Socially Situated Experiences of Substance Use: A Photo Elicitation Pilot Study

Introduction: Contextualizing Substance Use

Our study was designed to pilot a photo elicitation methodology and undertake preliminary examination of substance use from the perspectives of two potentially disparate groups. One group included those embedded in a high demand institutional context—in this case, a university. The second included health providers who prescribe and/or dispense pharmaceuticals. The study was undertaken in Nova Scotia, Canada. Canadians are situated in social contexts that implicitly and explicitly promote the use of substances to achieve optimal experiences in daily life, such as anxiolytics to alleviate nervousness during public presentations, over-the-counter sleep aids to manage shift work, and alcohol to unwind at the end of the day. We explored psychoactive substances collectively—including licit substances (e.g., alcohol, over-the-counter medication), prescribed medication (e.g., benzodiazepines, oxycodone), and illicit substances (e.g., cocaine, MDMA)—alter brain function, affecting consciousness, mood, and/or perceptions (Kiepek, 2016). From a lens of method assemblage (Law, 2004), we understand substance effects to be fluid (Duff, 2013; King, 2014) (e.g., opioids may alleviate pain or produce a “high”) (King, 2014) and classifications in flux (e.g., coffee ban in the 1600–1800s; cocaine an ingredient in Coca-Cola in the 1800s).

Internationally, there is very little research that examines substance use outside individualized, problem-focused epistemologies (Kiepek, Van de Ven et al., 2019). Discourses and research are shifting to recognize non-problematic factors influencing substance use, such as pleasure (Lancaster et al., 2017; Moore, 2008; Nutt, 2012; Race, 2017; Ritter, 2014; Winstock & Nutt, 2013), performance enhancement (Enck, 2014; Kiepek, Harris et al., 2019), spirituality and ceremony (Labate, 2014; Laughlin, 2018; Tedlock & Tedlock, 1975), and enhanced lives (Evans-Brown et al., 2012). Use of substances for enhancement is primarily conceptualized as a means to compensate for disease- or illness-related dysfunction and/or facilitate performance beyond a persons’ typical capabilities (Forlini, 2018). For example, antihistamines alleviate physiological symptoms associated with allergies, thereby improving mood and reducing fatigue, which can enhance performance, sleep, and quality of life (Davis, 2015). Caffeine may enhance performance beyond typical capabilities by increasing alertness and wakefulness beyond natural limits (Lee et al., 2009).

Actual and perceived performance expectations vary between contexts, When considering students, the institutional context of the university is marked by competitiveness and high performance demands, which can create incentives for substance use, such as improved wakefulness and alertness, focus, concentration, attention, working memory, amelioration of natural age-related cognitive decline, and self-control (Emanuel et al., 2013; Enck, 2013; Habibzadeh et al., 2011; Hughes et al., 1991; Petroianu et al., 2010; Reiner et al., 2017). Productivity is not confined to certain hours of the day or days of the week; in fact, one medical resident program in the United States developed a policy that limits residents to an 80-hr work week (White et al., 2006). Among university students internationally, past-year prevalence of non-prescribed cognitive enhancement substance use ranges up to 20% (Dietz et al., 2013; Racine & Forlini, 2010; Webb et al., 2013; White et al., 2006). Use is predicted by cramming to view online lectures, having more than one exam on a single day, having an assessment worth 50% or more of a grade, and increased frequency of all-nighters (Dunn et al., 2021).

Health providers and the general Canadian population may be particularly influenced by “medicalization.” Medicalization refers to social processes that identify aspects of lived experienced as constituting a “problem” treatable primarily through medical interventions (Conrad, 2007). Prescription and reliance on pharmaceutical are common occurrences, with 41% of community-dwelling 6- to 79-year-olds taking at least one prescription medication in the past 2-day, with rates of use as high as 83% among 65- to 79-year-olds (Rotermann et al., 2015). Using five or more prescription medications concurrently was reported by 30% of 65- to 79-year-olds and 11% of 45 to 64-year-olds. Women tend to report higher prevalence use of prescription medications than men (47% vs. 34%) (Rotermann et al., 2015). Most commonly used pharmaceutical substances by children and young adults were to treat asthma, ADHD, and depression, whereas adult medication treated heart disease, pain, and depression (Rotermann et al., 2015).

Reliance on pharmaceuticals as a therapeutic intervention may influence people’s decisions about the perceived advantages of using non-prescribed substances to deal with daily discomforts. Availability of substances has redefined health and well-being while causing us to “rethink how we view our bodies, how they work, how we can change them and what it means to be human” (Evans-Brown et al., 2012, p. 14). Some people may select substances they deem to be less harmful than pharmaceuticals (e.g., microdosing psychedelics) (Gregoire, 2016). As such, medicalization has blurred the line between normal life events and disease, whereby substances are used to alter natural phenomena such as aging processes, social functioning, weight, sexual performance, mood, cognitive functioning, shyness, and tiredness (Evans-Brown et al., 2012).

