Defining Addiction

Unit introduction
Defining Addiction
Transdisciplinarity
Summary & suggested Reading
Unit References

1. Unit Introduction

This unit provides an overview of definitions of addiction and various disciplinary approaches used to study addiction: medical/disease, neurobiological, social and psychological perspectives.

This unit also introduces the concept of transdisciplinarity as a way of collaborating across different disciplines, areas, and sectors.

Using examples, this unit demonstrates how transdisciplinary collaboration can combine knowledge from a range of perspectives to generate new and more nuanced understandings of addiction, and thus better approaches to treatment, service design and public health policy.

2. Defining Addiction

The term addiction has been around for centuries and has been used in many different ways. Variations in how addiction has been defined reflect diverse disciplines, professions, as well as historical and cultural contexts.

Addiction is a complex and multi-faceted phenomenon, making it difficult to arrive at a single, common definition. Addiction can be understood in terms of biological predispositions and consequences, psychological processes, medical models and outcomes, sociocultural and/or spiritual influences. What is more, many terms are used with addiction, including substance misuse and abuse, as well as harmful or hazardous use. Some researchers and clinicians extend the label of addiction to include behaviours, such as sex, eating, and gambling (Greaves, Poole, & Boyle, 2015).

Addiction is sometimes used in the singular form, referring to an overarching tendency toward compulsive behaviours, but can also be used in the plural to represent different ‘types’ of addiction independently (i.e., alcohol, gambling, smoking, sex, etc.). Addiction can be viewed as a social problem, both in terms of its antecedents and its effects on society at large. Conversely, addiction can be conceptualized as a disease state, or a disorder rooted in the pharmacological effects of the given drug. Alternative theories frame addiction as a psychosocial adaptive response to adversity or isolation, where no alternative coping mechanisms are accessible (Alexander, 1990).

In the World Health Organization’s (WHO) Lexicon of Alcohol and Drug Terms (1994), addiction is defined as repeated harmful use of a psychoactive substance(s), to the extent that the user is

periodically or chronically intoxicated,
demonstrates compulsive use of the substance,
has great difficulty in voluntarily ceasing or modifying substance use,
will obtain the given substance(s) by almost any means.

Aspects of this WHO definition have been challenged by those who study substance use. For example, the criterion of “intoxication” would seem to exclude from this definition the chronic use of and dependence on substances like nicotine or caffeine.

More recently, the WHO refers to substance abuse as the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. According to this definition, use of psychoactive substances can lead to a dependence syndrome, which consists of:

a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use,
a strong desire to take the drug,
difficulties in controlling its use and persistent use despite harmful consequences,
a higher priority given to drug use than to other activities and obligations,
increased tolerance, and sometimes a physical withdrawal state.

The diagnostic manual of North American clinical professionals (e.g., clinical psychologists, psychiatrists), the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), categorizes substance use disorders along a continuum, ranging in severity from mild to severe, depending on the number of criterion symptoms that individuals experience as a result of their substance use.

Diagnostic symptoms include loss of control, craving, and interference with daily life activities, continued use despite harm, tolerance, and withdrawal. Gambling is also recognized as a form of addiction in the DSM-5, and represents the sole condition in the section on behavioral addictions. See DSM-5 Substance-Related and Addictive Disorders

However, some warn against overusing the term addiction to encompass behavioral problems, out of fear of pathologizing normal behaviors or diverting attention away from debilitating forms of addiction. In the following slides, we will define addictions from multiple perspectives (i.e., neurobiological, disease, psychological, social), considering the contributions and limitations of each.

Watch this TED talk by Johann Hari: Everything you think you know about addiction is wrong

2.1 Disease or medical perspectives

Disease or medical models of addiction view addiction as an illness, requiring treatment or medical intervention. More specifically, this perspective sees addiction as a chronic, relapsing disease, requiring continued care in hospitals, clinics, and other treatment facilities. Contrary to moralistic views, which identify persons with addictions as bad or deviant, medical perspectives view these individuals as patients with a chronic illness. This approach to understanding and treating addiction engages medical professionals, including doctors, psychiatrists, psychologists, nurses, and social workers. Proponents of this perspective believe there are effective acute and long-term therapeutic interventions for addiction, just as there are for conditions like asthma, hypertension, and diabetes mellitus (Chez et al., 2001).

