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ARC Journal of Addiction
Volume-2 Issue-1, 2017, Page No: 9-25

The Concept of Context in the Field of Addiction Research, A Review

Sara Calogiuri,Claudia Venuleo

Department of History, Society and Human Studies University of Salento, Italy.

Citation : Sara Calogiuri,Claudia Venuleo, "The Concept of Context in the Field of Addiction Research, A Review". ARC Journal of Addiction. 2017;2(1):9-25.

Copyright : © 2017 . This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract:

In the field of addiction research, studies have typically focused on the identification of individual factors that affect the onset and maintenance of addictive behaviors. However, there has been growing interest in the role of social and cultural factors. The authors reviewed the literature on addictions with the purpose of investigating how scholars have conceptualized and incorporated contextual influences in their work. An analysis was made of studies investigating “context”, in the period 2012-2014, in one of the most representative journals in the field. From a total of 142 studies examined, 14 macro-categories and 48 sub-categories were identified. Most of the articles identify context with socio-demographic variables, exposition to addictive behaviors in the social environment and different social and family factors. The review reveals that many studies lack an explicit theoretical model; furthermore, there is a huge variability in the way of defining and analyzing the role of context; only a few studies addressed the role of culture and the meaning of the experience.

Keywords: Addiction research, Conceptualization of context, Theoretical framework, Addictive behaviors ,Addiction

1. Introduction

Addiction is a complex concept that has been explained with a broad range of definitions, most of which agree upon a condition which is characterized by an unhealthy and uncontrollable urge to use a substance, or to engage in a certain activity that brings maladaptive and disastrous results, on both mental and physical health and in the areas of work and relationships[1].The DSM 5[2] defines addiction as a problematic use of a substance, which leads to suffering or clinically significant damage, characterised by continuous use and progressively higher doses, persistent desire or unsuccessful attempts to quit, large amount of time spent on activities to obtain the substance, use it, or recover from its effects, craving, tolerance and abstinence.

Different theoretical models have been proposed to explain the origin of addictive behaviors and to organize the research in the field. They have often been related to individual factors: cognitive biases and irrational beliefs[3-7] defense mechanisms against psychic pain[8],[9]; or dissociative mechanisms which repair traumatic emotions[10]; bad functioning of the Central Nervous System [11],[12] and so forth. Even when recognizing their differences, all these perspectives share the idea of the ―addict‖ as an isolated individual, free from external influences and ―out of control‖, a perspective, defined by Reith[13] as a ―model of sickness and disease‖.

In the past two decades, the awareness of the limitations of such a model of addiction has been growing. That kind of model represents a new moral vision, which cannot treat away addiction, but encourages more misbehaviour under the guise of addictive symptoms[14]. In fact,the illness model only takes into account the sick person‘s responsibilities and considers him disempowered and kept there by policing policies, hiring practices, and supportive programs all designed to help those who cannot help themselves[15].

A more appropriate view, broader and more integrative, conceives addiction as a complex social process[16], in which cultural and interpersonal contexts give meaning to addiction and show that applying addiction to the human body is not a simple stimulus–response relationship leading to predictable outcomes[17].

Nevertheless, it is the lack of well defined boundaries that makes context an umbrella concept, including a lot of ambiguity and leading to different interpretations and identifications with various dimensions. The context has been identified, for example, with the social environment, interpreted as a set of social policies and regulations[18], such as the increase of taxes on alcoholic drinks and cigarettes[19]. It has also sometimes been connected to socio-economic variables, such as social norms and moral disengagement[20], neighbourhood disadvantage and lack of community involvement[21],[22]; or to characteristics of the environment, such as the number of alcohol stores in a district[23] or merely to the framework in which the act takes place, so-called functional contextualism[24],[25]. In some other instances, as in the case of norms of a specific ethnicity[26] or subculture[27], context has been identified with culture.

We can claim, then, that while the importance of the concept of context has been stressed by most authors, it is so global and abstract, that it runs the risk of becoming virtually meaningless. Moreover, authors who aim at the same concept differ on what this concept might encompass, that is to say the ways they operationalize the concept. Scholars who conceive context as culture, in fact, may measure it through the influence of ethical norms[28], through the level in which the subjects are culturally integrated[29], whether or not they have migrated[30]. Other scholars who identify context with social influence may measure it by detecting media influence[31], or the level of approval/disapproval of addiction within the micro-social context to which one belongs[32].