Alongside normalization of substances to enhance health and well-being, addiction remains a dominant discourse in Canada. A predominance of research about substance use pertains to potential or actual risk for harm and/or substance use disorders (Kiepek, Van de Ven et al., 2019) and politicians and policy makers tend to construct substance use and “problems” in specific ways that legitimize certain perspectives, while underrepresenting the voices of those who use substances (Fraser & Ekendahl, 2018). Although Canada is regularly ranked high in terms of overall standard of living, significant pockets of marginalization and disadvantage are experienced in relation to health and substance use (Fraser & Ekendahl, 2018). Representations of substance use among marginalized and disadvantaged populations tend to be highly profiled in public media, not least because of high mortality rates associated with overdose. In response to these circumstances, Canada was an early adopter of harm reduction philosophies (e.g., opioid substitution, needle distribution) (Fraser & Ekendahl, 2018), which, variably shapes policy, intervention, substance use practice, health, and public opinion.

Our study was designed to uncover how people in a high demanding context describe substance use within their lives compared to how health providers describe substance use in the context of patients’ lives. We were interested in the ways in which health providers may or may not condone and/or recommend substances as a primary means to address aspects of lived experience (e.g., difficulty sleeping, pain, stress, unhappiness) when alternative measures may be suitable (e.g., sleep hygiene education, pain management clinic, counseling, building social networks). We were also interested in how both groups positioned substances in relation to an “optimal” or “enhanced” life.

It is not our intent to uncover a unifying theory or understanding of substance use that bridges perspective. We share Becker’s (1963) belief that “We cannot describe a ‘higher reality’ that makes sense of both sets of views. We can describe the perspectives of one group and see how they mesh or fail to mesh with the perspectives of the other group” (p. 173). How substance use is judged is complex and influenced by multiple factors, such as medical rationale, legal classification, perceived risk for harm, age of the person using, positionality of the person/entity making the judgment, and so on. In this study, we aim to examine the way substance use is depicted and talked about across two distinct groups, explore how these perspectives may or may not “mesh,” and describe potential implications. This study contributes to nuanced understandings of substance use among the general population by integrating non-problem-focused theoretical perspectives (Bacchi, 2016) considering contextual factors that extend beyond individual, often pathologized, factors.

Methods

Photo elicitation is a visual methodology grounded in hermeneutic (interpretive) theories (Margolis & Zungarwad, 2018) that involves participant generated photos and elicitation interviews. This method was selected to purposefully explore (i) how people who use substances depict and discuss their own substance use, and (ii) how professionals who prescribe/dispense pharmaceuticals depict and portray how substances impact the lives’ of patients/clients.

Photos are an effective means to engage participants in critical reflection on taken-for-granted aspects of lived experience (Brazg et al., 2011) embedded in social and economic contexts (Copes et al., 2018; Liebenberg, 2018) while “staying close to participants’ views of their life” (Padgett et al., 2013). Images elicit emotions, thoughts, memories, and interpretations of lived experience and engage participants in critical reflection and narration that is not afforded in the same way during research interviews or storytelling (Harper, 2002; Liebenberg, 2018). Elicitation interviews offer rich opportunity to “connect ‘core definitions of the self’ to society, culture, and history” (Harper, 2002, p. 13) and with the distance of a photo to afford contemplation (Liebenberg, 2009).

Photo elicitation is a quick and easy means of data collection that provides unobtrusive access to private activities and worlds. Photo elicitation is generally viewed to facilitate trust and rapport (Glegg, 2019; Murray & Nash, 2017). Interviews around photos are generally directed by the interviewee about topics important to them, provide comprehensive data while minimizing interviewee fatigue, and are less structured by interviewees (Collier, 1957; Harper, 2002). Participants may be more comfortable engaging with the researcher, knowing the interview will revolve around photos, topics, and meanings they have chosen to share (Glaw et al., 2017). Compared to semi-structured interviews, photo elicitation has been found to provide new information and more details (Padgett et al., 2013).

Photos are viewed as a form of “social fact” (p. 601) that arises through both the image captured in the photo and the person who took the photo (Margolis & Zungarwad, 2018). Boundaries between participant and researcher are bridged, as photos taken by participants shape the dialog and create a “mutual initiative” (Liebenberg, 2009, p. 445) and meaning(s) becomes intertwined and co-constructed between the participant and researcher (Kantrowitz-Gordon & Vandermause, 2016). This approach provides an alternative to researcher-directed research that is argued to “have a propensity for reinforcing discriminatory and oppressive practices” (Liebenberg, 2009, p. 442).

While our research team had envisioned piloting a thematic analysis congruent with grounded theory to inform the design of a larger study, once immersed in the data and repeatedly asking ourselves “what story is the person telling?” it became evident that narrative methods were ideally suited to inform analysis. Our study to incorporated three forms of narrative data: (1) photographs; (2) written descriptions of the photos; and (3) semi-structured interviews. This aligns with Chase’s (2018) description of photos as “socially situated narrative texts” (p. 547) and Jurgenson’s (2019) claims that photos are a form of “oral storytelling” (p. 17) and “visual discourse” (p. 18).

Photo elicitation projects are acknowledged to incorporate elements of self-representation and self-exploration to enhance relevance of information explored, contextual accuracy of analysis, and co-construction of knowledge (Liebenberg, 2009). Our study extended beyond self-representation to include representations of the experiences of others. Given ethical restrictions around including photos of clients or artifacts specific to “health information,” metaphorical photos are prominent within this study. This is consistent with propositions that photos are “metaphors for human experience rather than fixed representations of reality” (Murray & Nash, 2017); participants deliberately make choices about what to include and exclude, what perspective to share, how to frame subjects/objects in the photo, and what meaning is ascribed (Kantrowitz-Gordon & Vandermause, 2016; Murray & Nash, 2017). Both images and discursive choices may draw on metaphors to convey meaning (Richard & Lahman, 2015).