Advocates for the disease model of addiction suggest that addiction is, first and foremost, a health issue, as substance use can have significant health consequences. For instance, links between cigarette smoking and certain forms of cancer, heart and lung disease are well established, as are links between chronic alcohol use and liver cirrhosis and cancer. As another example, injection drug use can act as a vehicle for transmitting infections, such as HIV and hepatitis C. Moreover, comorbid substance use and mental health disorders occur at high prevalence rates. This co-occurrence of different forms of addiction and mental and physical health outcomes lends support to viewing addiction as a medical or public health problem (Jellinek, 1960; Leshner, 1997; National Library of Medicine).

Examples of research topics from a disease perspective include:

Clinical trials evaluating novel pharmacological treatments for substance dependence
Evaluating treatment efficacy of existing pharmacological and behavioural interventions
Understanding disease aetiology, with a focus on biological and health behaviour variables
Identifying genetic and non-genetic susceptibility factors
Evaluating, validating, and refining diagnostic tools (both objective and self-report)

Contributions: The disease or medical view offers that addiction is a problem that can be managed by behavioural or pharmacological means, in the same way that high blood pressure or diabetes is treated. Framing addiction as a disease may also serve to reduce blame, and increase compassion toward individuals with addiction problems.

Limitations: . Since this approach necessarily emphasizes biology, genetics, and individual level health behaviors, it largely ignores social and cultural influences that may confer vulnerability for (or protection against) addiction. See Greaves et al. (2015) and Peele (1987).

2.2 Neurobiological Perspectives

From a neurobiological standpoint, addiction can be seen as a chronic brain disorder, characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disorder because drugs change the brain – in terms of structure, physiology, and function. Although separate classes of drugs have unique mechanisms of action, certain neural changes appear to occur for all forms of substance addiction. In particular, addiction-related changes have been localized to the mesolimbic reward system, and the prefrontal cortex (i.e., the seat of self-control). These changes are long-lasting, and are associated with increased impulsivity and drug wanting, accompanied by a reduced interest in natural rewards.

At its core, the neurobiological model of addiction focuses on incentive, motivation and how addictive substances hijack the brain’s natural reward circuit. For instance, there is evidence that the dopaminergic reward system is implicated in experiencing pleasure, pursuing incentives, and avoiding aversion. Each of these functions has obvious roles in the development and maintenance of substance use and addictive behaviours. Beyond the dopamine reward system, neurobiological research also indicates that systems underlying stress responses (i.e., the hypothalamic–pituitary–adrenal axis) and higher order cognitive processes (i.e., the prefrontal cortex) play important roles in compulsive substance use, and in relapse following quit attempts. See Koob and Le Moal (2001) and Lyvers (2000).

Examples of research topics from a neurobiological perspective include:

Identifying unique neural mechanisms of psychoactive drugs
Investigating common neural pathways activated by substances (as well as addictive behaviors)
Examining the neural basis of incentive motivation, withdrawal, and learned conditioning
Documenting physiological event-cascades following drug-receptor binding
Pinpointing neural underpinnings responsible for the switch from voluntary to compulsive substance use

Contributions: Work in the field of neurobiology has provided insight into the mechanisms underlying the progression from initiation of substance use to compulsive use. Defining addiction as a neurobiological process also contributes to removing moral stigma from substance misuse.

Limitations: Some question whether this approach is unhelpful in its focus on the neurobiological mechanism of the substance over the agency of the individual. Others question why it is that not everyone who tries drugs with addictive potential becomes addicted to them, and how resilience comes into play. See Kelley & Berridge (2002) and National Institute on Drug Abuse (2007).

