My Explanation for my Condition / Situation

Two important concepts existed under this heading. Firstly, the belief that external factors played an important role in a participant’s condition or secondly, that internal or personal factors were dominant in the development of their condition. External factors varied in source; parents, family distress, trauma, ‘the devil’, imprisonment, drug dealer, availability of drugs, social anxiety, peers, loneliness, life and work related stress. Internal or personal factors stemmed from beliefs about ones self such as a condition being self inflicted through weakness, gullibility, changed perspective on life or environment, and the development of a mental illness or emotional distress.

Psychosis participants described an influence on their condition that they perceived to be external yet could arguably be described as internal. For instance visual or auditory perceptual disturbances combined with delusional beliefs. Those non psychosis

participants who described their condition as being caused by more concrete external factors such as sexual abuse, like their psychosis counterparts, explained their condition by attributing it to others (‘blame’). Those participants who regarded themselves, rather than external factors, as being causal in their condition also expressed themselves using blame language. The concept of blame or attributing their condition to a single source or experience appeared important. This concept appeared in other categories too, such as ‘Significant Childhood and Adult Incidents’ but of particular relevance was its appearance in the help-related categories. Here participants processed the concept of help by explaining the causal factors. From the causal factors grew a remedy that might work, and equally remedies that failed. In order to examine more deeply this concept of blame (relational to attribution theory) the specific function or role of a substance was raised. Within the category ‘Role of Substance(s)’ (Category 10) a mass of material appeared that cross cut the explanations and also thrust the concept of cause (blame or attribution) into one of remedy. This is understandable when considering the function of attributional thinking. Attribution theory is based on the assumption that an individual will interpret their environment and circumstances in a manner that maintains or promotes a positive sense of self (Weiner 1980). Factors influential upon the degree of attribution, and ability to change or be motivated to change, are the individuals’ circumstantial stability (external) and their personal stability (internal / psychological). If they attribute their problems to external factors then change is conceivable if accompanied by lifestyle changes. Should they attribute their difficulties or distress to internal factors substantial psychological support or intervention is required. Either attribution bent appears surmountable.

The prospect of applying such theory to my study participant group requires care. Within the general population widespread biases and judgmental errors exist when accounting for problems and successes but overlaid upon those individuals with mental health problems these matters may be amplified considerably. Debiasing techniques within the mental illness population are applicable and considered effective (Hayes & Hesketh 2005) however the presence of substance misuse and the accompanying lifestyle and difficulties in sustained engagement add further problems. The relevance therefore of study participants’ focus on their distress and formulating a

attribution was conveyed by participants in blame language which in turn appeared both motivational and straightforward. The resultant focus upon practical solutions was empowering through its conceptual simplicity.

Both externally and internally attributed explanations for service user participants’ condition shared a key component - distress. Table 11 presents the distress in 3 types; mental, physical and social.

Table 11. Mental, Physical & Social Signs of Distress

Mental Physical Social

Paranoia, worry, anxiety, low self-esteem,

confidence and motivation, sedating effects of

medication, low mood, suicidal feelings, poor concentration, insomnia.

Low energy levels, feeling docile, drug withdrawal symptoms (‘cold turkey’), back pain, muscular pain, itching (formication), insomnia, poor appetite.

Social anxiety, perceived social incompetence, fear of peers, strangers or general public, loneliness, inactive, unemployed, excluded, isolatory.

In the quote below Daisy explains that the drug component of her dual diagnosis is beneficial in improving social and recreational aspects of her life. The explanation also reveals how she sidesteps stigma by entering a social group accepting or encouraging of drug use behaviours.

Mark …even if it was drug induced, if, I don’t mean whether you disagree with them (the doctors), but if you thought it was drug induced, would it make any difference?

Daisy Yeah, but, yeah because my illness is serious, I have a nervous breakdown quite often.

Mark Yeah. So as far as you’re concerned and from what you are telling me anyway, that your drug use is quite controlled, that it is, you know, all the stigma and boredom and stuff like that of having the illness that is

(drug use) actually a positive thing in your life.

Daisy Yeah it keeps solid ‘cos I get out I get to meet people and that, and I get to see everybody and that’s what (inaudible) I'm only stuck in the flat and I’ve got nobody to talk to and I'm bored. I’ve got no neighbours and then I’ll only see doctors and nurses coming up and I don’t get much people round in my community that will talk to me cos they think her she ill, and I get out and I meet students that come to Manchester every year and that’s how I meet people. It is good for me.

The explanations provided by participants for their condition (drug or mental health or both) appeared to pivot on the concepts of cause and distress, which later progressed to a concept of remedy. However it also appeared that drug use was a culturally and age related activity that preceded distress for some. When drug use was cited as a ‘right of passage’ participants were more likely to see distress as a progressive entity that was not necessarily caused by drugs but simply existed. On experiencing distress drugs were found to provide relief suggesting that distress had become a central point to drug taking as a consequence rather than a cause.

Mark So they (practitioners) should be helping what you need help with and not judge or condemn?

Simon Yeah, you have to treat it as a form of illness, and there’s always a reason why people go on drugs, its usually circumstantial. Things are going bad in their life, they’ve had a nasty experience they can’t get over, they can’t seem to face ordinary day-to-day life like other people, you don’t just go hey, lets take drugs.

Participants who used drugs to relieve mental, physical or social distress were likewise less inclined to see drug use as a causal or exacerbating factor of any distress. Subsequently whilst ‘Drug Taking’ formed the core category that cut across all other categories it did not get identified by service user participants as the core concern.

“Getting started” (on drugs) due to culture or environmental influences (peers, gangs, friends, family and other inpatients) was a term used by a focus group participant that attracted strong agreement from others. The emphasis upon this social reason for drug taking (without the emotional charge conveyed by participants when using blame language) appeared acceptable and understandable to focus group participants. The phrase “if you can’t beat them join them” was used by one. This appeared to represent a sense of fatalism or disempowerment to prevent the inevitable lapse.

Even though I had four pints, I didn’t even want to have a drink at first, it was just the upset and the kids, we was having a meal, they were crying, I were crying. I used to call him baby (Ron’s lost child), but he is older than them, you know, he’s not older than my eldest lad, he’s 21. Well it was, but like I said to my one to one counsellor, I’ve got over his death. Christmas, I didn’t have a problem, I had a great time, but this was the part I was dreading more, where normally I either get locked up, have a fight…..(Ron)

Sociological and psychological explanatory models for fatalism exist (Vogt 1993) that disempower individuals in two ways. First, societal positions characterised by limited wealth, health and power can promote an acceptance of negative incidents, (gun crime or drug use for example). Second, by psychologically accepting negative incidents or circumstances a sense of resignation can be achieved. Thus prominent properties emerged that based drug taking and mental illness into a potentially socially explainable domain as well as the mental and physical domains cited above.

Finally, participants conveyed a belief in external remedies for their distress or social circumstances that matched a medical understanding that distress (or dis-ease) can be treated. Furthermore, it has been suggested that since mortal health risks have declined in recent centuries society in general now possesses a psychological explanation for distress regardless of its appropriateness (Foucault 1970). It appeared understandable that participants conveyed an external attribution theory to both remedy and cause. This section closes with Connor describing his internal attributes (worries), what they led to, (drug use) and how they changed to external attributions (paranoia). Both worry and paranoia are prominent and reflect wider participant consensus that psychological or emotional distress are integral explanatory factors.

I am a worrier, worry too much about the word and… when I took this LSD, I just went on one. It got to a stage that it, that I was drinking that heavy, it got to a stage that I was paranoid, that I needed that drink. A few drinks to stop the paranoia, but… (Connor)