Bailly et al. (2018) define photo elicitation as a “visual mediation” that focuses on discourse facilitated by images and not on images themselves (p. 71). Photos serve to contextual discourse and provide illustrations, rather than being the direct subject of analysis (Bailly et al., 2018). However, in our study, we deal with the three data sources as a collective narrative, rather than giving primacy to verbal interview data.

Analysis

Narrative analysis integrated data collected through photos, written description, and interviews. The first and second authors read the interviews numerous times to conduct preliminary analysis, followed by team debriefing with all members to review the appropriateness, consistency, and completeness of analysis and interpretations.

Riessman (1993) posited narrative analysis is “well suited to studies of subjectivity and identity” (p. 5). While her work focussed predominantly on oral narratives, visual choices made about what to share with others through photos is increasingly recognized as a means of sharing subjectivity (Zappavigna, 2016). Our narrative analysis aligned with Gubrium and Holstein’s (2009) description that “narrative practice brings what is told and the telling together to employ a rich empirical terrain. The particular form of analysis required to describe and understand this reality takes account of both the substantial and the performative, drawing together diverse stories of selves and social worlds on the one hand, with the concerted work of storytelling on the other” (p. 17) [italics added]. In other words, analysis integrated examination of the story being told and how the telling of the story, though photos and words, influenced meanings conveyed.

Layered on analysis “stories of selves and social worlds,” were “stories of others.” While participants in the university group foregrounded narratives around self, health providers “stories of self” were revealed more through the performative, while “stories of other” and “stories of social worlds” through the substantial. To understand “stories of self” among health providers, analysis shifted toward examining “how they anchored their position from where they want to be understood” (Bamberg, 2012, p. 207).

Analysis involved iteratively working with data at the levels of individual, group, and whole. Analysis shifted between (i) photos as primary data source complemented by written descriptions and interview narratives and (ii) interview narratives as primary data source complemented by photos and written descriptions. To focus analysis on photos as primary data source, the first and second authors independently identified a metaphor associated with each photo, referring to interviews to inform interpretations, then came to consensus through dialog. Interview narratives as primary data source were initially examined for themes and compared across participants; however, comparisons across a small number of participants limited the appropriateness of this approach. Instead, a narrative approach was undertaken to identity unifying “stories” told by each participant (examining stories of self, stories of other, and stories of social worlds).

To strengthen the co-construction of meaning, participants were emailed an individualized preliminary analysis and invited to comment on their level of agreement with the themes identified and verify the accuracy of quotes. No changes were requested. The preliminary findings were taken from a late draft of this paper, so the findings here correspond directly with those reviewed by participants.

Results

Stories and Metaphors

In this section, interpretations of underlying participant “stories” are told. University students tended to tell “stories of self”: ST1 tells a story of “mastery” and ST2 of “social adeptness.” Health providers stories blended “stories of others” and “stories of social worlds” that indirectly revealed “stories of self”: HP1 told a story of “hope, beauty, and compassion through interactions with clients,” and HP2’s story told of “societal expectations of what it means to use substances.” Although consent was provided for some photos of self and friends, photos of people, and identifying images will not be publicly disseminated to protect confidentiality and privacy. Written descriptions are included in the tables, as well as interpreted metaphors that informed the overall analyses.

ST1: Mastery

ST1 provided five photos (see Tables 1 and 2). Her underlying story of “mastery” and pride related to processes associated with substance use and experiences afforded through substances.

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Table 1.

ST1 Student Photos and Metaphors.

ST1 Photo 1	“I smoke a bowl from my pipe after coming home from drinks with my friends to relax me before bed. I woke up this morning feeling foggy but could be due to lack of sleep, drinks, or weed.”
	Metaphor: Typical routine
ST1 Photo 2	“These are my ingredients for making a Cesar that I may have a few times a week at the end of the day. I love making them and find it a nice little mindless task. I try to have a Cesar with or after dinner because they make me full.”
	Metaphor: Making everyday moments special
ST1 Photo 3 Photo of the lower half of two people’s faces, each with a tab of acid on the tip of their tongue.	“my partner and I did a tab of acid while in [a] national park. while I was initially hesitant that I would be less coordinated and therefore less safe I actually felt very strong and capable and coordinated. I also connected with my partner and with nature in a new and different way and appreciated it”
	Metaphor: “on top of the world”; heightened sense of self and quality of experience

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Table 2.

Additional ST1 Photos.

ST1 Photo 4	“this photo shows some 2cb capsules I did before a night out in [a city]. I was with my partner and we took this on the first night together after doing several months long distance. We had an amazing night and reconnected with new experiences”
ST1 Photo 5	“I smoked weed and my roommate and I watched the crown and relaxed. I found the show a bit more boring when I was high and found myself getting lost/distracted more often than while watching other shows high.”
This picture shows a person lying on a couch and watching television in a dim room.

ST1 Photo 1 shows a cannabis pipe and lighter sitting on a clean wooden table, with a delicate teacup and saucer and a lid of a water purifier resting in the background. ST1 described a sense of “pride” associated with her ability to roll a joint, saying “not that many people know actually how to smoke- roll joints. So, it’s kind of a point of pride for me, you know. I’m like, oh look how pretty this one is [laugh]…” She described joints as potentially less intimidating for people not familiar with pipes, so she likes to roll a joint to bring to parties and share with others.