2.3 Psychological Perspectives

The psychological view of addiction focuses on neglect of the self and self-destructive behaviour in the individual. Theories of addiction from a psychological lens are diverse, however they generally reference cognitive, emotional and/or behavioural processes that lead to compulsive substance use. Dual process psychological approaches take into account explicit cognitions (deliberate cognitive processes, such as beliefs about the tension-relieving effects of a substance) and implicit cognitions (automatic cognitive processes, such as heightened attention towards substance-related cues) in explaining compulsive substance misuse. Learning theories (e.g., classical conditioning, operant conditioning, social learning theory) help to set up the context in which addiction and related cognitions are shaped (Siegel, 1983; Stacy & Weirs, 2010; Bandura, 1977).

Psychological definitions of addiction emphasize a continued pattern of substance use despite significant consequences that are a result of problematic use. The Diagnostic and Statistical Manual (5^th edition) states that… the essential feature of a substance use disorder is a cluster of cognitive, behavioural and physiological symptoms including that the individual continues using the substance despite significant substance-related problems (American Psychiatric Association, 2013). The DSM-V acknowledges that addictions may manifest as substance misuse as well as behaviours (e.g., gambling).

Examples of research topics from a psychological perspective include:

Investigation of how personality variables are related to substance misuse (e.g., negative affectivity, impulsivity)
Individual difference factors (e.g., motivations for use, expectations of the outcome of use) and how they relate to substance use and misuse
How explicit (i.e., deliberate) and implicit (i.e., automatic) cognitive processes interact to predict use and misuse (i.e., dual process models)
Treatment approaches and their efficacy (e.g., substance cue exposure, distress tolerance, enhancing non-substance coping strategies, interpersonal effectiveness)

Contributions:

The psychological perspective has aided in the understanding of key processes and motivations underlying substance misuse and addiction. For example using substances as self-medication is identified as an important feature of the development of addictive disorders (Cox & Klinger, 1988). The psychological perspective on addiction, and related research, provide a framework to involve and support individuals in recovery by targeting both explicit cognitions (e.g., beliefs that substance use will relieve negative emotions) and implicit processes (e.g., heightened attention and reaction to substance related cues).

Limitations:

While psychological theories help us to understand how addiction may develop in individuals, they often ignore the broader social context in which addiction occurs. The individual is often labeled with a mental illness or a substance use disorder and expected to overcome social forces to manifest change. Without parallel change in the individual’s social environment, efforts to manifest change may be hindered.

2.4. Social Perspectives

While substance use is practiced by individuals, the nature of our use of alcohol, tobacco, and illicit drugs is also closely tied to social rituals, cultural and policy contexts and to social positioning or status. The sociological perspective on drug use considers how the social context of substance use influences why people use drugs and how society should respond and treat problems related to various addictive drugs or substances.

Social theory is concerned with how social life is organized, reproduced and sometimes transformed. Social theory shifts the focus from the individual to how broader cultural and structural forces shape our lives. Social theorists typically study both micro- (individual or interpersonal) and macro- (structural or group-level) social interactions, groups and contexts in order to theorize the nature of society and social life (Adrian, 2003). Applying a sociological lens to the study of substance use issues provides a means to navigate the complex and often intersecting social, criminal, legal, political, and health issues connected to addictions.

Examples of research topics from a sociological perspective include:

Examining the socio-cultural construction of drugs and addiction over time (e.g., changes in how certain substances are viewed over time)
Societal and regulatory responses to substance use and addictions (e.g., policy responses, such as the War on Drugs)
Understanding the social locations and contexts of persons with addictions issues (e.g., socioeconomic status, gender, stigmatization, criminalization, discrimination)
Understanding the meanings and embodied experiences of people experiencing addictions issues (e.g., balancing pleasures and risks)

Analysis of media representations of substance use

Contributions: In a field of study that has been largely dominated by psychological and biomedical perspectives, sociological theory and research methods provide the tools to document, deconstruct and challenge the social etiology of substance use; to move past one-dimensional anti-drug rhetoric or laws, and to understand the roles played by pleasure, intoxication, ritual and risk in shaping drug use practices. The sociological approach thus provides a framework to address the root social causes of substance misuse and challenges us to consider the role of social structures, gender, economics, power and marginalization in producing substance use problems rather than simply focusing on individuals and their behaviour. Sociological approaches can offer rich data to inform policy making, practice and education regarding addiction and substance use.

