This article is available in: HTML jgi:

Journal Information
Journal ID (publisher-id): jgi
ISSN: 1910-7595
Publisher: Centre for Addiction and Mental Health
Article Information
© 1999-2005 The Centre for Addiction and Mental Health
Received Day: 30 Month: 4 Year: 2003
Accepted Day: 10 Month: 8 Year: 2004
Publication date: March 2005
Publisher Id: jgi.2005.13.3
DOI: 10.4309/jgi.2005.13.3

A theoretical exploration of culture and community health: Implications for prevention, research, and problem gambling
Jennifer Borrell
Jacques Boulet
Borderlands Cooperative, Auburn, Victoria, Australia E-mail: jborrell@vtown.com.au
[This article prints out to about 20 pages.]
It was adapted from a conference paper entitled “Culture and the prevention of problem gambling” presented at the 11th National Association of Gambling Studies 2001 conference “Culture and the gambling phenomenon” (Sydney, Australia).

For correspondence: Jennifer Borrell, Social Research Consultant, C/-Borderlands Cooperative, P.O. Box 3079, Auburn, Victoria 3123 Australia. Phone: 9818 3239, fax: 9819 3439, e-mail: jborrell@vtown.com.au.
Contributors. Both authors shared the research and writing of this article.
Competing interests: None declared.
Ethics approval. There were no human or animal subjects and so ethics approval was not necessary.
Funding. Neither author was funded for the preparation of this article.
Jennifer Borrell (BBSc., BSW, PhD candidate) is a social researcher and gambling research consultant. She has provided extensive gambling research consultancy to local governments and community organisations to inform their policies and initiatives, often in association with Borderlands Cooperative. Her consultancy work has also included research for municipal health plans, community needs analyses, program evaluations, leisure needs studies, and community arts projects.
Dr. Jacques Boulet has worked in social work, community development, and as an academic for about forty years and across five continents. He left university teaching in 1996 to start the Borderlands Cooperative in Melbourne, Australia. The cooperative is involved in research and consultative work as well as in stimulating processes of local community development. In the context of that work, Jacques has been involved with several universities as a free-lance teacher, researcher, and in curriculum development and change, especially in the subject areas of social work and community development.

Abstract

While predominant models of prevention focus on the prevention of specific diseases and disorders and/or on the minimisation of harm arising from them, the authors argue for a (theoretical and practical) reinsertion, or a reconstruction, of subjectivity within a web of social connectedness—including a sense of culture (we propose an action-relevant frame of reference), a sense of health as a social construct, and a sense of community—the latter two arising from implications of the former. Specifically, there are said to be three theoretical and potential intervention areas, all with a focus on the reconstruction of subjectivity, that require much greater attention in the study of addiction, especially gambling, as well as in practical and policy responses to these issues.


Introduction

The present contribution, whilst resting on solid theory, empirical evidence, and common sense, takes a bit of a punt at creative speculation and intends to suggest the interweaving of three theoretical—and possible intervention—areas. The common denominator of these areas is the recognised need to reconnect our understandings of the personal-individual with appropriate conceptions of the social-collective (or, in still more general terms, the need to reconnect the societal-structural dimension with the dimension of human agency). While predominant models of prevention, of problem gambling as well as of other forms of addiction, focus on the prevention of specific diseases and disorders and/or on the minimisation of harm arising from these, they overwhelmingly assume an individualised locus in which the disorder is thought to “reside” and therefore needs to be addressed. We suggest a re-insertion—indeed a reconstruction—of subjectivity within a web of social connectedness, including a sense of culture, a sense of health as a social construct/social “issue,” and a sense of community.


