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Part 1
What is the Promise of Transdisciplinarity?
This section addresses some key questions affecting transformation in addictions research and treatment. Why do we need a new approach? Why are transdisciplinarity, the integration of issues such as trauma and mental health, and the inclusion of sex and gender in research and treatment, necessary? How will including these ideas assist in elevating our understanding of addiction and substance use and improve our responses? What does transdisciplinarity promise?
The introductory chapter covers the general approaches that have been proffered over the years to explain addiction and to frame societal responses to addiction. These vary widely, from punitive, legalistic approaches to public health and, harm-reduction approaches, and drawing on medicine, psychology, law, usersā views and lots in between. This variance is emblematic of the wide set of opinions, voices of dissent and the mix of rational and emotional positioning on this vexing and volatile issue.
The rest of this section demonstrates the value and promise of improving our approach. Boyle and colleagues reflect on creating and managing a training program aimed at fostering a community of scholars and clinicians in taking a transdisciplinary approach. Such organized attempts to bring very different disciplines and research projects together may be the route to encouraging transdisciplinarity in education and training. As a key example of current thinking, Poole reflects on various discipline-based interpretations of the concept of trauma, noting their vast differences. She then offers two examples, one on womenās service provision and one on Indigenous approaches to trauma, that offer insight into how trauma can be integrated into practice, indicating a way forward.
Weinberg and colleagues reveal how introducing sex (and gender) into rat-based laboratory work on fetal alcohol syndrome disorder contributes brand new knowledge to the field and uncovers huge gaps in biomedical science. The idea of introducing a range of disciplines and a sex-based framework in animal research is long overdue, but this chapter shows its huge promise for improving science. Finally, in an interview with the editors, Hall discusses Two-Eyed Seeing, the idea of weaving together the insights of Indigenous and Western ways of knowing. She marks its potential for widening the understanding of addictions and contributing to transdisciplinarity in research, training and treatment.
Taken together, these seemingly disparate chapters reveal a range of attempts to make sense of, and improve upon, the current state of addiction research and treatment. They all add to the argument that transdisciplinarity mattersāthat it requires training and skill development, an open mind and the courage to innovateāeven in discipline-based environments and varied cultural contexts. Most of all, they show the promise of transdisciplinarity in a range of contexts, from various points of view.
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1
Cracking the Problem of Addiction with a Transformative Approach
Lorraine Greaves, Nancy Poole and Ellexis Boyle
Addiction is a complicated, expensive, painful and sometimes tragic social problem. In the interests of seeking pleasure, altering consciousness or submersing pain, people can develop addictions to a range of substances and behaviors, often, but not always, to the point of interference with daily life, long-term aspirations and social, family and work relationships. Societies pay the burden in lost lives, productivity, crime, social and health costs.
Over the centuries, many explanations have been offered to make sense of addiction. Varied responses have been made to people with addiction, in societal reactions to addiction and in regulating the sources of various addictive substances. These have included medical, moral, legal, social, economic, cultural and religious perspectives, theories and frameworks. More contemporary responses include public-health and harm-reduction approaches, reducing the blame and shame historically applied to those with addictions, and rethinking policy, legal and justice responses to the sale and distribution of substances. But even these more contemporary approaches remain built on an historical bedrock of legal, medical and moral perspectives that are often hard to ignore.
This book is about addiction: Its vexing complexity and its hard-to-solve and hard-to-remediate effects. It is also about failure: failure of any one type of response to treating addiction or controlling addictive substances; failure to bring scientific evidence to practice in a timely fashion; failure to think about addiction and act on addiction in a consistently humane manner, free of stigma and blame; and failure to think broadly and to listen to all sectors and perspectives. This book addresses those failures with a view to transformation. In addressing failure of any kind, options can be reduced and choices narrowed, but the process can open up our thinking to more intriguing insights and higher level solutions. While this book will not solve the problem of addiction, it explores the viability of transforming our approach to addiction in research and treatment and policy, by unambiguously and consciously doing things differently.