Limitations:

The social approach, in isolation, does not include genetic, biological and individual-difference factors in substance misuse and addiction. Therefore, it may ignore the issues of genetic predisposition that raise the chances of becoming addicted, or individual differences in resilience and how they may be compromised by nonsocial factors.

2.5 Bio-psycho-social model

While each of the aforementioned perspectives contributes something crucial to our understanding of how addictions emerge within a society and within an individual, in isolation, each misses providing the whole picture. First articulated by George Engel in 1977, the biopsychosocial model is a reaction to reductive and undisciplinary perspectives, recognizing how suffering and illness are affected by the interplay of biological, psychological, and social factors. Some treatment providers and communities also consider spirituality as part of a holistic model of health and wellness. Applied to addiction, the biopsychosocial approach attempts to combine biological, psychological, and social processes, and their interactions – making some room for a more comprehensive understanding of addiction. For example, biological and psychological traits may interact with social circumstances such as poverty or gender to increase vulnerability for substance use and abuse. Any combination of factors may act as predisposing influences, and risk factors within one domain can shape predictive antecedents within other domains. As an example, stress (i.e., psychological and social factors) can alter gene expression in brain reward regions involved in addiction (i.e., biological factors). This interaction between genes and environment is referred to as epigenetics. The biopsychosocial approach also views the consequences of addiction in terms of biological, psychological, and social outcomes.

Biopsychosocial model of heroin addiction

Figure1_BPSS

Buchman, D. Z., Skinner, W., & Illes, J. (2010). Negotiating the Relationship Between Addiction, Ethics, and Brain Science. AJOB Neuroscience, 1(1), 36–45.

Figure reprinted with copyright permission of the American Journal of Bioethics: Neuroscience and with permission from the authors.

Examples of research topics from a biopsychosocial perspective include:

Investigation of the biological, personal, social and learning experiences influencing disposition to addiction
investigation of the social and neurobiological influences on predisposition to trauma, mental health issues and addiction
mixed-methods study of chronic pain that examines the biological effects of pain on the central nervous system together with individuals’ subjective experiences of pain.

Contributions:

The main strength and limitation of the biopsychosocial approach are one and the same: attempting to understand addiction in all of its complexity is complex. The biopsychosocial approach unapologetically pushes the researcher or knowledge user to reach for a richer, more holistic and humane understanding of addictive processes. Ultimately, this model contextualizes substance misuse in its multiple contexts and directs all members of a society to question how they contribute to addiction.

Limitations:

While many agree that this approach has strengths as a framework, its application is limited in that it does not ensure that all aspects- biological, psychological, social, spiritual are integrated in research or that each are given appropriate representation and weight.

3. Transdisciplinarity

“Finding solutions to complex health problems, such as obesity, violence, and climate change, will require radical changes in cross-disciplinary education, research, and practice. The fundamental determinants of health include many interrelated factors such as poverty, culture, education, environment, and government policies”

Neuhauser, L., Richardson, D., Mackenzie, S., & Minkler, M. (2007).

Addiction is a complex health problem with multiple dimensions including biological, psychological, social, economic and political influences. While many lenses, disciplines and sectors are applied to research and treatment of addiction, and make their own contributions, rarely do they converse or collaborate to create shared and more nuanced approaches to research and treatment.

3.1 What is Transdisciplinarity?

Transdisciplinarity involves “blurring boundaries” between disciplines and the synthesis of a new epistemology– new conceptual and theoretical frameworks, and new methodological approaches that ultimately yield a deeper understanding of the problem being studied “as a complex dynamic system” (Kessel & Rosenfield, 2008, p. S228).