Part One: Culture as collective systems of meaning—guiding patterns of social interaction within identifiable social groups

Within the discourses of the helping or healing professions, one finds a common and historically long-standing split between the theorisations of the social/societal and the individual/personal. These splits are often referred to, if not explained away, as encompassing the macro—or structural—and micro—or agency—dimensions of social and human reality. Concomitantly, social interventions into these respective halves are often conceived of in a dichotomous way (even if one regularly hears calls for complementarity between the two dimensions, they often remain rhetorical or empty of substance). This is not the place to enter in this debate; suffice it to say that various attempts at “closing the gap” and to dialectically reconstruct the relationship between social structure and personal experience have been developed in the past and continue to be developed within the context of different epistemological traditions. Neo-Marxist, feminist, and critical theory approaches have variously informed such attempts, as have phenomenological and postmodernist ones. Bridging the theory-practice gap as well as the macro-micro gaps in reflective professional practice has been recognised as an indispensable task for:

…critical professionals of the future [who] have to be able to interpret the world through cognitive frameworks and be adept at handling those frameworks in action. There can be no arbitrary limit to either of these dimensions of professional life. In a world that is subject to rapid and global change […] there can be no limit on the frameworks that professionals might deploy to make sense of their world (Barnett, 1997, cited in Cooper, 2001, p. 734).

And that certainly also includes the need to attempt and develop holistic models of (anticipated) practice—especially in the field of addiction and of so-called “problematic” engagement in certain practices and “problematic consumption” of certain substances. If, indeed, “addiction is endemic in western free-market societies” and if it is related to the inevitable dislocation from “traditional sources of psychological, social and spiritual support” such free markets cause, then the need to look at both the structural and personal aspects of such problematic behaviours and at the interrelationship between them should be obvious, especially if “addiction professionals [are to gain] a view of their field that is both broader and more practical” (Alexander, 2000, p. 501).

An action-relevant frame of reference, derived from and informed by both structural and (inter- and intra-) personal theory fragments, needs to be developed to support conceptions of intervention and prevention, responding to problematic behaviours and to the structural aspects which have been identified as causally involved in their emergence and reproduction. Following Giddens (1979, 1982), Bourdieu (1977), and others, one of the authors of this paper has attempted to develop such a frame of reference (Boulet, 1985, 1988), and both of us have been involved in the implementation of research and consultancy activities—especially in the area of community development—which draw from such a framework, however implicit that may have been in the respective instances of our practice.

The fledgling field of cultural studies can be understood as one contemporary attempt at theoretically filling the conceptual (and therefore also practical) gap between the notions and realities covered by “structure” and “agency” or—in other words—between subjective experience, everyday interaction, institutional process, and societal structure (understood with Giddens as “recursive practice”). As one of us has said elsewhere (Boulet, 1985, p. 184), “culture allows us to inject meaningfully the dimension of collectivity in the otherwise individualising semantic context of subjectivity” and therewith avoid the construction of the collective as generalised (individual) personality or as simply an ideal type, as unfortunately so often happens in theoretical discourses emanating from the disciplinarian confines (and trenches!) of the established human and social sciences. Often in these discourses, the only conceivable relationship between the dimensions of the macro and the micro is one of unidirectional causality, whereby the environment (or macro) occupies the role of the behaviourist stimulus, and the human agent (enmeshed within micro situations or processes) is allowed the similarly behaviourist response role—certainly in as far as those are concerned who are variously referred to as clients of the helping or healing professions. The causality is—more often than not implicitly—allowed to run the other way around when those occupying positions of power are examined and dealt with as to their relationship with societal structure and process. It would be rather surprising to hear someone say that poor millionaires and members of governments are so terribly dominated and victimised—exploited?—by the ways in which our societies are organised nationally and globally. We usually do think about them as movers and shakers, as innovators, as being in control.

Be that as it may, Zygmunt Bauman's earlier work (1973, 1976) provides a useful conceptualisation—and operationalisation—of culture as he distinguishes (1973, p. 39) among its hierarchical, differential, and generic notions and meanings. The first such conceptualisation, juxtaposing the refined and coarse ways of life (often with strong classist and ethnocentric undertones), suggests an educational bridge between them, which those of the coarse ways would have to travel across, in order to reach the more elevated and refined hierarchical levels. The second notion—the one often used when talking about multicultural and such issues—concerns the countless and endlessly multipliable oppositions between the ways of life of the various human groups. The generic notion of culture, finally, is:

construed around the dichotomy of the human and the natural world, …it is about attributes which unite mankind in the way of distinguishing them from everything else. In other words, the generic concept is about the boundaries of man and the human (Bauman, 1973, p. 39).

