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The last four decades have seen important medical advances in pharmacology. Barbiturates offered a cure for insomnia, benzodiazepines promised relief from anxiety, methadone a substitute for heroin and perhaps less contentious antidepressants a treatment for low mood or suicidality (Gournay et al 1997). These examples of medical intervention echo the dominant rationale given by service user participants for the role of substances in their lives, which was “to feel better”. Equally the rationale for drug taking or the role that the drug performed was consistently conveyed in medical terms or within a medical framework. It followed then that deconstructing distress as a concept into its component parts demonstrated the role drugs performed for participants in symptom management. For example insomnia aided by alcohol or cannabis, lethargy relieved by cocaine. This could mirror the process of constructing individual symptoms of distress into clusters to form medical diagnoses by doctors and psychologists. It appeared then that the participants’ fundamental treatment beliefs varied little from those of medical health beliefs in that distress represented a disorder that could potentially be remedied by drug taking / medical prescription. The remedies were the variant whilst the rationale was the same.

This section presents its findings in Table 13 (‘Role and Properties of Substance Use’, Page 127) and incorporates sample quotations accordingly. It concludes with a theoretical model (Figure 6, Page 130) explaining the possible course of substance use

and how substance use compensates for difficulties in coping. It examines the role of drugs largely from a lay-medico perspective however the concept development concerning distress and remedies (found also within the two help-related categories) floundered at times when social influences such as “to fit in” or “peer pressure” were raised. Similarities between relationship orientated categories and those categories of ‘Help’ were evident. Importantly this demonstrated through cross-cutting concepts that it did not appear possible to separate concepts entirely. They were connected in a co-dependent manner that explained their existence and was relevant in predicting their future impact.

To develop this theme further and clarify the connections I selected matching properties of three categories; (i) Role of Substance(s) (ii) Relationship with Substance(s), and (iii) Things that Helped/ Might have Helped. The connection ran in linear fashion; (i) an alcoholic drink relieved loneliness, (ii) alcohol became a reliable source of comfort (“a friend… it was a love affair”) and (iii) as a replacement for company it proved to be helpful.

By identifying the properties that connect one category with another an understanding of the chronicity emerged. Drug use in alleviating social and personal woes (‘Role’ category) created other problems such as dependency, financial hardship or relationship breakdown (‘Impact’ category) that subsequently generated a second reason for drug use. This cycle revealed the psychological, physiological and social elements to the core category of ‘Drug Taking’. It also discovered the sites (the precise function of the drug) at which the major ‘Help’ category could be located.

Nineteen separate roles for substance use were described which started to expand on the cycle and provided greater understanding of the phenomenon of dual diagnosis. Table 13 overleaf lists the roles and cites the key properties most prominent in each.

In its entirety the role substances played for participants was wide and varied. It appeared to be chosen for specific reasons such as to help relieve anxiety, to generate enough energy and motivation to socialise, or to generate confidence or improve mood. Regardless of the specific reason for using, the properties in each subcategory revealed evidence that supported a form of self-medication against the negative

aspects of life. The nature of the negative aspect appeared to be an influence on, or a reason for, drug use and the role it played. It transpired through axial coding, that properties inter related or cross cut on this theme.

To understand this point further it was necessary to find facets of drug taking behaviour that were located across a number of the subcategories. Boost energy, counteract sedating effects of medication, increase alertness to threats, enhance pleasure, and aid socialising were subcategories that all shared the stimulating effect of drug use. Yet to simply group these together as a subcategory of stimulatory effects for example would have detracted from any emerging explanation for drug use. It would also carry the implied quality that stimulatory effects were sought for pleasure or to enhance a sense of well-being. It would have created a pattern of thinking in the analysis that would not be open to exceptions. An exception here being increased alertness to threatsfor example. Whilst stimulatory in nature this related to survival or safety for the participant and differed considerably from other subcategories. The need to be alert (*) to danger, in a case that was symptomatic of paranoid ideation, transferred the drug use from a theme of self-medication to one of self-preservation. In both cases a direct link between mental health symptoms and drug use was evident however the view of the participant needing to be alert for danger did not fit into a self-medicating model, despite being a response to a symptom. Danger was an external factor (perceived or real), whereas stimulation to feel motivated or boost energy was an internal factor, the latter being attributable to an illness or internal absence in need of relief (through a ‘form’ of medication, the self-medication hypothesis).

Table 13. The Role and Properties of Substance Use

Role Properties (explanations given, substance used, behaviours before and after)

Aid Sleep Cannabis and alcohol used Boost

Energy

Improved concentration and motivation to achieve tasks such as reading, shopping or going out.

Energy accompanied by sense of achievement and satisfaction leading to sense of well-being, happiness and contentment.

*Increase Alertness of Threats

Alcohol and crack cocaine.

Promoting courage and allaying fear.

Generating anger and hostility deliberately to feel unassailable. Aid Ecstasy, alcohol and cannabis boosting energy for socialising.