How is transdisciplinarity different from other approaches?

Mono or uni-disciplinarity occurs when theories and methods from a single field are applied to a problem. This type involves no collaboration
Multidisciplinarity refers to when different disciplines work on a common problem but do so separate from one another. Their results are reported separately and there is typically no sharing or integration of perspectives
Interdisciplinarity indicates when individuals from two or more disciplines integrate their methods and theories to study a common problem. Yet this process is often hierarchical where one discipline frames and leads the research.
Transdisciplinarity goes further than those described above where multiple individuals representing different disciplines and or sectors work together to share perspectives, develop a common language and a shared approach to a problem. It is the most integrated type of collaboration because individuals with different views and perspectives are required to learn about each other’s approaches and integrate their methods and theories to develop new solutions

Isolation ——————————- Some integration ————————Integration
(unidisciplinarity) (multi/interdisciplinarity) (transdisciplinarity)

Watch IMPART mentors Lorraine Greaves, Nancy Poole, Chris Richardson, Joanne Weinberg, Catherine Goldie and Christy Sutherland discussing transdisciplinary collaboration.

The blind men and the elephant: a parable for transdisciplinary collaboration

elephant

Broadly, the parable of the blind men and the elephant highlights how perspectives are subjective and limited and that one perspective cannot capture the whole. This is a helpful analogy for underscoring the limitations of disciplinary perspectives on addiction. For some, addiction is a disease or disorder of the brain while for others it is a malfunction of society or a result of trauma. Gulfs between disciplinary perspectives are further enhanced by their underlying ontology: what one believes about the nature of reality. Is addiction objective and measurable or is it subjective and immeasurable?

While the concept and practice of transdisciplinarity is not new, it is rarely utilized as we currently operate in a discipline-bound world. Given the separation and hierarchy among disciplines, sectors and services, there are many challenges to forming this type of collaboration. Some challenges include siloed practices of institutions hierarchical and competitive practices of funding, promotion and publishing, hierarchization of disciplines and what counts as evidence; experience of mentors to train students and surmounting disciplinary jargon to create a common language

Transdisciplinarity requires a “suspension of disbelief;” an openness to accepting other ways of knowing and understanding addiction than one’s own. As in the picture above, those examining the elephant must be willing to step back from their own perspectives on addiction and realize that there are multiple and valuable other ways to see the problem and in a more global way. Transdisciplinarity thus has the potential to harness the knowledge of diverse researchers, clinician, service providers and policy makers to produce more nuanced and effective approaches and treatments.

Honouring our Strengths: Indigenous Culture as Intervention in Addiction Treatment

This project examined the use of cultural interventions to support the wellness and healing of Indigenous people within the context of addictions treatment. Its key goal has been to develop a wellness instrument to measure the efficacy of culturally based addiction treatment services for Indigenous clients. The research team has involved a multi-disciplinary and sectoral group of quantitative and qualitative researchers, treatment providers, executive directors and Indigenous knowledge keepers. To frame all of these approaches while holding Indigenous culture at the center, the project used a “Two- Eyed Seeing” approach. This approach weaves together Indigenous and Western knowledge systems. This involves a careful and reflexive dance between these different (and internally diverse) knowledge systems in order to create the best, yet culturally rooted treatment approaches for Indigenous populations. As with all transdisciplinary approaches the challenges facing this project included the application of Western scientific approaches (and language) to addiction and measurement that have historically been colonizing for Indigenous people. The research team saw this as an ongoing process of evaluating tools, theories and methods of analysis to ensure their cultural relevance and integrity. Honouring our Strengths offers a promising model and products such as the Indigenous Wellness Framework, which can benefit Indigenous populations and addictions more generally as it integrates mind-body-heart and spirit within one framework.