Like Giddens (variously, 1979, 1982), Bauman attempts to avoid an antinomy between structure and culture (here understood in its generic sense: as collective processes of human meaning-giving) and he understands them as dialectically related: “Being structured and being capable of structuring seem to be the twin-kernels of the human way of life, known as culture” (1973, p. 51).

If cultural analysis is to be relevant for examination of the relationship between societal process and individual experience (and also minding Inglis's [1993] warning that “culture [is] a mess, [which] refuses…beautiful simplifications,”), it has to avoid blunt oversimplifications and generalisations, so easily arrived at when one applies the notion of culture in Bauman's two first senses mentioned above. Culturally oriented and locally relevant social analysis needs to en-compass the multitude of, and the relationships among, the wishes, the strivings, the experiences, the expressions, and actions of the people—or of specific groups of people—as they pertain to the situations of their normal daily preoccupations, dependencies, and routines. It has to be sensitive to the fractures and frag-mentations within and between people, their relationships and the processes impinging on them, especially the power differentials and the tran-sactional forms in which these are expressed, and, finally, the traces of oppressed and suppressed needs and aspirations and the ways in which the associated frustrations translate into sets of—often (self-) destructive—actions and practices. Or, again with Inglis (1993, p. 147):

…whatever culture is, it isn't something which divides without remainder into social data (the brute facts) and mental states (values and attitudes). But nor is it the material determination of consciousness by classes or economies. It lives (or dies) in the symbols, institutions and actions which produce, embody, renew and circulate the values of the society…

A theoretical frame of reference informed by such generic understanding of culture would allow us to also rethink and incorporate its hierarchical and differential meanings, as identified by Bauman. Instead of looking at the expressive-symbolic everyday activities and experiences of—say—working-class people, older women, people of culturally and linguistically different backgrounds or (other) marginal groups (or, relevant for this paper, of “problem gamblers” or people with an addiction) as coarse, primitive, problematic, nonadapted, or dependency-creating or, indeed, as personalised “disorders” generated by certain aspects of an ethnocentrically stereotyped culture, they could be reconceptualised as culturally specific acts of resistance against the threat of the total loss of identity, due to experiences of domination and alienation. Culture, then, would become the totality of daily practices of (oppressed, alienated) individuals and groups, involving—in a deeply contradictory articulation—realisations of their own productive, creative, and reproductive activities, which, at the same time, (can) signify their utter domination and the destruction of their livelihoods. Watching mindless TV programs, playing amateur theatre, getting drunk, losing all your money gambling, making love, doing permaculture, or being involved in volunteering, are thus only superficially opposite articulations of people's deep-seated urge to remain a whole person (including their urge to stay connected with others like them!), in spite of all the pain inflicted in the course of a lifetime of daily experiences.

Paul Willis has captured this cultural reality close to perfection in his Learning to labour (1977); he stresses the necessity to insert a cultural level between (the understanding of) the structural requirements of society and the individual experiences of (and reactions to) these requirements.