ST1 Photo 2 depicts ingredients for cesar cocktails. ST1 explained that she and a friend spent a summer perfecting their skills concocting the beverage. While it took her more time to learn to roll joints, she sees similarities in the processes: “Kind of like rolling the joint where, you know you, there’s a lot of ingredients: and you’re adding them together, and then you get a final result. And it’s good and your- you’re happy with it.”

ST1 Photo 3 showed the lower half of two people’s faces, each with a tab of acid on the tip of their tongue. ST1 described having taken acid with her partner prior to a challenging hike:

I was actually really proud of myself for, doing the hike because I was like you know what [pause] I did, a decent amount of drugs today, and I did a really really cool activity and I think that combination is something that [pause] just like, it’s such a unique experience and it’s something that I’m really proud of.

Mastery in this example related to taking a larger amount of acid than she had used before, having the physical endurance to complete the hike, trusting her judgment in her partner’s knowledge about drugs to provide her safe and enjoyable experiences, and trusting her capacity to “handle” drugs.

ST1 elaborated on mastery in relation to enhancing the quality of experiences associated with substance use. Cannabis was described as a means to decompress, turn off your brain, and wind down. STI described having routines that involved cannabis (e.g., at the end of a night out or when doing errands) but avoiding it when needing to be productive and viewing it as “reward” afterward. Caesars were likewise integrated into routines (e.g., preparing dinner) and also special events (e.g., holidays, brunch). She described taking a quarter or third of a tab of acid on occasion before social events to “upgrade an experience.” She described one experience saying, “Like I just feel really light and happy and airy and I’m really happy to be here. I’m not like, tripping balls and can’t see.” ST1 elaborated on her experience during the hike:

I felt very, capable and strong and, I really think it enhanced the hike for, first of all visuals just, seeing everything and, the way that being kind of in that, scenario, being, I’ll say quote unquote on top of the world, makes you feel. I felt it really enhanced that. And, brought us closer too just, seeing like, you know, we did this, big hike together: and it was a huge challenge and we did it together. And, you know we, communicated well and we talked about it and, it- it brought us a lot- I think a lot closer too. And then when we, were on the way back down to the, um bottom of the hike […] we were, still feeling the effects of the acid but, differently. […] And I was like wow like, this looks so different to me. It’s like a new adventure again.

This mastery of experience conveyed a sense of responsibility and choice around substance use. Deliberate decisions are made about what to use, how much, in which context, and with knowledge about how it would impact other important activities and routines. ST1 conveyed understandings that other people may not share her perspectives, which she attributed to their unfamiliarity with the potential range of experiences afforded through substances:

Not that I, pressure anyone to do drugs, but I just want people to be aware of, kind of like, okay like, these are the drugs you can do, and I think that these drugs, you would really enjoy. Like, if you went to a great restaurant and you had like some great food, you’d be like, oh my gosh. You should go there. It was so good. You want your friends to like share, um positive experiences.

ST1 submitted two other photos that were not coded for metaphors.

ST2: Social Adeptness

ST2’s story of “social adeptness” was depicted through three photos related to alcohol (see Table 3). Although she reported using cannabis, she described some hesitancy submitting related photos due to social judgments: “if like weed was in the picture, then I feel like, um [pause] if someone random saw it they’d be like oh my god those girls are such, stoners. Like, they’re so lazy. Um, it’s just like, whenever like weed is in the picture, like, it just gives the picture a more like, negative, uh, connotation I guess.”

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Table 3.

ST2 Student Photos and Metaphors.

ST2 Photo 1	“this photo represents how substances impede my wellbeing because I took this photo of myself after throwing up all morning because I drank too much the night before”
Portrait style photo of person looking disheveled.	Metaphor: One of us
ST2 Photo 2	“substances improved my wellbeing in this photo because alcohol’s ability to relieve anxiety made for a good evening with all sorts of friends”
Two people (arms around one another?), appear to be laughing, each holding a drink.	Metaphor: Immature fun
ST2 Photo 3	“this photo represents how substances enhance my wellbeing because after pulling a 12 hr shift at work, feeling completely awful, we had some drinks with friends and were cheered up”
Two people smiling, standing behind a kitchen island covered with a variety of food.	Metaphor: Mature adult

ST2 described typically experiencing social anxiety and finding it difficult to make friends. Throughout the interview, she described alcohol as a social lubricant. Underlying this was a story of social adeptness, where alcohol use was shaped according to immediate social contexts. Starting with ST2 Photo 2, ST1 described a party of “immature” fun during a summer job:

“it was a little bit more immature, I didn’t really have to worry about people judging me that much ’cause everyone was just kind of, having a dumb night and it was just like, fun, to [pause] just be like yourself, I guess […] when I’m with, like a certain, group of people drinking, like I don’t want to like, embarrass myself in front of them […] I- I want them, to, like respect me or, think highly of me or think that like I have my life together. This is kind of like the image that like, I always like people to, um, see when they think of me? Um, and so, but like with the work people like it just didn’t really matter cause, like, everyone was younger. Like, they were more, immature.”

In contrast, ST2 Photo 3 was included the participant and a friend behind plates of food in a kitchen, with a wine rack in the background. ST2 describing this event as more mature and discussed it in relation to dinner parties hosted by ones’ parents when guests bring wine and flowers. ST2 acknowledged the photo was framed in a way that appeared the two friends had done all the cooking, but it was a potluck, with contributions from all guest. She had purchased beer and cider for guests, noting alcohol choices had changed as people aged:

when I was younger it was just like, hard liquor like, straight vodka and stuff. But now like, people are more like drinking beers and ciders as something to like, sit on and casually drink instead of like buying, hard alcohol to like, um, just, for the sole purpose of getting drunk.