3.2 Benefits of a transdisciplinary approach

Snow et al (2010) identify characteristics of transdisciplinary researchers based on the literature that include: “…inclusive thinking, broad-gauged, contextually oriented in their theorizing, methodologically eclectic, open-minded, respectful of divergent viewpoints, and adept at promoting good will and cross-disciplinary tolerance” (p.160)

Milestones for successful transdisciplinary collaboration include:

listening across the gulfs that separate disciplines,
learning the language and methods of other disciplines at sufficient depth for meaningful exchange of ideas,
developing a common language for conceptual translation among researchers
jointly developing new measures and methods, and
conducting research that reflects an integration that generates rich new hypotheses, perhaps resolves prior anomalies or counterintuitive results, and adds explanatory power (Abrams, 2006)

Watch IMPART director, Dr. Ellexis Boyle discuss the philosophy and practice of transdisciplinarity in research training.

3.3 Example of transdisciplinarity

A survey of literature on trauma/violence, sex/gender and substance use/addiction from a cross-pillar perspective.

As a deliberate exercise in transdisciplinary collaboration, a group of trainees in the Intersections of Mental Health Perspectives in Addictions Research Training program undertook a literature review on the following topic: the intersections of sex/gender, trauma, mental health and substance use. Their task was, in groups, to review the literature from within each of the Canadian Institute of Health Research’s key research ‘pillars’ (biomedical, clinical, population health and health services) and to integrate the findings from each.

Through deliberate sharing of findings from diverse perspectives, these IMPART trainees wished to a) illustrate how health research is strengthened by the inclusion of concepts of sex and gender by diverse disciplines/areas and b) highlight how transdisciplinary collaboration can generate new research questions and evidence-based practice and policies.

Biomedical perspective

The biomedical pillar team took into account the interplay of sex-related hormones, genetics and epigenetics, environment and development, and the biological actions of specific substances. The pillar often thought of as ‘reductionist’ was anything but. There are striking sex differences in the underlying neurobiological mechanisms of substance use and mental health disorders. In rodent models, fluctuation of sex hormones in the female impacts acquisition, maintenance and relapse of substance use, such that females tend to escalate their consumption of drugs more quickly and are more prone to relapse than males (Becker & Hu, 2008; Haseltine, 2000; Sofuoglu, Mitchell, & Kosten, 2004). Psychological trauma is arguably best modeled in the biomedical domain by examining the neurobiological systems that underlie stress responsivity. The hormones released by body and brain in response to stressors interact with sex hormones and with brain systems involved in addiction. Evidence suggests that women are more prone to long-term alterations in their stress systems, conferring increased vulnerability to adverse trauma-related health outcomes (MacMillan et al., 2001). The interplay between early environment, childhood or adult trauma, and alterations in stress and sex hormones is still remarkably understudied in biomedical research on mental health and substance use, but all available evidence points to the intersections of these factors as “a perfect storm” in neurobiological terms.

Clinical perspective

The clinical team recognized that the definition of trauma in their pillar is defined much more specifically (as post traumatic stress disorder) than in other fields of research. They found that gender is a key mediator of the experience of trauma and outcomes of treatment, and that substance use may be an important lens through which to investigate these processes. The majority of individuals in substance use treatment report having experienced a traumatic life event (e.g., Wasserman, Havassy, & Boles, 1997). Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized by the re-experiencing and avoidance of the trauma and increased arousal; these symptoms are longstanding and cause significant distress and impairment (American Psychiatric Association, 2000). Importantly, women are about twice as likely as men to develop PTSD; lifetime prevalence rates for men and women are 5% and 10.4%, respectively. Men and women with PTSD and substance use disorders differ: for example, women are more likely than men to report sexual assault and less likely to report physical assault (Cottler, Nishith, & Compton, 2001; Peirce, Kindbom, Waesche, Yuscavage, & Brooner, 2008; Wasserman, Havassy, & Boles, 1997). Compared to men, women are particularly likely to use substances other than alcohol and appear to use more avoidance and emotion-focused coping strategies (Langeland, van den Brink, & Draijer, 2005; Lipschitz, Grilo, Fehon, McGlashan, & Southwick, 2000; Matud, 2004; Ouimette, Ahrens, Moos, & Finney, 1998). Thus, compared to men, women may experience different forms of trauma and may develop more serious health consequences as a result of this trauma (including anxiety disorders and substance dependence).