For Willis (1977), culture is specific, always engaged and active and involved with real everyday context and therefore always changing and changeable. Moreover, culture is a shared internal capacity of people—and not just something derived from or imposed by the outside world or by the “social structure” and quasi-measurable as to whether or not individuals have “absorbed” its units or fragments or behavioural expressions. Such an understanding of culture locates it between structure and agency, as a “mediating” terrain, offering possibilities of acceptance of or resistance against what the structure and its several institutional embodiments may be requiring. It provides the space where individuals acquire a sense of the choices they have and don't have, where they learn to negotiate power and its expressions in relationships—like between teachers and pupils and between (young) men and women and within and between their gangs and the several kinds or types of students—pre-figuring the status differences they will encounter in the “real economy” of their future workplaces and have already encountered mediated through their parents and their experiences in their (working class) families. Culture is the real-life context in which they also learn how to accommodate to the “bottom lines” of the real economy and its conditions, both at work and in their respective private spheres. Importantly, there's nothing passive about this accommodation, as it does change both content and modalities of what is asked by “the powers that be.” The way in which the dialectics between agency and structure usually is conceptualized, i.e., the determinist “stimuli” of the structure and the adaptive responses by the oppressed, leaves no space for the complex interpenetration of the different degrees of power real people have and engage with in their real-life interactions. Hence, culture as a relatively autonomous realm and as a theoretical notion is indispensable if one wants to avoid perceiving and understanding people's actions as resulting from mere coercion, manipulation, or as responses to mere myth-making or magic.

Or, one may add, one is back with the coercive imposition of labels of medical categorisation, of assumed personality disorder and the insult of psychotherapeutic morbidisation (or twelve-step culpability) added to the injury of societal exclusion and alienation.

The relevance of all of this to the area of so-called problem gambling should be obvious; marginalised people are more susceptible to problematic gambling. Women who are socially isolated or who want to escape from difficult life circumstances are drawn to electronic gambling machines (EGMs) (Borrell, 2004). They often report being drawn to a place where they have a sense of belonging, are treated with what looks like respect, and where they feel welcome. In general, male problem gamblers tend to gamble to be “winners” and to have their sense of skill and competence validated (“beating the machine!”).

At the same time, there is great shame and stigma associated with problem gambling that is consistently reported in all local qualitative research. This has implications for the design of “preventative” advertising, which may unwittingly be counterproductive in those cases where it increases stigma and thus prevents people from identifying that they may have a problem (however this is understood) or from seeking help or from calling on solidarity within their own cultural groups and relationships.

Research and intervention in gambling issues thus seems to have a lot to gain from adopting a cultural perspective in the above-understood sense. Whether that is possible in the context of mainstream social science and intervention remains to be seen.

In advocating a hermeneutic approach wherein the imbeddedness of meaning in social “data” is recognised, Inglis states that:

Understanding actions-as-part-of-a-narrative…still sounds utterly unreliable to the helots of empiricism. They want fixed data even if they have to separate “findings” from what they agree to be the subjective realm in which survey questionnaires are compiled…(1993, p. 146).

It should have become obvious that many interventions based on such understandings of the scientific investigation of social reality (including “empiricist” culture) will revert to the apparent security and certainty of fixed definitions and to the authority of those who prefer the clean and distinctive (but often murderous) order of the normal and the abnormal.

Such a theoretical bias, whether referred to as empiricist, positivist, or reductionist, is more than evident in the vast majority of research studies into problem/pathological gambling or gambling community impact—specifically in experimental research and population surveys, with methodologies invariably serving to omit cultural considerations by default (see Borrell [2000] for a critique of survey research commissioned by the Victorian Casino and Gaming Authority). Invariably, key dimensions for examination are ossified and to differing degrees removed from context, time, dynamic process, and social meaning—perhaps arising from the “common sense” and social imagination of the researcher and/or from a theoretical or methodological convention approved of and adhered to by the research community. The examples are numerous and would be recognised by anyone familiar with the gambling research when named—typologies or schemata of “co-morbidities,” “maladaptive behaviours,” attitudes, (irrational) beliefs and cognitions, etc., that are said to coexist with pathological/problem gambling. What is common to the associated mindset is the push to reduce, compartmentalise, itemise, and generally render phenomena amenable to experimental or statistical manipulation.

The problem with this fast track past the search for meaning to the imperative of grouping to category (of putative likeness) is that key aetiological dimensions may be lost. For example, “irrational beliefs” may not be irrational at all within the full context of a person's life or in the context of the fact that gaming machines may be designed to create illusions that induce excessive spending (Horbay, 2004; Park & Griffiths, 2004). The point that, in general, machines are designed to facilitate maximum spending also points to regulatory and corporate considerations (for example about product safety and the placement and accessibility of machines), which play a potent role in the constant generation and re-formation of culture.