ST2 Photo 1 was a “selfie” taken while hungover. ST2 mentioned circulating this photo among friends in a way that fostered social bonding. She explained it is not typical for her to overindulge:

I can usually like, hold my, my, liquor pretty well, um, my friends are usually the ones, like, we’re usually- I’m usually the one taking care of them. And so, like, I have seen them at their, like worse [laughing]\in the morning\, um, afterward. And so, um, I just, kind of thought that [cough] um, they would [pause] appreciate seeing the same thing. So we were kind of all, equally, awful now [laugh] if that makes sense [laugh].

Awareness of social connotations associated with alcohol use were understood to extend into the future. ST2 indicated she was comfortable with the Photo 3 being available publicly: “Um, this is more of like a posed picture, and like, I look more put together. And, um, it- and like, it just kind of like makes you look more like, mature.” However, the she was concerned Photo 2 could have negative repercussions with within professional contexts:

I try to keep my social media profile clean just, because um, like for future like, work or, education opportunities or stuff like that […] Like I just- I just wanna keep my options open for the future, and I know that um, employers don’t, r- they like to um [pause] have people representing their company […] they want their, like staff to be, like [pause] um [pause] presentable. And, professional and, that picture is not very presentable or professional. And so, um, it just- not posting that stuff on social media just, um, kind of, keeps, the door open, for me for whatever I may want to do.”

HP1: Hope, Beauty, and Compassion Through Interactions With Clients

HP1 submitted three photos (see Table 4), each of which reminded her of specific clients. “Stories of other” were told that implicitly constructed “stories of social worlds” and “stories of self.”

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Table 4.

HP1 Photos and Metaphors.

HP1 Photo 1	“This is a rock painted by a patient who find arts helps her to cope with addictions and other stresses in her life.”
	Metaphor: Thrive instead of survive
HP1 Photo 2	“I saw a young man who was depressed. He wants to care about life, about work, but can’t get out of his rut. He said he just smoked pot, played video games and vapes. Of vaping he said he started as a teenager a few years ago because he likes the flavors, especially mango.”
	Metaphor: Enticement
HP1 Photo 3	“I saw a couple who were new to [the community]. they had left [the community where they were residing at the time] quickly because they wanted to get away from the dangerous situations they were facing related to their drug use. The man had been brutally attacked and his injuries will impact him lifelong. In the midst of discussing their issues, the woman said ‘I love the color of the walls. it’s my favorite color.’ I hadn’t really noticed the color. She compelled me to look, in the midst of her many burdens.”
	Metaphor: Seeing hope

HP1 Photo 1 shows a picture of a painted rock, embedded in the crook of a tree. HP1 described a client who experienced depression and anxiety, stating:

I also, love that in the mid of- midst of, all the things that were going on in her life, she, she painted rocks and she thought about, kinda sharing, the, the goodness that was in her with other people and sharing happiness and, and bringing joy to people […] it just gave me this little window in turn, to her life that I, just loved. […] in a, in a time where, you know, decisions that you’re making may, may be impeded by substances, you’re- you’re also able to make this decision to, to, do something, creative and artistic and, still have that, agency in your life at a time when you might feel like, you know, things are overwhelming and you don’t, always have, the ability to make the choices that, you want to make.

HP1 Photo 3 related to a couple who were being seen for an initial visit:

they were telling me this, this, this traumatic, terrible, story [violence and, uh drugs and, all kinds of stuff] and after all of this, the woman kind of looked over and said oh, that’s a really beautiful painting. And I had- I can’t even picture it now but I never really, looked at it. And, I just thought how, wonderful that in the midst of, like all this stuff going on, she, took the time to look at something that I sit beside for, you know, hours every Thursday and I’ve never looked at, I’ve never thought about.

In the process of sharing photos and details about experiences of clients who use substances, HP1 shares pieces of her personal self narrative. She explains that time to get to know clients is often “lacking” and clinical interactions tend to focus on immediate medical concerns. She acknowledges a power dynamic constantly at play, where health providers verify clients’ self-reports, such as by requiring a urine test for illicit substance before providing a prescription. Further, it is acknowledged that clients who use substances may have had prior negative interactions within the healthcare system. As such, it appears that having the opportunity to hear stories about clients’ lives, to witness clients’ appreciation for beauty in the context of struggle, and to enact positive “choices” in the context of “overwhelming” substance use disorders are those are that valued by HP1 and bring happiness, love, and meaning to the work she does.

HP1 Photo 2 related to a young man experiencing depression and feeling in a “rut.” This story appeared to demonstrate compassion regarding the ease with which one can be exposed to factors that can lead to a substance use disorder. In this scenario, mango is a metaphor for how companies target population, namely youth, toward addictive substance though appeal and enticement. She later relates the photo to her child: “my kid, will say… that smells really good and that freaks me out, that my 8 year old knows how good [laughing] \it smells\.”

HP1 recalled few specific details about client diagnoses and types of substances used. The stories conveyed more about the lasting impression on her emotionally.

HP2: Expectations of What it Means to Use Substances

HP2 submitted three photos (see Table 5) that complexly represent expectations about what it means to use substances. “Stories of social worlds” are told, situating substance use in relation to peoples’ lived experiences, expectations about what substances can do, and societal judgments about people with substance use disorders.