Population Health perspective

A more typical health determinants approach might identify women as better off than men, in that men are 2 to 3 times more likely than women to have substance use problems (Grant et al., 2004). However, the experiences of subgroups can be masked by this simplistic approach. If we look at the use of substances in a population that has experienced severe forms of abuse and other traumatizing violence, the gender pattern may be quite different. Women who report serious childhood abuse are significantly more likely to report abusing prescription drugs, illegal drugs, tobacco and alcohol than women who did not report childhood abuse (Agrawal et al., 2005; Logan, Walker, Cole, & Leukefeld, 2002). Social support can be a buffer against interpersonal violence among impoverished women, but even this support does not protect women who use drugs or alcohol (Golinelli, Longshore, & Wenzel, 2008). General population data suggest that the gender “advantage” for women is disappearing: alcohol use is on the rise in young women, perhaps mirroring increased pressures and changing social roles inhabited by women (Poole & Dell, 2005). Identifying the characteristics that confer risk and resilience for women and men in varying situations is vital for the effective prevention of substance-related disorders and harms, and it appears that a gendered investigation of childhood trauma and interpersonal violence may be central to this process.

Health Services perspective

While research in the health services pillar has the potential to document the territory of marginalization, it could be said that the health services pillar itself is often “marginalized”. As such, the authors explicitly looked for health services research that captured the topics of trauma, resiliency, gender and substance use, and valued these findings with legitimacy alongside research on neurobiological alterations, clinical approaches to post-traumatic stress disorder, and the impact of early childhood adversity. Colleagues in the USA undertook groundbreaking health service/clinical research in the Women Co-occurring Disorders and Violence Study (WCDVS). The goals of this study were the generation and application of empirical knowledge about the development of an integrated service approach. This approach included an appropriate blend of services and interventions for the target populations of women (and their children) with co-occurring experience of trauma/violence, mental illness and substance use disorders. The results showed that women with these complex co-existing problems were able to reduce these problems when provided with integrated service models that were trauma-informed and financially accessible (Cocozza et al., 2005). Integrated counseling in a trauma-informed policy and service context was more effective than services as usual (Amaro, Chernoff, Brown, Arevalo, & Gatz, 2007). Complex collaboration including consumers, providers and system planners in all aspects of the policy, design, implementation and evaluation of services, improve the quality of the work (Markoff, Reed, Fallot, Elliott, & Bjelajac, 2005). Importantly, from a systems perspective, the costs of such integrated care were not higher (Domino et al., 2005). As this study showed, the integration and coordination of services informed by evidence from the other pillars of health research is central to addressing the interconnections of gender, trauma, mental health concerns and substance use.

Modelling a transdisciplinary perspective

Based on the integration of these four perspectives, the trainees came up with the following model to illustrate the complexity of the intersections of sex/gender, trauma, mental health and substance use as a whole and how this complexity might be understood and approached from a cross- pillar or transdisciplinary approach.

Health_findings

Figure 1. Key findings from a survey of the literature on trauma/violence, sex/gender and substance use/addiction from a four pillar perspective, a transdisciplinary project (unpublished) by Vittoz, N., Coghlan, M., Poole, N., Uban, K., Hellemans, K., Michelow, W., Rostam, H., Sliwowska, J., Snow, B., Greaves, L. 2009. Diagram inspired by Logan et al (2002).

Reprinted with copyright permission from Routledge.

