin users start to consider their life as a story with a beginning and an end and a narrative self starts to develop, it appears to be one of the strongest motivators to leave heroin. They start to develop a reflective stance and think about a different ending to their story. The ‘start of a new chapter’, is an analogy my participants use frequently; Jeremiah even wrote poems about it, see Figure 2.3 (and also Appendix A.5). As they withdraw from their “addict, junkie, living a wasted life”-identity, to anything else, large self-transformation is required. In the course of this chapter it will become clear that narratives can be not only expressive, but also transformative and even therapeutic (Hunt, 2000; Ram´ırez-Esparza and Pennebaker, 2006). A personal narrative
2.2 A New Chapter Chapter 2. The Narrative Self
2.2 A New Chapter Chapter 2. The Narrative Self
is concurrently born out of experience and shapes experience. In that way, self and narrative are inseparable (Ochs and Capps, 1996).
The new ‘chapter’ starts on the first day of MMT, according to my participants. That they linked this new beginning to MMT instead of their job slightly surprised me at first: considering the fact it usually takes a few days or weeks to start with MMT after they started working at the Organisation (because of management restrictions ), I expected the chapter to start once they started their new life as a peer educator. However, although their job played a big role in structuring the contents of the narratives, MMT appeared paramount in developing a narrative identity in the first place. MMT (accompanied by decreased heroin intake) gave my respondents back a sense of control over their life, because they no longer felt slave of heroin.7 In my participants’ words: “withdrawal fucks with your thoughts”, but if the right dosage is reached, methadone takes away the excruciating withdrawal symptoms caused by leaving heroin. Methadone tempers the craving for ‘more in life’, enables one to focus on other things than drugs, to think about life and reflect on the self. Consequently, instead of being a slave to heroin and the world, methadone gives them a sense of being the authors of their own story. In order to sustain this sense of control over their story and their life, however, some of my respondents expressed they preferred to not think or talk too positively about methadone much, afraid to put too much confidence in the substance instead of themselves and become either reckless or dependent (see Appendix A.7). At same time, they also sometimes appeared to avoid acknowledging a negative influence of methadone in their narrative, because they did not want to lose their hope in methadone either. For instance, the peer educators attribute side effects to other factors than methadone and withdrawal symptoms due to dosage inadequacies are interpreted as positive symptoms of recovery (see Appendix A.8). This results in a conflict; my participants prefer not to occupy their minds with methadone, but also feel obliged as peer educators to give a good example and instill hope in the service beneficiaries by advocating for methadone. In other words, MMT enables a narrative way of thinking and a feeling of control over the narrative, but
7Although for some respondents it initially felt like they were replacing the one addiction (heroin) for
another (methadone), after they realized the positive effects of methadone on their lives, they no longer regarded methadone as a substitution for heroin, the substance that has been devastating for their lives
2.2 A New Chapter Chapter 2. The Narrative Self
its role is not easily integrated in their narratives because of tension between their role as recovering addict and peer educator.
The newfound ability the peer educators discovered to take charge over their own life and start a new chapter, concerns not just the future or ending of their story, but also their past. In line with Giddens (1991), I argue that the self is reflexively made: a growing reflective awareness of being-in-the world, involving a sense of someone’s past and future (Heidegger, 1927). Narratives are used to create continuity between the past, the present, and imagined worlds. The narrated past matters because of its links with present and future life worlds (Ochs and Capps, 1996). For my respondents it is not simple to create a coherent sense of self: many try to oppose their ‘former’ self or lost all sense of their selves when they were using. And that by leaving heroin, becoming a peer educator and receiving methadone, they completely changed person. My respondents adhere to a future focused narrative; their stories focus on who they are becoming and on the move away from their past self as soon as possible. However, since the past cannot be avoided—a past which is suddenly revealed, remembered, felt, regretted and reflected upon as soon as MMT is started and the numbing veil of heroin is removed (see Appendix A.9)—they need to find a way to align their past with their future in order to create a coherent sense of self. Sorting out how they can present and view their selves as the same person they used to be, but simultaneously as new and different, is not easy and straightforward (Bamberg, 2012). Narrative seems to lend themselves for such navigation in three ways. First, it enables to distance their present selves from past events, by explaining that heroin had taken over. The distinction between the self and the drug is beautifully expressed in a poem by Jeremiah:
Second, they ascribe a purpose to their past, by calling it a preparation for their current life. The only reason they became a peer educator and are able to help people, is because of their past hardships. Daniel even said: “We all still think like drug users, that’s why we are so good at our job”. Third, although they picture a hopeful and ‘normal’ future and a complete break with the past, almost all of my respondents at the same time acknowledge they will stay a recovering heroin addict for the rest of their lives. As Matt explains in Appendix A.10, the uncertainty and the possibility of relapse will always be there, heroin will always be their comfort zone and they have to say no to
2.2 A New Chapter Chapter 2. The Narrative Self
2.3 I Share My Story Chapter 2. The Narrative Self
heroin every single day. In this way, their past self is connected to their future. Yet it does not make them hopeless, they say, as long as they accept that fact, and keep their achievements and future goals in mind. It might be argued, that the ‘leaving heroin’ part of themselves, is constitutive of and stays the common thread of their narratives.
2.3
I Share My Story
People find my life very interesting and also the fact that I am so open and talk so freely about my past. But my history made me to the person who I am today. Why would I not talk about it? It is part of my story, part of who I am. My experiences don’t define who I am today, but they made me who I am today.
Theo
Theo is not the only one who talks openly and freely about his past (and future) life. Building on Billig (1987), drawing up a sense of who one is, is based on dialogues that one enacts in the realm of everyday interactions. Sharing stories plays a central role in my participants’ creation of a new social life and social self in three different ways. First, it became a standard practice for the team when they start each day at the office. Everyone always comes early and takes their time for a shower, coffee, some cigarettes and stories. (See Appendix A.11 how Daniel explains how this evolved) They listen to each other’s “junk stories” (stories about their addicted past), and laugh about it together. It releases shame and guilt and pain, and enables my participants to come to peace with their past. Some even get to feel proud of the fact they have such a story, full of hardships and difficulties, to tell. In the car on our way to the starting point of our harm reduction route, Lesego expressed that metaphorically as follows:
“Imagine this: There are two lions. One lives in the zoo, one lives in the jungle. They both die and they both go to heaven. Which one of them has had the best life?” Thabo: “The one from the jungle.” “Yes, true!” Lesego exclaims, “Because the one from the zoo, he has no story to tell. No scars to show. He always just got food.”
Lesego and Thabo
Second, these morning moments, but also conversations with service beneficiaries, also bring up positive memories, experienced together on the streets. Both the negative and
