The Importance of Considering Culture (and Questioning ‘Truth’) in Addiction Treatment

An academic look at how assumptions about the “truth” about addiction and its treatment can inadvertently disempower those we are trying to help.

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Addiction and Culture, Truth and Ethics

As we look at the research and context of addiction treatment, we’re beginning to see the importance of considering a person’s individual cultural background into the treatment plan. Here, we take a look at – and question – the “truth” behind our assumptions about substance addiction, especially in the academic and research world of substance use disorders.

Your feedback and comments are welcomed at the end.

What is “Truth”?

The sense of ethical responsibility in writing a critical text on any subject comes from the idea that an essay is presenting a fact. As writers create academic texts, they tend to present their ideas as immutable truth when, in fact, the knowledge they propagate approximates the truth. However, the “truth” that has been created in much the same way as fiction; it is experience-mediated through the senses and the intellect

This is how we produce knowledge.

(Oh dear, we’ll continue to push on anyway.)

What is Culture?

We might define culture as a collection of patterns of belief and behaviour. A “culture” is an ideological belief system which is at once created by and influences the members of society.

What Is Substance Use Disorder?

Substance use disorder, a.k.a. addiction, could be defined as a chronic compulsive behaviour despite negative consequences. Substance addictions are usually thought of as a perceived loss of control) caused either by the nature of the substance itself or by the psychological process the substance creates or heightens.

The concept of addiction originated in the field of substance abuse, particularly the abuse of alcohol, opiates and cocaine. Researchers have been working in this area for well over a century. They have produced a substantial body of theoretical models and empirical data.

Historical Roots of Substance Abuse

Mood altering chemicals in one form or another have been used for thousands of years. There is evidence that alcoholic beverages have been fermented from an array of plants and fruits since at least 4000 BCE. Some of the earliest references to the use of alcohol are found in ancient Sumerian clay tablets that contain recipes for the use of wine as a solvent for medications. The Sumerians also cultivated the opium poppy, which they named “hul gil,” -the plant of joy. It was used for its medicinal properties – for pain relief and for stomach problems – as well as for its soothing effect, for sedation, and for euphoria.

The Role of Culture in Intoxication

Historically, excessive substance use appears to correlate with periods of rapid social change, often among cultural groups who have had little exposure to a drug and have not developed protective normative behaviour. The brutality of colonial times has taught us much about Anomie, or loss of a healthy ethnic or cultural identity. Anomie may occur among native populations whose cultures have been devastated by the extensive and sudden invasion of outside influence.

Acculturation is thought to be related to substance use and abuse. For example, in North America, higher rates of substance use have been found in those who closely identify with non-Native American values. The lowest rates are found in bicultural individuals who are comfortable with both sets of cultural identity.

Talking about ‘Others’

As we look at addiction treatment, the imagining and the representation of “the subject” is deeply important. We have seen repeatedly that the unethical representation of a subject or a group leads to horror across the world. The press are particularly notorious for this assumed moral superiority over various sections of the community, aligning itself with the dominant social group (rich, white men again I’m afraid). Historically, the press has dehumanised black people, the Irish, and women. More recently, the media has turned its dead-eyed gaze on immigrants.

Can we consider addicts a “Coherent Group?”

We might. But is it beneficial?

Psychiatric categorisation may create a false binary between people that are emotionally ‘well’ and those who are ‘sick.’ People are specific and complex individuals. Limiting stereotypes and binaries have been found to be obsolete when discussing the nature of identity. Perhaps most of us could find our personalities laid out between the pages of the DSM IV if we had a good look.

Creating a People

The subject of representation and creating a voice with which to speak for an ‘other’ are subject’s common to academics, feminist researchers, and creative writers. The subject of representation carries much political weight, as the practice of representation is closely linked to the production and dissemination of knowledge. Thus, the subject of representation and subjectivity are linked with epistemological debates concerned with how to ethically engage with ‘others.’

When we speak about and for an oppressed group, we should be aware that we are engaged in a political act and consider whether enable/empower those who are oppressed.

Gayatri Spivak famously shone a light on the processes of academics with benevolent intentions ‘constructing’ oppressed groups through asking the question: “Can the subaltern speak?” Spivak discusses the layered meaning and consequences of the choice of academics to speak for the subaltern woman, “Between patriarchy and imperialism, subject-constitution and object-formation, the figure of the woman disappears, not into a pristine nothingness, but into a violent shuttling which is the displaced figuration of the ‘third-world woman’ caught between tradition and modernization.”

The Nature of Truth

The pursuit of an immutable truth or a perfect state of objectivity however seems noble, yet sadly impossible. Though everyone likes to believe they have some access to truth, no one has full access to ultimate truth. Further, any individual only has their own, limited perception at the time; the process of approximating the truth is part of a dialogical relationship among subjects who are differently situated.

A More Diverse Population

As the population becomes more diverse, it is important to consider a person’s cultural background when assessing for substance abuse or dependence. The publication of DSM-IV was an important turning point in the application of cultural psychiatry principles in that it provides an outline for cultural formulation. Updates included:

  • A discussion of the cultural variations in currently recognized DSM disorders.
  • A glossary of culture-bound syndromes.
  • An outline for a culturally relevant case formulation based on 5 major areas: cultural identity, cultural explanation of the illness, cultural factors related to psychosocial environment and levels of functioning, cultural elements of the relationship between the individual and the clinician, and overall cultural assessment for diagnosis and care.

How All of This Affects Treatment

The sociocultural beliefs of the addict and that of the treatment provider play a central role in forming the expectations of individuals about potential problems they may face with drug use.

Often, the definition of an addict has been based on observed male characteristics that seemed common in the white, male drinking culture of the 1930’s and 40’ s. The traditional definition describes addicts as “self-absorbed” and “self-centred”; it posits that recovery from addiction must entail an ego deflation, a breaking of the self-focused pattern of thinking.

Much treatment is based on this construction of the white, male experience of addiction. Although something might have defined as non-gender specific it is often actually male. In addition to this, most of the policy makers and academics writing about addiction are still mainly men, as are the directors of many treatment facilities. Thus, women are not reflected in the administration, structure, policy and funding delivery policy within the treatment field.

Hopeful Prognosis

However, as treatment providers and mental health professionals update and adapt their understanding of addictions and the multifaceted nature of it all a different treatment approach emerges. Therapeutic approaches are being developed which consider the individual and the nature of addiction from a multidimensional and interconnected perspective in a way that does not exclude an individual’s own reality of what has happened.

In sum, it is important to honour the stories that addicts have to tell, both their content and their context.

About the author
Jason Shiers, Dip Psych, MBACP is a Transactional Analysis Psychodynamic Psychotherapist, and Head of Digital for and Jason has been helping people with all types of addictions for 23 years. He practices holistically calling on various modalities including, psychotherapy, 12 steps, mindfulness, energy and meditation to help people empower themselves to make positive change in their lives.
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