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Table 5.

HP2 Photos and Metaphors.

HP2 Photo 1	“this photo shows how certain substances can bind people to different providers (both illicit and regulated providers) and the lack of consistency that can develop as addiction and mis-use disorder develops.”
	Metaphor: Instability of lives
HP2 Photo 2	“this photo shows the type of relief some patients are hoping to attain from substances, and having the knowledge or realization that treatment is multi-faceted and the coveted balsam of life does not exist.”
	Metaphor: “Balsam of live” and “quick fix for everything”
HP2 Photo 3	“this photo represents a medication that can potentially stabilize the life of someone who is destabilized through opioid use disorder. bringing to light the potential enhancement and impeding of substances depending on the person and situation.”
	Metaphor: Stigmatization and judgment

HP2 Photo 1 depicts the destruction of unused methadone prepared for daily consumption. HP2 explains that colleagues often interpret missed doses by clients as irresponsible. This photo is meant to represent “the instability, that people’s lives, um, [pause] offer depending on what kind of drugs they’re using. Or what types of substance they’re using. Um, and [pause] what their positionality is, if that makes sense?” She described “positionality” as relating to access to transportation, one’s relationship with one’s body, the potential to encounter a person from whom they previously bought drugs, and immediate legal concerns. She recognizes the burden of having to attend the pharmacy for medications on a daily basis, potentially for one’s whole life, and conveys an understand of other complex factors that influence whether or not a person attends the pharmacy. She acknowledges clients are “not always fond of being on a long, acting, opioid. Um, which, methadone is,” and side effects can be unpleasant. As such, she summarizes: “I think the autonomy can be totally different depending on what your, what your, like faculties are. Like how your, how you’re, surviving or thriving or, what have you in the world.” She seems to recognize, in a compassionate way, that her life is not the same as clients and she attempts to refrain from making judgments about other based solely on her own positionality. With regard to Photo 1, she observed, “with this particular type of, medication or drug [methadone] I think, often, um, people’s, lives are definitely, more unstable than my life.”

HP2 Photo 2 shows an aged pharmacy advertisement for “the balsam of life.” HP2 explains her impression that in contemporary society, people seem to seek a substance that will “fix everything.” She explains this photo is about:

things that people are using to try to make them feel better or cope better or, whatever. I think sometimes people are looking for something that will fix everything. Um so that was my story behind that. The, inability for any medication, or anything that I know of, to fix everything.

HP2 explains that many people think taking a substance, such as antidepressants, anti-anxiety medications, or pain medications, will make them feel “perfect,” which is an unrealistic expectation. She suggests more accurate messaging around substance might be “this medication’s gonna help me,” as opposed to current beliefs of “this medication’s gonna fix me.”

HP2 Photo 3 captures part of a warning label on a medication container that reads, in full, “Warning: May be fatal to adults/children.” HP2 explained she had meant to include a photo with a label that read, “Keep out of reach of children.” These photos (the one submitted and the one not submitted) are a commentary on how it is determined “who’s deemed a safe parent, and who’s not.” She explains that people with substance use disorders are often assumed to pose a risk to their children because of this part of their ascribed identity. Yet, she opines that knowledge of substance use disorders is insufficient rationale: “I do, think that people, generally feel […] they can cast judgment on, what someone’s ability to do something is. Right? Like based on like a piece, a piece of who they are.” While she acknowledges that some people are not “resourced, enough, and healthy enough to take care of their kids without support,” it seems to her that decisions are made more on assumptions than knowledge of circumstances asking: “at what point it’s deemed unsafe” and “who judges?” She expresses concern that parents are “forced to separate with their children” without any choice or opportunities for social work or addiction services. HP2 distances herself from what she considers dominant social perspectives. For instance, she contends: “it’s like some people are like, why would you have- why would you have, kids if you don’t have your life together. But everyone having their life together looks differently.” She further wonders why substance use disorders are treated different from other challenges parents might experience, such as being young, being inexperienced with children, or being highly emotional.

HP2’s stories seem to focus more directly on the social world. She critiques dominant perspectives about how people understand the potential for substances (largely focusing on pharmaceutical) to optimally enhance health and well-being. She also critiques negative assumptions about people who are identified as having a substance use disorder. In terms of “stories of self,” it is possible to glean details from her use of discourse that subtly position her perspectives as distant from dominant perspectives. However, personal life experiences that contribute to the development of these critical perspectives remain untold.

“Meshing” Perspectives on Substance Use

Analysis of these narratives uncover novel perspectives with areas of convergence (“meshing”) and divergence (“failure to mesh”). Each participant provided distinct stories of self, other, and/or social worlds: ST1 shared specific personal experiences with alcohol, cannabis, and psychedelics; ST2 shared personal information primarily about alcohol and cannabis; HP1 shared about clients who have complex experiences around addiction, mental health, and trauma; and HP2 spoke about pharmaceuticals generally and clients who have substance use disorders.