The present paper reviews the literature on addiction with the purpose of investigating how scholars have conceptualized and incorporated contextual influences in their work, in one of the most important journal in the field. Special attention will be given to the definition of the theoretical model which organizes the studies in the field, because it is thought that such a model, however simple it may be, should be the start of any scientific enterprise. Furthermore, attention will be given to the kind of addictive behavior investigated by the studies, to explore if different addictive objects lead to focus on different aspects of context.


2. Method

At first, we identified the most important journals in the field, through ISI Web of Knowledge. Cultural studies, clinical psychology, social psychology and substance abuse were selected as the main areas of interest. Among different journals, we analyzed Addictive behaviors, as one of those with higher impact factor during the last 5 years, in the field of addictive behaviors.The journal, consistently with the aim of this review, deals with works about substance-related addictions such as the abuse of alcohol, drugs and nicotine and behavioral addictions such as compulsive gambling and internet excesses, with an emphasis on studies which help to acquire more knowledge about etiology, prevention, social policy or treatment.

We used Scopus to easily search within the journal. The key words, which needed to be searched in titles and/or abstracts, were: culture, context, society, environment, psychosocial, subculture and social. We first selected papers written in English, published between 2012 and 2014.

From the original total of 566, only articles and reviews were selected, excluding editorials, commentaries and letters, all the articles providing validity studies for treatments and screening tests, and all those that referred only to individual variables: personality traits such as impulsivity or self-esteem; neuronal diseases such as those related to the dopamine system, or mental diseases such as depression, anxiety etc. After applying these criteria, the resulting pool of literature consisted of 142 articles and reviews.

Papers that have been considered for this review are listed in appendix A. Each article was coded for all the variables listed below:
1. Source of the data analyzed in the study, intended as geographical area (Asia, Europe, North America, South America, Australia, Africa, mixed continents) or databases;
2. nature of paper (empirical, theoretical or mixed);
3. theoretical framework (cognitivism, psychoanalysis, social theories, family theories, unspecified and mixed);
4. addictive object, that is to say the particular object the individual is addicted to, considering as a possible object not only a substance but also a behavior, like surfing the internet (nicotine, alcohol, marijuana, hard drugs, internet and multiple addictions);
5. conceptualizations of context: macro-categories;
6. conceptualizations of context: sub-categories;
7. measuring tools (questionnaires, re-adapted items, ad hoc items, other, unspecified)

Data Analysis

For all variables considered, frequencies and percentages were analyzed. Then, the relationships among the most representative macro-categories of the core variable (conceptualization of context) and the categories theoretical framework and type of addictive behavior rs were analyzed through SPSS.


3. Results

In order to identify relevant categories of contextual variables, we first proceeded with a round of open coding of the papers. Then, following an axial coding strategy[33], codes with the same content and meaning were grouped into 14 macro-categories and 48 sub-categories, which are listed below:




The coding was validated by two researchers. A consensus approach was used to resolve discrepancies

3.1. Descriptive Statistics
Tables 2 to 7 show the descriptive results of all variables considered. year of publication: publication of the articles reviewed is equally distributed over the years considered, with a slight downward trend.




Nature of project: as we can see from table 3, none of the articles analyzed have a mere theoretical aim, most of them are empirical studies (93%), while the residual 7% are of a mixed nature, namely the aim of the study is to demonstrate a theoretical model, using empirical data.




Theoretical framework: most of the articles analyzed do nots pecify the theoretical background (80.3%), but merely show results of data collection and analysis; among the theoretical frameworks of the articles analyzed, the most frequent is cognitivism, with a percentage of 10.6%, followed by social theories (4.9%), while all other frameworks share the residual 4.2% (1.4% each).




Addictive object: in 85.9% of cases, the studies consider single addictive behaviors, while in 14.1% of cases multiple addictions are analyzed. Among single addictions, alcohol is the one most analyzed (42.3%), followed by nicotine (26.7%) and hard drugs abuse (13.4%). The percentage of studies considering marijuana abuse (2.1%) and internet addiction (1.4%) is significantly low.




Source of the data: most of the studies were conducted in the US (65.5%) and Europe (14.8%), 7% of them in Asia, 5% in Australia, only 0.7% in Africa and some of them were conducted across different continents (mixed: 3.5%). There are also some articles which analyzed data from databases (2.1%).