Even the very idea of problem/pathological gambling is contentious. While there is no doubt that problematic gambling exists (even industry figures no longer seem to dispute this), the area of contention lies with its concretisation, such that there are deemed to be two distinct groupings: the problem/pathological gamblers and the recreational gamblers—a dichotomy which serves to mystify rather than elucidate the social processes and contextualisation of problem gambling. (See Borrell, 2002, for a case study.) This dichotomy is adhered to in experimental designs, despite the fact that the screening tools used to identify problem gamblers incorporate the concept of problem gambling as operating on a continuum. Furthermore, there exists periodic or transient problem gambling, whereby people may move in and out of a state of problem gambling. This is also factored out of concretisations of that entity or thing called a problem/pathological gambler, inevitably leading to distortions in research findings. Importantly, for our subsequent discussion in Parts Two and Three, an overemphasis on problem- or pathological gamblers in examinations of aetiology and in prevention, leads to an overemphasis on individual human deficit (as illness or pathology) rather than on human strength. It also de-emphasises other possible causations, such as marketing, machine construction, atmosphere creation, and much more, as already mentioned. While there is no doubt that problem/pathological gamblers are deserving of support and should receive this when they seek it, it would be a mistake to put all of our “prevention eggs in this basket,” an argument that will be further developed in later sections .

Whilst conceptual dimensions are often reified for survey or experimental manipulation, there is also the age-old criticism that experimental research may lack ecological validity, i.e., that the foci of study are removed from the context in which they usually occur, thus leading to a distortion of what is observed and analysed. Because so much gambling research is psychological or experimental, the implications of such a criticism are profound, and the theme of this discussion forms an essential antithesis to such a singular decontextualised (and minimum-variable) approach. At the same time, we would like to acknowledge the field of social psychology that attempts to address this type of criticism (though it is more predominant and influential in European scholarship than in the English-speaking world). There are a growing number of gambling research psychologists who are attempting to take their studies out of the laboratory and away from the questionnaire-type interrogation and into the gaming venue, even while theoretical underpinnings may remain fundamentally individually oriented and reductionist.

We do believe that what is required is the utilisation of a more broadly based, theoretical approach that acknowledges human life and existence as social, collective, dynamic, recursive, interrelational, multi-faceted and in constant flux (yes – all of these things!). As an intellectual approach and a mode of analysis and thinking, this will inevitably have implications for all layers and stages of the research process as well as for prevention. In particular, true person-in-context research is able to account for a multitude of key existential dimensions in dynamic relation to each other, freed from the requirement to reduce human reality to a few (putatively) key variables for statistical manipulation. We would also argue that such a research approach is necessary to inform the strengthening of healthy communities with the involvement and ownership of its members (and, concomitantly, key to the prevention of ill health and “maladaptive” responses to problematic life situations).

In the following sections we will explore alternative approaches to both person- and community-oriented interventions in the (mental) health field and possible strategic applications in the area of (problem) gambling.


Part Two: Community action focused on creating healthy communities

In Part One, we briefly described the need to account for both individual agency and social structure (and all that happens in between) within a holistic and action-relevant frame of reference, and we pointed out that this is essential for adequate theorising about problem gambling; for guiding research and social inquiry; and, implicitly at this point, for forming the basis of strategies for social intervention and prevention.

The discussion from here on may necessarily diverge in large part from an explicit focus on problem/pathological gambling or its adverse social impacts, as we argue for a conceptual approach to intervention that emphasises the aetiological complexity of social life, the importance of robust community relationships, and the need to position prevention approaches in the daily life worlds that people inhabit. That is, our discussion will follow the decentring from a deficit model of intervention or treatment towards a more holistic strength-based focus on community health. At the same time a more holistic prevention approach, while being necessarily multi-faceted, may well be constituted of a wide range of discrete actions informed by community-based research that are both familiar and unfamiliar.