One topic for elaboration and further investigation relates to the high influence of dominant social perspectives on shaping people’s understandings of substances, substance use, and substance use disorders. Certain substances were viewed as more or less acceptable than others. Both health professionals and students spoke of alcohol as being socially acceptable and cannabis as increasingly acceptable (though less so among the “older” generation) as a result of national legalization. Compared to illicit substances, licit substances are “a more acceptable, form of drug use. So I think people, generally are like oh it’s just something, people do or like, maybe they’re having a hard time coping but, I think there’s a lot more leeway.” (HP2)

ST1 and HP2 both speak to the different ways that alcohol (and other substances) can be consumed, impacting how they are viewed as more or less acceptable. ST1 described this as “levels” or a “range” of possible experiences:

like you can have one drink, or you can have twenty drinks, and if you have one drink you’re not gonna be, blacked out on the floor. So, there’s like levels to it as well. So that’s something that I just, like to share kind of the range of what people can do with different, substances.

HP1 refers to this as a “gradient” and described:

Some things have been, seen as more socially acceptable, especially when they’re, done by, people who, do have more, I think power in, society or [pause] yeah. Or just seen as more, respectable. It’s, it’s different. I think that glass of wine versus, you know, perceptions of someone who may be, you know, on the street, and having a glass of wine.

Neither student spoke about substance use disorders, though this form of substance use was a predominant focus of the health professionals. Students were more likely to speak of social misperceptions associated with illicit substance use, such as erroneous beliefs about the likelihood for an “insane experience,”“messing up” your mind, or not being able to function.

HP1 recalled an incident when a person at a coffee shop learned about where she worked and asked “how do you find working with those people.” She replied, “we’re all people and, you know, everybody, either, might’ve had or know someone who’s, had some kind of addiction whether it’s, you know, coffee or whether it’s, um, you know, cocaine or, you know, whatever drug it is. Like we all, almost all of us have something.”

Both HP1 and HP2 spoke about broad social factors related to addiction. HP1 focused on factors contributing to the onset of addiction:

I think a lot about like how do we change these circumstances and how do we, not have them happen in the first place that, someone who is, you know, who is, racialized or Indigenous or, living in poverty is at higher risk of, of addictions, if not, anything in here just because, of, things that, we have created in society that makes it, more likely.

HP2 noted that people identified to have a substance use disorder are held to higher expectations than others, such as emotional expressions: “I wonder, how, often, people have like, normal quote unquote, responses that might be- you know like a normal angry response or a normal sad response or normal, um, frustrated response, and because of this other piece of their identity [addiction], they’re judged in a m- in a more harsh way.” She went on, “do you always have to be on your best behavior because you’ve done something wrong or you- again I’m gonna, keep saying like, wrong is a, such a weird word but, It’s just a word that I’m, using in this context.” She concluded: “I think, being judged all the time would be really [pause] difficult.”

Another topic of “meshing” relates to framing interpretations of substance use. As mentioned, HP2 spoke favorably about substance use as a “social lubricant” and both students spoke about substances as increasing sociability and connectedness with others. Tables 6 and 7 provide a comprehensive list of descriptors that occurred throughout the interviews in relation to the substances discussed.

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Table 6.

Reported Experiences Associated With Substances (ST1 and ST2).

Substance	Experience
Cannabis	Decompression, routine, reward, turn off brain, “just another thing that people do,” increasingly normalized, wind down, unifying experience with friends, chill night, close friends, not as loud, less upbeat/energetic, not go out to a bar, red eyes, dry mouth
Caesars	Social, fun drink, special event/ceremonious/occasion, refreshing, not associated with intoxication, light/bubbly/tipsy, “treat”
Acid	Strong and capable, enhanced visuals, feel “on top of the world,” feel closer together with partner, adventure, pride, unique experience, upgrade experience, happy, need to dedicate a day to higher dose, enhanced experience, bubbly, talkative, social, not the same side effects as weed, all encompassing
Alcohol	Reduce impact of social anxiety, easier to talk to people, have more fun, laughing, being silly, relieve anxiety, chill out, not overthinking, stops brain from being messy, fewer thoughts/worries/cares/fears, let loose, relax, talk to people more, open mind, be social, calm nerves, not stress, calm nerves, more energy, lose coordination, embarrassing self
Psychedelics	Augment reality, happy, airy, calming, happiness, emotional, visual effects

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Table 7.

Reported Experiences Associated With Substances (HP2).

Substance	Experience
Methadone	incredibly helpful, better alterative despite side effects, offers stability, less drug seeking, enhance health and wellbeing, safer administration, social/family connection, enhance stability/stabilize, time availability, reduce cravings
Antidepressants/anti-anxiety medication	“help” not “fix”
Illicit	“looking to escape something painful”

Health professionals also discussed the potential for social factors to influence substance, using terms like “fitting in,” and “peers using.” HP1 described a client whose use was enhancing: “maybe [substances] helped him to, to fit in with other, others who were doing the same thing so, just kinda being part of the, the group…that’s, often why people, use any substance. It’s cause their peers are doing it. They’re, part of a group…”

Among the students, reference to substances in social contexts told stories of positive social connections through shared experiences of substance use and effects that contributed to increased sociability. Among health professionals, with a lens toward addiction, these stories shift to ones of risk and undue external influences.

Parallel to this, ST2 spoke positively of “alcohol’s ability to relieve my anxiety for, a good evening with all sorts of friends.” She explained,

it’s just kind of, makes me [pause] feel, um [pause] like more chill I guess. I don’t really, um, overthink things. It stops my brain from, like, being too, um, messy […] I just don’t have as many like thoughts going through my head. I don’t really have worries or cares or fears or anything […] it just, kind of, helps you let loose and feel more relaxed and able to, talk to people more and just, have, like, a more of an open mind and just be more social.