Measuring tools: to detect the influence of context,in 57.9% of the studies investigated,items were created ad hoc; in 16.2% of the cases scholars adapted items from previous studies or from other questionnaires/scales; in 13.5% contextual influence was detected through questionnaires; only 1.5% of the studies used other types of tools, such us epidemiological data or observation data. In 11% of the articles analyzed, measuring tools were not specified. It is worth noticing that in each study more than one instrument may have been used.




3.2. Conceptualizations Of Context
Table8 reports the frequency and percentage of each of 14 macro-categories identified. It is worth noticing that it was possible to find more than one conceptualization of context in the same study.

In the following paragraphs more frequent macro-categories will be described, with respect to their micro-categories and the trend of their appearance.




3.2.1. Socio-Demographic Factors
This is the most representative section inthe literature, with a percentage of 43.4. Here we can find all the studies considering the mere socio-demographic factors, which are often considered collectively,such as age[34],[35] gender[36],[37] marital status3839, educational level[40],[41] ethnicity[42],[43] socio-economic status[44],[45]as well as religion[46], job status[47],[48] place of birth[49],[50] geographic zone5152 and relatives‘ socio-demographic factors[53],[54]as predictive factors themselves[55]-[57] or associated with other factors, for instance the exposure to addictive behaviors in the micro-social context belonged to[58], the level of social integration[59],[60]social influence[61]or also family climate[62].

Although socio-demographic factors decreased over the years, it is still significantly higher than all the others classes, in all 3 years considered.




3.2.2. Exposure to addictive behaviors in the micro-social context belonged to
This is the second most significant category, with a percentage of 12.7% of the total. Here we can find all articles that analyze the influence of the micro-social environment people belong to. They mostly refer to the influence of family (6.23%), claiming that people with ―addicted‖ relatives are more prone to develop an addiction themselves, in the case of nicotine[63],[64]and alcohol[65],[66]as well as people with ―addicted‖ peers[67]-[67].

Exposure to addictive behaviours in the micro-social context of belonging is the second class by frequency in 2012, significantly more numerous than other classes, but it undergoes one of the most considerable decreases over the 3 years, starting from a frequency of 27 (6.7%), in 2012, falling to only 8 (2%) in 2014.




3.2.3. Social influence
In 10.3% of our sample, society is studied as the most important influence over people, in the field of addictions. The most important influence, once more, seems to come from the micro-social context to which people belong, from family, in particular from the rules which stem from it[70],[71] and peers[72],[73].

Social influence is the fourth class by frequency in 2012 (3.3%), it reaches a peak in 2013 (5%) -while all the other classes decrease- and falls in 2014 (2%), with the same percentage of the category exposure to addictive behaviors in the micro-social context belonged to.




3.2.4. Family climate
This class of predictive factors represents 10% of the total and includes all the factors related to family, focused on relationships between parents or parents and children, family climate (i.e. contentious, peaceful etc.) and functioning (i.e. cohesion, adaptability etc.). Here we find the relationship with parents and their parenting style[74]-[76] to be the most frequently examined family aspect.

In 2012, family climate was the third class of factors by frequency, 17 (4.2%), but it slightly decreases during the years, falling to a frequency of 10 (2.5%) in 2014.




3.2.5. Violence/abuse
This section represents 7.2% of the sample and includes all the articles in which a predictive factor for addiction is being a victim of violence and abuse or witnessing them.In most cases, the context of violence is not specified, consistently with the idea that violence is always a risk factor, especially sexual assault. There are several studies, within the sample, that consider the correlation between alcohol and sexual assault[77],[78] or between the latter and hard drugs abuse[79].

Violence/abuse is the fifth class by frequency in 2012 (2.5%); it declines in 2013 and it increases again in 2014, becoming the second most numerous class with a frequency of 12 (3%).




3.2.6. Level of social integration
Among all the variables analyzed,level of social integration has a percentage of 5.7% and shows a similar pattern of violence/abuse: it decreases considerably in 2013 (n= 8; 2%) but increases significantly in 2014 (n= 11; 2.7%), becoming the third class of variables, after socio-demographic factors and violence/abuse. The articles from our sample mostly conceptualize the level of social integration as social network(2.2%), interpreted as the structure of social relations that individuals have,and as social support(2.2%),interpreted as the group of people an individual can count on, in the case of nicotine[80],[81] alcohol[82],[83]and hard drugs[84],[85].