The following sections will focus more on the latter—on approaches to social intervention that are informed by understandings of the experiences, values, meaning-systems, and emerging and existent patterns of operating in the world by people in their everyday lives—particularly in this case, those that relate to gambling. While approaches to intervention and prevention need to be based on solid, consultative community research, complemented by research findings derived from a range of methods, an additional point needs to be reiterated, and perhaps reframed, at this point: both research and intervention need to be underpinned by a theoretical base that gives recognition to the familiar life-worlds of people in their communities as an eminently legitimate site of research and of intervention. While this would seem self-evident to some of us, it is still all too common to have reflections on this sphere dismissed as anecdotal or as somehow inferior to hard data—not the stuff of real research. In fact, if we are to recognise that individuals are affected by a continually forming and re-forming social structure, and that society is made up of acting individuals responding to and working within their social context, then we must also recognise that the life-worlds of people are the very stuff that we need to study and work strategically with, to address issues of health and well-being.

And, of course, we must never forget that the researchers, helping professionals, and social support specialists, far from being separate from or above the world under study, are part of the very culture that we need to examine in our analysis of problem gambling and intervention (and that does include their own position and role in research and practice institutions, which are often resourced by the very industry which stands to make financial gains from the phenomenon which it pays to have objectively analysed).

In conducting community research to inform municipal health plans, both of us have drawn on extensive community consultations, in combination with quantitative demographic and health data, when available. This qualitative, consultative research has formed an essential and core component of our investigations into, and analyses of, local-area community health and well-being, presented in health plans, community studies, and gambling research.

Though most of the hallmarks of our research approach are well documented in the research literature, with many contemporary examples and discussions of the relevance and scientific nature of nonpositivistic epistemologies and nonnumerical methodologies (Denzin & Lincoln, 2003; Wadsworth, 1997; the journal Qualitative Inquiry), and with utilisation to some degree by most social researchers, they are far from predominant in the problem gambling research. These hallmarks include:

a) Community consultation, often through focus groups and in-depth interviews—and perhaps surveys following from these—with open-ended questions that allow participants to largely determine the agenda or life-areas for research and analysis, rather than following prescriptions of what is pertinent as preset by researchers);

b) A reference or steering group of community representatives as research collaborators, which has input to varying degrees into the subject(s) and direction for the research, sampling decisions, method, analysis of the meaning of findings—at all stages of the research process;

c) An emphasis on the sharing of information, knowledge, and expertise for community empowerment towards ongoing, self-determined goals;

d) A reiterative process, whereby the research is seen and implemented as a conversational, discursive process. As part of this approach, the findings at different stages of the research process are communicated back to community members for feedback and to inform the subsequent research stages. (This process influences the methods being used, the people consulted, and topics or questions raised and may occur through the reference group as well as more widespread dissemination of findings at different stages of the research process);

e) A willingness to engage with the complexity (and concomitant social wholeness) of the interrelated factors that form people's lives and their interactions with each other, the community, organisations, governments, and society; and

f) “Triangulation” which refers to the procedures employed by researchers to integrate data and results deriving from different but complementary social research methods. Combining research approaches and triangulating the variously obtained data and findings strengthens the overall findings, their validity, and their reliability (an approach that could well be integrated into experimental research designs, both to inform design and to analyse findings).

In general, the above points entail a willingness to engage with the complexity (and the above-mentioned social wholeness) of the interrelated factors that form people's lives and their interactions with each other, the community, organisations, governments, and society. Importantly they also entail a recognition of people and communities as active agents and ends-in-themselves (rather than the researched-upon), thus facilitating community ownership of research, prevention, and health, and constituting potentially emancipatory practice and action. Last but not least, of course, this type of research approach requires great humility and a willingness to enter into dialogue with, and learn from, those consulted.