Specifically, we advocate for taking a transdisciplinary approach in addiction treatment, research and policy. This means that all disciplinary perspectives are actively sought, welcomed and valued and a there is a conscious and shared decision to transcend, or rise above any one perspective or discipline. The effect of taking a transdisciplinary approach is not merely a melding of perspectives but the encouragement of a conscious aspiration among researchers and treatment providers to contribute to the growth of a new, transformed perspective that reflects a range of different knowledge and contributions, experiences and successes. For example, responding to alcohol overuse with knowledge derived from biomedical or clinical research alone is important, but melding such with social, cultural, psychological and legal perspectives is essential. This approach will foster the growing of a more informed and broader understanding. Indeed, all forms of scientific research are critical, but melding those with the voices of those affected, their helpers and families and program and policy developers expands the discourse to a more meaningful level.
Second, we advocate for an integrated response to addiction. This means that we pay heed to the linked issues often underlying or co-occurring with addiction, such as trauma and violence, mental health and multi-substance use. Many individuals with addiction are experiencing one or more of these issues, either in their past or present. These are some of the key reasons that addiction is so vexing, as the short-term pleasures, gratifications or escapes associated with addiction are often interwoven and knotted up with a range of other serious issues, making singular treatment or policy responses insufficient, and in some cases irrelevant. These links between adverse child experiences, addiction and trauma, violence and mental health issues are not just correlative curiosities, but rather they indicate systemic interactions that either underlie or manifest in peoplesā bodies and brains, and make addiction such a tenacious phenomenon. The preponderance of these linkages, mixed with short-term rewards, often make addiction an ongoing and sticky social problem as well, defying neat solutions, prescriptions or treatments. It also means that an integrated approach to treatment and policy is crucial, one that engages multiple voices and sectors, to bring forward action on addiction.
Finally, we advocate taking sex and gender into account. Integrating sex and gender into research, programming or policy means better science, practice and public policy. This is a simple concept, and one that is finally gaining critical acceptance in several areas of health research and practice. Both of these factors are important to addiction research and treatment. Key changes in research practices, analysis, writing and reporting could illuminate the effects of sex (biological) related factors on addictive processes, and on treatment options and trajectories. Equally important, assessing gender-related factors (social and cultural), taking into account gender identity, gender relations, power structures and their concomitant limitations and expectations could illuminate the effects of gender on addiction onset and treatment. Together, these approaches take into account the biology of addiction, and the powerful forces affecting becoming and remaining addicted, as well as the gendered social aspects of addiction that are as important in becoming and remaining addicted, or seeking treatment.
These three components, transdisciplinarity, integration and taking sex and gender into account, form the backbone of this book. All of the chapters address these issues somehow, and delve into different substances, populations, issues, problems or approaches. However, shifting from unidisciplinary, gender-blind, non-integrated responses to addiction to these more complex approaches does not come easy. There is little structural support for broad transdisciplinarity in research training, or indeed in higher education or in health care systems. Some multi-and interdisciplinary approaches have been encouraged, but actively seeking to reach a new, common understanding of addiction is rarely aspired to. Further, seeking integrated solutions make sense from an individual clientās perspective, and often can lead to increased interagency or interdepartmental or ministry policy development. However, creating the space for integrated solutions is typically avoided. And while integrating sex and gender into research, treatment and policy is increasingly required by funders, much addictions research and treatment still ignores these factors.
This book will demonstrate a range of efforts to try to bring these threads together. It explicitly describes training and knowledge transfer, along with research, policy and practice, in order to bring the meaning of transdisciplinarity, gender and integration to life. In discovering the essence of transdisciplinarity in relation to addiction, and explicitly recognizing real-life factors such as trauma and violence and the crucial contributions of sex and gender to better science, it is hoped that our collective understanding and response to addiction and those who experience addiction is improved, and our motivation to work across sectors and disciplines increased.
What Does Addiction Mean?
Addiction has been variously defined over the years, and the word is used in different ways by different players (Alexander 2008). These differences often reflect position, location or discipline, but also evolve in cultural contexts over time. Often, uses of the word addiction reflect prior beliefs, training or value positions. While often focused on the overuse of alcohol, tobacco and drugs to the point of dependence, there are increasing numbers of behaviors that get labeled as addictive such as sex, eating and gambling, stretching the boundaries of meaning of the term. Schaef (1987, p.19) usefully distinguishes between substance addictions (where ingestion occurs) and process addictions (such as accumulating money, workaholism, worry). But, according to Alexander (Alexander 2008, pp. 41ā42), the use of the term addiction can be exploited, taking away from the essential meaning of addiction as a practice or phenomenon that is destructive to individuals and societies.