Among health providers, this might be viewed as self-medicating. HPs were more likely to frame these types of instances as indicative of problematic use: “It’s like a coping strategy right? We all do what we can to cope. But I- I don’t know. I’m like, in the, in the, in the, place of hoping, that there are better coping strategies. But maybe I’m just naïve” (HP2). HP2 noted desirable alternatives to substances to address underlying factors, such as cognitive behavioral therapy, interpersonal therapy, or dialectic behavioral therapy that are not funded as readily through health plans as pharmaceuticals.

This is not to suggest that either students or health providers hold polarized views about substance use and effects, but within the context of the interviews certain perspectives were more prominently expressed. Despite being asked a generic question about the way in which “substances enhance or impede the health and well-being of your patients/clients,” health providers predominantly spoke about the ways in which substances impeded health, likely reflecting instances when substances use is addressed within their scope of practice.

Discussion

This study confirmed to utility of our methodology to explore how perspectives of one group mesh or fail to mesh with perspectives of the other group. When instructed to submit and describe photos depicting how substances enhance or impede health and well-being, all participant stories conveyed an overarching positive message about the person/people captured or represented through the photo. To some extent, this “meshing” of narratives might relate to the nature of photo elicitation methodology. It has been observed in previous studies that some aspects of people’s live may be less amenable to photographic visualization, such as aspects of a person’s life that are viewed as less positive or that represent emotional, less tangible, and/or sensitive topics that may require verbal elaboration (Padgett et al., 2013; Sestito et al., 2017). As noted by Padgett et al. (2013) photo elicitation methods involve “portraying participants’ lives as they want them presented—both visually and verbally” (p. 1442). Positive representations of self through photos is a practice increasing commonplace in contemporary daily life through maintenance of social media platforms. Between 2010 and 2016, over 20 billion images had been shared via the Instagram mobile App alone (Zappavigna, 2016). Personal media profiles are “carefully curated” to showcase features such as personal expertise and to enhance “likeability” (Richey et al., 2018, p. 426) with an awareness that viewers form judgments about the person’s character and capabilities (Richey et al., 2018). As such, probing questions may be incorporated to explicitly draw out stories that may be viewed as less positive by the participant.

Another instance of “meshing” relates to the observation that all participants confronted dominant social perspectives, offering alternative interpretations and challenging such opinions as incomplete or erroneous. There were differences, with health providers more explicitly integrating critical discussions of contextual factors that influence problematic experiences associated substance use and social judgments about substance use disorders. Health professionals also challenged social constructions of pharmaceuticals as inherently positive and spoke about therapeutic limitations.

There were also instances when perspectives between the two groups diverged. When asked to talk about the place of substances in their clients’ lives, health providers tended to talk about people who have experienced difficulties related to substances and, to a lesser extent, the expectations people have about the purpose and effectiveness of pharmaceuticals. Experiences and perspectives shared by the students were minimally reflected in how health providers framed substance use and vice versa. It may be that health providers are less aware of client substance use that is not, in some way, causing reason for concern. The scope of practice of the health professional would also influence what aspects of client experience most readily come to mind. This is not to say that the health providers were unaware of potentially non-problematic or beneficial use or students were unaware of potential experiences of problematic use. One might assume that if health providers were talking about their own use of substances, the framing may include descriptions of rational choices and control (Kiepek & Beagan, 2018; Kiepek et al., 2018) and students frame stories of others to include the potential for substance use disorders. To elicit these nuanced understandings, probing questions may be refined to more explicitly elicit stories of self and stories of others. Such divergence in perspectives is a desired outcome of this type of study. It was not our intent to formulate consensus about perspective of substance use. Quite the contrary, the intent is to give voice to a myriad of personal and disciplinary perspectives to bridge understanding across diverse experiences and perspectives and to challenge assumptions and potentially over-simplified representations.

Substance use research, policy, and practice is critiqued as being predicated on assumptions of individual risk and social harm, prioritizing attention to risk, pathology, and prevention (Bacchi, 2016; Kiepek, Van de Ven et al., 2019). Neglecting to include more diverse experiences of substance use “overlooks, and effectively silences, potentially beneficial and non-problematic substance use which poses little or no risk to the individual or others and does not reflect diverse motives for or experiences of substance use” (Kiepek, Van de Ven et al., 2019, p. 59). Our findings may have implications for informing health professional education by incorporating diverse perspectives, experiences, and interpretations of substance use. Such nuanced understandings may contribute to destigmatising practices and mitigate Othering people who hold different beliefs and engage in substance use in ways that differ from ones’ self (Seear, 2020; Tam, 2019; van Boekel et al., 2015).

In Canada, there are increasingly calls for de-criminalizing possession of small amounts of drugs and drug use [i.e., Canadian Association of Chiefs of Police (Zimonjic, 2020); Nova Scotia police chiefs (Cooke, 2020); Canadian Public Health Medical Officer (Mangat, 2020); Vancouver City Council (Councillor Swanson, 2020); Toronto Medical Officer (Casey, 2018)], with the introduction of Bills C-22 and, more recently, C-216. As such, more research is required that comprehensively examines diversity of experiences including beneficial use, non-problematic use, problematic use, and substance use disorders (First Nations Health Authority, Province of British Columbia, & Government of Canada, 2013) from the perspectives groups with diverse interests, including citizens, health professionals, law enforcement professionals, and public service employees.