3.2.7. Other conceptualizations of context
Among the groups of factors that appear less frequently we find:
1. Cultural dimensions (3%), referring to all we commonly interpret as -culture‖: social and cultural norms[86], cultural integration level[87],[87] ethnic factors[89], migration[90] and belonging to a subculture[91].
2. College (1.7%), which involves entrance to college[92],[93] and all the consequences, such as living arrangement[94] or social integration -i.e. being a member of a fraternity/sorority[95],[96].
3. Socio-economic conditions (1.2%), at a micro-social level, as in the case of Marschall-Lévesque and colleagues[97],referring to school and neighbourhood environment as predictive factors; or from a macro-social point of view, as in the case of Vijayasiri and colleagues[98] who analyzed the impact of the Great Recession on alcohol use.
4. Lifestyle(1.25%), here interpreted merely as doing sport. Some studies show that playing sport and being a member of a team are often a protective factor, especially during adolescence or young adulthood[99],[100].
5. Addictive object setting of use (1.25%) refers to where and how people drink[101], smoke marijuana [102] or use drugs[103].
6. Level of satisfaction (1%) considers the satisfaction with relationships [31][104] and life in genera[105],[106].
7. Performances at school (0.75%) refers to the level of commitment and outcomes at school, related to internet addiction[107]as well as drug abuse[108] and multiple addictions[109].
8. The last conceptualization of context –in percentage terms,0.5%- is that of interpersonal issues, in terms of relationships with partner[110]and with colleagues[111].


3.3. Conceptualization Of Context And Theoretical Framework
This section will analyze the correlations between the most frequent conceptualizations of context and the theoretical frameworks Socio-demographic factors are the predictive factors most investigated across all the theoretical frameworks except psychoanalysis. In particular, when the theoretical framework is not specified and when it is mixed,socio-demographic factors account for around half of the sample; the percentage is still high in the case of family theories (42.8%) and social theories (32%), reaching the lowest percentage of 20% in the case of cognitivism.

Exposure to addictive behaviors represents 26.7% of the conceptualizations of context in studies based on cognitive theories, and around 15% in all other theoretical frameworks considered, except for psychoanalysis.

Social influence does not seem to be significantly related to the theoretical frameworks examined. The highest percentage it reaches is 20% in cognitivism-oriented studies.

Unsurprisingly,family climate represents 75% of the contextual influences analyzed by psychoanalytic studies and more than 40% in the studies based on family theories. It also appears frequently in studies based on mixed theoretical frameworks (33.3%) and social theories (24%).

Level of social integration and violence/abuse have lower percentages than the other macro-categories, but it is worth noticing that the former represents 25% of the context analysed in psychoanalytic frameworks.




3.4. Conceptualizations Of Context And Addictive Object
The correlations between the most frequent macro-categories of context and the addictive object will now be considered.

As we can see from table 16, socio-demographicfactors is the most commonly analyzed variable across the different addictive objects. In the case of nicotine addiction, about half of the factors studied are represented by socio-demographic factors (49.6%);percentages in the case of multiple addictions (43%) and hard drugs (51.6%) are similar, and although less marked, this frequency is also high in alcohol studies (37%). Concerning the less frequent studies on marijuana use,socio-demographic factors represent 80% of the contextual variables analyzed, while in those on internet abuse, it represents only 20%.

Exposure to addictive behaviors in the micro-social context belonged to is the second most recurring factor in studies about nicotine addiction (22.3%), especially referred to ―smoking‖ parents and ―smoking‖ peers[112],[113] while it does not have a particular frequency in studies on the other addictive behaviors.

Social influence is the second most important factor in the case of alcohol abuse (16.5%) and marijuana (20%), and it seems to be an important aspect to be taken into account also in studies on nicotine (12.8%).

Family climate is an aspect which frequently focused on by studies on multiple addictions (17.3%), while its relation to other addictions does not seem so significant.

Concerning the less frequent macro-categories, level of social integration appears frequently in studies on internet abuse (20%) -while in the other addictions its percentage is below 10%- and violence/abuse is studied mostly in connection to hard drugs (14.5%) and multiple addictions (13.4%).




4. Discussion

This review highlights specific trends of current research about addiction.

The first element that leaps out is that many studies lack an explicit theoretical model outlining the manner in which the context is thought to be related to the addictive behaviour. In fact, among the 142 papers of the sample, we cannot find any theoretical paper, and there is a surprisingly high percentage of unspecified theoretical framework (80,3%) among the empirical papers. They mostly report findings in terms of data collection and analysis, without mentioning any theory that led to that specific choice of conceptualization of context and that specific operationalization.Previous studies showed that the tendency to accumulate data seems to be predominant in current psychological literature, at the expense of detailed theoretical research[114]-[116]. A case is that of Empirical Supported Treatment (EST), in psychotherapy, where the mere fact that a treatment has been proved many times through clinical trials makes it efficacious[117].