What Understandings of Addiction Have Been Proffered?
There are some entrenched explanatory views of addiction that present themselves as threads in our social discourse and shape our collective and individual understandings (Schaef and Fassel 1988). Historically, addiction has been viewed through a moral lens, invoking issues of weakness or depravity, or in other cases a religious lens, invoking issues of evil, sin or sloth. In these frameworks, people with addiction and mental health issues have suffered through the imposition of stigma, isolation and in some cases, punishment, incarceration or sterilization. Both addiction and mental illnesses have been associated with weak characters and moral depravity, and often associated violence and poverty have exacerbated these views. These perspectives rarely led to humane and treatment-oriented responses.
These historical attitudes have supported a legal framework surrounding the issue of addiction that has often largely focused on demand for, and control of, addictive substances. It highlights damage done to society and individuals but also aims to control addiction, by curtailing or limiting access to drugs, alcohol, tobacco or other substances and opportunities, such as gambling. In addition, there have been evolving legal and judicial responses to those who use addictive substances and exhibit negative behaviors such as violence, drunk driving, public intoxication, illegal sales or selling to minors. Such regimes have varied in their punitiveness or liberalness, and are, like any norms, subject to change over time. Depending on social values and cultural context, responses, legal or otherwise, vary in their coerciveness and severity.
A more recent framework is the disease model, first proposed by Jellinek (1960) rendering addiction as an illness, requiring treatment, or, in some cases, a medical response. From this perspective, addiction is commonly perceived as a disease that overtakes an individual: a viewpoint put forth by organizations such as Alcoholics Anonymous and its various offshoots. Many addictions professionals also use this approach and see the disease of addiction as chronic and persistent, rendering an individual āsickā and in need of continuing care in hospitals, clinics, treatment centers and doctorās offices. This view of addiction is not benign, having significant effects on health systems, social perceptions of addictions and on people with substance use issues. It places addiction firmly in the category of illnesses, albeit one still very stigmatized. More fundamentally, it suggests that addiction controls individualsā behaviors and actions, often requiring a blend of treatment, containment and sometimes separation or seclusion. The disease model of addiction engages medicine, psychiatry, psychology, nursing, and social work. It places addiction as an inhabitant of the personās genes, brains or body. It implies that addiction needs to be controlled, often by controlling the individual, especially when the disease is out of control and behaviors appear to be dysfunctional.
There are those who reject these approaches, preferring to suggest that the disease model is ultimately disempowering (Peele 1987), as it ignores the impact of social and cultural values and influences and the impact of values on individual choices. This perspective also references those who are not addicted, despite having similar circumstances, or those (some say the majority) of people with addiction problems who successfully recover without intervention, or āon their own.ā Peele suggests that processes of addiction and the myriad of circumstances, value positions and choices that go into the development of addiction can also be key to recovery, in that individuals can reflect on these elements in self directed recovery processes, preferably in a context of harm reduction and empowerment (The Fix 2011). In this way, his position implicates individual, cultural and social differences in values as critically important in making decisions about substance use and recovery, among other addictive behaviors.
Though perspectives inevitably shift and change, threads of these approaches persist in assumptions and stereotypes about addiction and those challenged by it. It is not unusual for individuals with addiction to be met with anger, frustration, stigma and shunning, with assumptions about strength of āwill,ā and weakness of personality still prevalent in general discourse and social response. While these attitudes are being addressed and challenged in contemporary society, and direct attempts being made to destigmatize addiction (and mental illness) residuals of these attitudes still emerge in casual conversation and media coverage.
Contemporary Thinking on Addiction
There are numerous contemporary approaches to explaining addiction that build on these general approaches, illustrating the complexities and contradictions of addiction and, in some cases, our responses to addiction. For example, Bickel and Potenza (2006) suggest that addiction is a multicomponent phenomenon that has its roots in evolutionary principles. They suggest that evolutionary-old portions of the brain are implicated in addiction: areas that reinforce food, sex, drink and social interaction (2006, p. 10) and that more recently evolved areas of the brain, such as the frontal cortical regions, are less implicated. In this sense, addiction can be understood as adaptive and survival-oriented. This perspective is a useful addition to our understanding, in that it identifies deep roots to current behavior, and signals some adaptive qualities to addiction. The notion of adaptation is pertinent, as substance use or other forms of addictive behavior...