Through the above and related means of tapping into the aspirations, experiences, values, and patterns of social interaction within the various overlapping layers of community, we have been able to work with local government and organisations in identifying webs of interrelating health and social factors. Furthermore, we have been able to explore and identify the loci and meanings of various issues within social systems and subsystems and, associated with this, the most appropriate means and sites of intervention and prevention. In fact, community consultation has been and is essential in developing effective community health plans.

Importantly, this research approach accounts for local variation and particularity, while drawing on more broadly relevant pools of knowledge for analysis. It also allows for the social complexity arising from our multiple affiliations and converging and overlapping subsystems, for example, those relating to dominant culture, subculture, class and gender.

Thus, consultative, community-based research that accords due legitimacy to the knowledge and experience that people have about their own lives and social contexts is able to address issues where they are situated—potentially informing sites for support and community strengthening. These sites typically include the individual, the family, the community, institutions and organisations, and the workplace.

Very much congruent with the theoretical approach that we have outlined, Municipal Health Plans, aimed at intervention, prevention and community strengthening, are typically modelled on health charters developed by the World Health Organisation in recent times. Though these would be familiar to most social researchers, they are reiterated here to support this discussion:

The 1986 Ottawa Charter outlines three health promotion strategies:

  • Advocacy for health to create the essential conditions for health
  • Enabling all people to achieve their full health potential
  • Mediating between different interests in the pursuit of health

Supporting these strategies are five priority action areas:

  • Building healthy public policy
  • Creating supportive environments
  • Strengthening community action
  • Partnerships for health; increasing community capacity
  • Empowering individuals to re-orient health services

Building on this, the Jakarta Declaration on “Leading Health Promotion into the 21 st Century (1997)” confirms the Ottawa Charter's strategies and action. The Jakarta Declaration identifies five priorities:

  • Promoting social responsibility for health
  • Increasing investments for health development
  • Expanding partnerships for health promotion
  • Increasing community capacity and empowering the individual
  • Securing an infrastructure for health promotion

It is important to note the holistic approach to health that is central to this model. Health and health problems are most emphatically not something residing solely or primarily in individual pathology. Health is a social issue. Furthermore, health is not conceptualised exclusively as something we only look at when it has become a problem—as some deficit to be corrected primarily or solely at the site of the individual. Good health is an attribute of communities, and in facilitating the spread of good health we recognise this, for example, by increasing community capacity and strengthening community action.

However, a holistic public health approach predates the WHO charters; it has its origins in the nineteenth century, when health issues were starting to be addressed through public health campaigns, such as those tackling public hygiene and sanitation. Some of these were massive social and organisational feats—for example, the establishment of London's sewerage system across a multitude of local jurisdictions. Unfortunately, in a historical shift over the last 150 years, the link between social change, pressure for social reform, and public health has been lost (Kickbusch, 1989; see below). This is largely attributable to the emergence and growing power of professionals and a belief in the potency of (professional) expertise in many areas determining or conditioning our lives and lifestyles.

Importantly, a public health approach not only views the individual within a social milieu and aims to foster healthy, strong, and safe communities and workplaces. It also looks at organisational and political behaviour and examines how public policy impinges on people living in their communities. The relevance of public policy in relation to problem gambling is obvious and is often hotly debated. Examples include the entrenched and growing dependence of many governments on gambling revenue, issues of product safety in relation to gambling forms, and the level of public accessibility to, and promotion of, the form of gambling that is indisputably most related to problem gambling, i.e., that on gaming machines.

While a public health approach is still far from predominant in measures to address problematic gambling, it should be said that such a general orientation (however this is specifically conceptualised) is more familiar in Canadian and New Zealand jurisdictions. In particular, a public health theoretical approach taken by the Centre for Gambling Studies, University of Auckland, culminated in the cohosting of a conference in 2003: “Gambling Through a Public Health Lens: Health Promotion, Harm Minimisation and Treatment.” Also consistent with a public health approach is a recent initiative of the Victorian Department of Human Services (Australia), the Local Community Partnership Project, which supports the collaboration of local organisations, services, and communities to address gambling problems.