The key Lessons learned by the participants were:

Despite evidence that female sex characteristics confer greater vulnerability to addiction, men in the general population are more likely than women to have substance use problems. Gender roles may be behind this protective effect in women. However, when trauma is taken into account, this gender advantage seems to disappear.
With increasing attention to knowledge translation and transdisciplinarity in health research, a sex/gender lens can lead to an approach to research, policy, intervention and services that integrates evidence from all areas of health research, embracing complexity in order to improve the lives of women, men and transgendered individuals.
Had each team worked on this literature review project in isolation and without discussion, they would have missed vital pieces from the other pillars. Together, a substantial, holistic edifice of evidence emerges that is directive for future research and difficult to ignore. Academic systems are not yet well suited to transdisciplinary inquiry; however, programs like IMPART are training researchers differently, challenging mentors and trainees to understand and utilize transdisciplinary techniques, and opening up the possibilities of communities of inquiry.

Questions to consider when applying transdisciplinarity:

How might a transdisciplinary and gendered approach enhance the study of complex health issues?
How might you (re)formulate the health problem(s) you study, so that those working in another ‘pillar’ of research could benefit from or link to your work?
What is the potential for improving research and practice through involvement with diverse communities of inquiry?

4. Summary & Suggested Reading

Key points:

Addiction is a complex problem that cannot be adequately defined or understood from any one perspective.
Perspectives on addiction are historical, multiple, and are shaped by the particular lens and priorities of a discipline, area and or sector
Transdisciplinary science moves beyond other forms of collaboration to create a common language and shared understandings among individuals from diverse research paradigms.
Transdisciplinary perspectives on addiction and related issues can produce more complex and nuanced understandings that can provide insight for each individual area as well as generate new questions and directions for research, treatment and policy.

Suggestions for Further Reading:

Alexander, B. K. (2012). Addiction: The urgent need for a paradigm shift. Substance use & misuse, 47(13-14), 1475-1482.

Canadian Mental Health Association – Addiction.

Greaves, L, Poole, N & Boyle, E (2015) Transforming Addiction: Gender, Trauma, Transdisciplinarity. New York: Routledge

Maté, G. (2010). In the realm of hungry ghosts: Close encounters with addiction. North Atlantic Books.

Snow, Mary Elizabeth, Amy Salmon, and Richard Young. 2010. “Teaching Transdisciplinarity in a Discipline-Centered World.” Collected Essays on Learning and Teaching 3: 159-165.

5. Unit references

Abrams, D. (2006) Applying transdisciplinarity research strategies to understanding and elimination health disparities. Health Education & Behavior, Vol. 33 (4): 515-531 DOI: 10.1177/1090198106287732

Agrawal, A., Madden, P. A. F., Heath, A. C., Lynskey, M. T., Bucholz, K. K., & Martin, N. G. (2005). Correlates of regular cigarette smoking in a population-based sample of Australian twins. Addiction, 100(11), 1709-1719.

Adrian, M. (2003). How can sociological theory help our understanding of addictions? Substance use and misuse, 38(10), 1385-1423.

Alexander, B. K. (1991). Peaceful Measures: Canada’s Way Out of the “War on Drugs”. Toronto, ON: University of Toronto Press.

Amaro, H., Chernoff, M., Brown, V., Arevalo, S., & Gatz, M. (2007). Does integrated trauma-informed substance abuse treatment increase treatment retention? Journal of Community Psychology, 35(7), 845-862.

American Psychiatric Association. (2003). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, DC: American Psychiatric Association.

Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.

Becker, J. B., & Hu, M. (2008). Sex differences in drug abuse. Front. Neuroendocrinol., 29, 36-47.

Chez, R. A., Andres, R. L., Chazotte, C., Lewis, D. C., & Ling, F. W. (2001). Substance abuse and misuse is a medical disease. Primary Care Update for OB/GYNS, 8 (5), 195-198.

Cocozza, J. J., Jackson, E. W., Hennigan, K., Morrissey, J. P., Reed, B. G., Fallot, R., et al. (2005). Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse Treatment, 28(2), 109-119.

Cottler, L. B., Nishith, P., & Compton, W. M. (2001). Gender differences in risk factors for trauma exposure and post-traumatic stress disorder among inner-city drug abusers in and out of treatment. Comprehensive Psychiatry, 42(2), 111-117.

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