As a consequence of such an extreme empiricism, a scotomization of the meaning of results collected can be noticed. It is assumed that the same variables, from socio-demographic factors to social influence, as well as interpersonal issues, themselves act as risk/protective factors,overlooking why these factors exist, how they are interrelated118, and why they affect people in the way they do.

Some scholars observed that psychology research typically neglects the role of the meaning used by people to interpret the characteristics of the micro-social and macro-social environment addressed by the study[119]-[123]. In the papers we reviewed, the role of meaning is neglected too.It is supposed that socio-demographic characteristics, economic and educational level, occupation, religion, social support and so on, affect the onset and/or the maintenance of addictive behaviors in similar ways. However, we have to recognise that people belonging to a specific social group or who are exposed to the same social environment do not develop in similar ways and do not proceed along a common path[124], neither do they have the same probability of becoming addicted. The personal and socio- cultural meanings[125] in terms of which people interpret contextual characteristics may play a role in explaining inter-individual differences[126]-[131].

Another note worthy aspect that this work reveals is the incredibly high heterogeneity of the definitions of what context is and how to measure it. The 14 macro-categories, found through coding, refer to aspects of context which are sometimes extremely different from each other: violence/abuses and college, or socio-demographic variables and level of satisfaction. This heterogeneity supports the idea, presented in the introduction of this paper, that context is a concept without well-defined boundaries that leads, of course, to a variety of conceptualizations[132].

However, among such an enormous variety of studies, few identify context with cultural dimensions (2.7%), and when they do, they focus on the level of cultural integration or acculturation of the individuals, their cultural norms, whether or not they migrated, if they belong to particular subcultures and if there are specific ethnic factors which are related to addictions. These perspectives seem to lead to two conceptions of context: 1) as a static phenomenon, only connected to a set of generalized value orientations or behaviours133, or as a set of features, or attributes of people living within certain areas[134], as if people can have culture or acquire it through assimilation or socialization[135]. By contrast, the view of culture as an ongoing process[136], more probably consistent with a social world which is continuously changing, is substantially absent in the literature reviewed; 2) as something out of one‘s mind. It becomes an explicans that allows researchers to explain something else[137], likeaddiction in this case, without any mention to the explanation of context itself. A view that leads to consider cultural meanings as a taken-for-granted, pre-existing, separatereality acting from the outside on the psychological process of construction ofexperience[138], thatthe mind – and therefore individuals- can do nothing but be subjected to.

Concerning the kind of addiction addressed by the studies, consistently with statistical reports[139],[140] alcohol and nicotine addictions are still the addictions most studied in our review, while there is an unusually low number of studies on hard drugs abuse in the sample, probably due to the decreasing trend of consumption. It is possible that this aspect is related to a wider acknowledgement of the role of social influences in the onset of alcohol and nicotine use; furthermore, it is plausible that the agenda of public health and related trend of social alarm play a role in explaining the privileged interest of the researchers towards certain kinds of addictions[141]-[143].


5. Conclusions

The acknowledgment that addictions and, more widely, maladaptive patterns of behaviour are affected by social and cultural milieus[144],[145]leads researchers to incorporate contextual influences in their work and thus to question how to conceptualize and analyze context appropriately. The review on the 142 studies published in the period 2012-2014 in one of the most representative journal in the field showed that –despite the enormous heterogeneity of conceptualizations of context and the huge variability of tools to measure it– studies share the tendency to privilege data collection and to neglect the theoretical framework which is used to select variables and to make sense of the results.

As in modern epistemology, the process and the ―context‖ of knowledge – in the sense of the researcher‘s background and system of assumptions – seem to be regarded as an inert dimension in construing the meaning of data.This sounds paradoxical when the general purpose it to recognize the role played by context in people‘s lives and experiences.

Before concluding, it has to be said that the map provided by the current review must not be intended as a detailed representation of the ever-changing scenario of addiction research and of its way of relating to the role of context in the onset of addictive behaviours. Certainly, the fact that we have reviewed only the more recent studies published in the Addictive behaviours journal, prevents us from making conclusive remarks. However, the review can be considered a useful device in deepening the understanding of how scholars conceptualize and incorporate contextual influences in their work.

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