Individuals Are Continents; or, Why It's Time to Retire the Island Approach to Addiction

Abstract

Individuals are not island isolates. This is an old insight that finds expression in indigenous worldviews, ancient philosophies, religious doctrine, and modern social theories. Even so, science remains encumbered by the false dichotomies and reductionism inherited from the capitalist revolution and reinforced by the fragmentation of modern life. This same heritage encumbers addiction research and efforts to devise effective interventions. It does so because the island concept at its core filters out the most decisive factors contributing to addiction. We therefore recommend its replacement with what we call the continental concept of the individual, which conceives of society and the natural environment as extensions of individual corporeal bodies. Such a theoretical reorientation has significant implications for intervention research and practice. More specifically, it radically expands the scope of what constitutes a valid intervention in the first place. We call this reorientation the continental approach to drug addiction.

Keywords:

• drug addiction
• interventions
• individualism
• holism
• capitalism
• models of addiction

Notes

¹ The insight, that is, that, as Marx says, ‘the individual is the social being’ (1992a, p. 350), ‘the development of an individual is determined by the development of all the others with whom he is directly or indirectly associative’ (Marx and Engels 1932), the ‘human essence’ is to be found in ‘the ensemble of social relations’ (1992b, p. 423), ‘the human being is … a [political animal] … which can individuate itself only in the midst of society’ (1993, p. 84), ‘society does not consist of individuals, but expresses the sum of interrelations, the relations within which these individuals stand’ (1993, p. 265), ‘nature is man's inorganic body’ (1992a, p. 328), etc.

² We use drug addiction, drug misuse, and problem drug use interchangeably.

³ The reader is referred to the thesis by Rittel and Horst who diffentiate ‘tame problems’ from ‘wicked problems.’ The former are solved in a linear, traditionally well known ‘water fall paradigm’ involving gathering data, analyzing it, formulating a solution, and implementing the solution. The latter, ‘wicked problems,’ can only be responded to individually, each time anew, with no ultimate, repeatable solution. Rittel, Horst, and Melvin Webber, (1973) ‘Dilemmas in a General Theory of Planning.’ Policy Sciences, Vol. 4, pp 155–169. Editor's note.

⁴ The reader is referred to a stimulating analysis about the underpinnings of ‘causality’ for which Hills's criteria for causation which were developed in order to help assist researchers and clinicians to determine if risk factors were causes of a particular disease or outcomes or merely associated factors. (Hill, A. B. (1965). Proceedings of the Royal Society of Medicine 58: 295–300.). Editor's note.

⁵ The reader is referred to the relatively new term ‘big events’ which has been introduced into the intervention literature. It refers to major events such as mega-disasters, natural as well as human-made, such as famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc. which affect adaptation, functioning and quality-of-life of individuals as well as systems. Existential threat, instability, and chaos are major dimensions as is the experience of loss of control over one's life. The endogenous and exogenous conditions, their levels, qualities, and interactions, which are necessary for them to operate (begin, continue, change as realities change, cease, begin again, etc.) have yet to be adequately documented. Editor's note.

⁶ Treatment can be usefully defined as a unique, planned, goal directed, temporally structured, multi-dimensional change process, which may be phase-structured, of necessary quality, appropriateness, and conditions (endogenous and exogenous), implemented under conditions of uncertainty, which is bounded (culture, place, time, etc.), which can be (un)successful (partially and/or totally), as well as being associated with iatrogenic harm and can be categorized into professional-based, tradition-based, mutual-help-based (AA,NA, etc.), and self-help (‘natural recovery’) models. In the West, with the relatively new ideology of ‘harm reduction’ and the even newer Quality of Life (QOL) and ‘wellness’ treatment-driven models, there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can also include controlled environments such as jails, prisons and military camps. Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models, including: (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and client(s)/patient(s) in which both are active, and (3) the ‘informed model’ in which the patient makes the decision(s). Within this planned change process, implemented relatively recently in various parts of the world, active substance users who are not in ‘treatment,’ as well as those users who are in treatment, have become social change agents, active advocates, and peer health counselors, list that represents just a sampling of their new labels. There are no unique models or techniques used with substance users–of whatever types and heterogeneities–which aren't also used with non-substance users. The reality that substance users, representing a heterogeneous group of people, patterns of use, and life styles, continue to be treated in ‘specialized’ programs which are distanced from the mainstream of the treatment of non-users—‘NORMED TREATMENT OF NORMED DISEASES’—and all-too-often manifest imparity in availability, accessibility and delivery of needed services, utilize policies which are stakeholder-driven and not evidence-based and may be ethically insensitive, does not change the reality that there is no ‘drug treatment’ and no ‘alcohol treatment’ per se. Part of the ‘unfinished business’ in the treatment of substance users, when needed and appropriate, relates to knowing, understanding and being able to effectively utilize when treatment is (1) indicated, (2) contra-indicated, (3) irrelevant, and, at times, can be (4) regressive. Editor's note.

⁷ Recall that Defoe's Robinson Crusoe was already a young adult who had been brought up in British society by the time he was marooned and that he was able to salvage tools and supplies from the shipwreck before it sank.

⁸ The reader is referred to a relevant issue raised by the cyberneticist Heinz Von Foerster who posited that there are two types of generic questions: legitimate and illegitimate ones. The former are those for which the answer is not known and is, perhaps, even unknowable during a given state of knowledge and technology and which is associated with knowledge breakthroughs, in this case—the effective control of man's ‘appetite’ for a range of psychoactive substances, whatever their legal status. An illegitimate question is one for which the answer is known, or, at the very least consensualized. The asking of illegitimate questions has been, and remains, by and large, the acculturated norm. Rarely have ‘legitimate’ questions been raised in the substance use(r) intervention literature. Heinz Von Foerster, Patricia M. Mora, and Lawrence W. Amiot, ‘Doomsday; Friday, 13 November, A.D, 2026,’ Science, 132, 1960. pp. 1291–1295. The reader is referred to Pablo Neruda's The Book of Questions for a poetic exploration of legitimate questions. Editor's Note.

Additional information

Notes on contributors

William Tootle

William Tootle, US, is a PhD student in the Department of Anthropology at the University of Connecticut. His research interests include the political economy of health, harm reduction theory and practice, and the ideological dimensions of drug issues.

James Ziegler

James Ziegler, US, is a PhD, student in the Department of Anthropology at the University of Connecticut. His research interests include the political ecology of drug use and structural violence in drug treatment interventions in America and China.

Merrill Singer

Merrill Singer, PhD, US, a medical and cultural anthropologist, is a Professor in the Departments of Anthropology and Community Medicine, and a Senior Research Scientist at Center for Health, Intervention and Prevention at the University of Connecticut. In addition, he is affiliated with the Center for Interdisciplinary Research on AIDS at Yale University. He has published over 265 articles and book chapters and has authored or edited 29 books.