Socialisation Drug use a passport to gangs and peer groups. Combat

Boredom

Drug use as an activity in itself provided a pastime (“something to do”) and company (“someone to do it with”)

Absence of alternative activities and poor employment opportunities for drug users / mental illness sufferers.

An Escape An escape or respite from distressing mental illness symptoms and the accompanying poor quality of life.

..from painful memories related to past traumas such as sexual abuse. ..from reality and a depressing or hopeless life.

To do crazy, otherwise ill advised, things not participated in when sober (“fun”).

..from problems or a change in the perception of problems. A

Punishment

Anaesthetised from feelings of guilt. For bad things done.

Relieve Anxiety

Cannabis, alcohol, cocaine and heroin commonly used as anxiolytic.

“Takes the edge off”. “Removes worries”.

Combat Loneliness

Alcohol, ecstasy and amphetamine popular.

Alcohol improved confidence and heightened level of self-esteem. Ecstasy used as an antidepressant relived depressing feelings of isolation.

“On drink girls found me attractive”

“Everyone was my friend”. “Alcohol was a reliable friend, it never judged me”. “Amphetamine is comforting”.

Lift Mood Ecstasy as an antidepressant.

Alcohol controlled mood and induced periods of euphoria.

Cocaine and heroin taken together (speedball) moderated mood and weakened unwanted side effects of both drugs whilst improving the desired effect of both drugs.

Amphetamine raised mood and increased confidence to handle delusions of paranoia.

Other bizarre or distressing thoughts became less significant and intrusive.

“Just something that instantly feels good”.

Counteract Sedating

Effects of Medication

Crack cocaine and amphetamine. Both promoting feelings of energy and motivation, the lack of being attributed to sedating effects of antipsychotic medication.

Experience Enjoyment

The absence of pleasure as a facet of mental illness counteracted by drug use.

“Just something that instantly feels good”. “Fun”, “Feel things”.

Boost Confidence

Alcohol creating sense of courage.

“Frightened of nothing” - when previously socially anxious or phobic. Generating anger and providing “Dutch courage” to cope with social anxieties and fear inducing psychotic symptoms (paranoid delusions, insulting or threatening auditory hallucinations).

Block Symptoms of Psychosis

Dampens auditory hallucinations (voices).

Reduced intrusiveness and preoccupation with voices.

Paranoid Fear

hallucinations (e.g. “we are gonna get you”). Enhance

Pleasure

Cannabis and ecstasy. Music, food, dance, sex improved. Partying common.

Combat Withdrawal Symptoms

Craving relieved.

Withdrawal symptoms (delirium tremens, sweats, diarrhoea for example) relieved.

Physical Role

Relieve withdrawal symptoms. Remain slim.

To become slim.

To relieve formication (itchy skin that feels like bugs under the skin). Analgesia (e.g. back pain).

Calming and Slowing Life Down

Heroin used.

Elaboration of this theme or arguably another angle altogether took the line that drug use was a replacement for the absence of something, for example physical energy. The model that emerged I labelled ‘Deficit Management’. Locating this theme throughout the nineteen subcategories (see Table 13) revealed a dimension for each that resembled a course upon which drug use (and the person taking drugs) embarked.

Figure 6 displays this course of drug use. It demonstrates that deficits become bigger rather than smaller and that the accumulation of drug use (impact of drug use) problems increase disproportionately yet they are in parallel with drug use itself. A simplistic example is the participant who used amphetamine to increase physical energy and activity. Short term energy increase occurred as desired. Their longer-term energy deficit increased because of the energy depleting effect amphetamine causes (‘comedown’ and serotonin depletion). The original reason for drug use (lack of energy) became more marked and subsequently drug use escalated in response.

Figure 6. Course of Drug Use: Deficit Management Model

In conclusion, the role drugs performed was varied. Specific roles revealed specific rationales. Little emphasis was openly expressed on the pharmacological category of the drug such as hallucinogenic, depressant or stimulant. The emphasis, in conveying the role of the drug, was placed upon the individual experience of the drug in relation to a participant’s problem(s). The strongest theme emerging appeared to be that of self-medication (Khantzian 1997). Another label for self-medicating could be deficit management or coping with life, with illness or with a lack of well-being.

The significance to the development of theory here is two-fold, the purpose and the manner of drug taking. One, for example, the nature and the role of drugs interlink

with achieving a sense of well-being. This is important because it links drug taking with the absence of well-being. It also confirmed the validity of ‘Drug Taking’ (in mental illness) as the core category. And two, whereby the nature of drug taking appeared functional in outcome (“it made me more relaxed and sociable”), the manner of drug taking integrated additional motivating and reinforcing factors. These were considered secondary factors but effectively sustained drug taking as depicted in the cycle of drug taking shown in Figure 6, ‘Course of Drug Use: Deficit Management Model’.