Finally, we would like to finish our theoretical overview of the public health approach with a few points from a paper by Ilona Kickbusch (1989), aptly titled “Good Planets Are Hard to Find”, which deals with public health as relating to environmental issues, and which would seem to be especially pertinent here.

The three points we will briefly cover include the complex causality inherent in health issues (which defies much of the linear or simple models necessitated by the methodology of much experimental research, as alluded to above), the need for collaborative, interdisciplinary work, and a reiteration of the need to start from everyday settings in addressing health issues .

Firstly, causality is complex. Environmental risk patterns elude simple models of causality and intervention. They tend to be cumulative, present no clear causality and do not allow for simple, straightforward cause-effect interventions.

Bateson makes the point that present day science is not able to offer the necessary explanations of the world any more and proposes instead to work with the notion…of the 'pattern that connects'. For an ecological theory of health, a key step would lie in understanding health as a pattern of relations rather than as a quantitative outcome (Kickbusch, 1989, p. 15).

Secondly, new public health needs to lift itself from petty professionalisation squabbles over specialised fields of intervention to a generalist and policy-based concern for the health of populations. This is evidently very relevant to the area of problem gambling research and prevention whereby the various research and helping professionals share far too little dialogue in addressing the complex social patterns, which lead to the generation of gambling related problems. With Kickbusch, we would highlight the need for interdisciplinary, or even better, transdisciplinary work and a wide range of research on social health, social integration, social support and belonging which could allow us to see how a break down in the ecology of human interaction leads to serious health effects. With Kickbusch, we would also like to emphasise the need to look at a science or study of health linked to feelings of belonging and social integration.

Thirdly, through a quotation by Kickbusch (1989, p. 17), we would like to reiterate the need to start from everyday settings where health or ill-health is generated and occurs:

An ecological approach moves health from an individual lifestyle/choice model to a broad gauged community issue. It starts its work with the basic and simple question: where is health created? The ecological answer—in the language of everyday—is: health is created where people live, love, work, and play. It is created by human beings in their interactions with each other and with their physical environments. The consequence for a public strategy is to commence from settings of everyday life within which health is created (rather than with disease categories) and to begin with strengthening the health potential of respective settings.

Which brings us to the third part of this discussion, attempting to locate person-oriented prevention work within the life-worlds of people.


Part Three: Person-oriented prevention that reinforces mediating structures in the form of families, communities, and other networks of people

We would like to give a brief overview of a model that goes some way towards re-establishing the importance and the legitimacy of the subjective realm within the areas of both social inquiry and community support and strengthening.

When Lloyd Williams, who founded and ran Melbourne's Crown Casino for some years, remarked (after he had left his previous functions in the Corporation!) that the spread of pokies (gaming machines) had done much damage to the “social fabric” of Victoria, he conjured up an eminently appropriate metaphor for society or community. “Fabric” refers to the (putative) existence of threads, woven and interconnected in such a way that the resulting cloth, textile, whatever, does what it is meant to do, that is, cover or support or dress its content. Fabric also refers to purposeful human activity; before coming to signify “making it up,” to “fabricate” meant to produce something. “Social” fabric thus denotes conscious and unconscious collective human endeavour, interaction, relationships, and connectedness, activities upon which our individual (as well as collective) survival depends.

There certainly has been a recent upsurge (notably in Victoria and other regions and states in Australia as elsewhere) of interest in, and attention for, community “building” and for things to do with social capital, another concept often used instead of social fabric. Witness Eva Cox, a chief proponent on the local scene of this framework for research and intervention: “Social capital refers to the processes between people which establish networks, norms and social trust and facilitate co-ordination and co-operation for mutual benefit” (1995, p. 15).

Furthermore, healthy societies and communities are said to require minimum levels of social capital, involving active relationships between community members, and the ability to:

  • work together collaboratively, resolve disputes, and respect each other's differences; and
  • trust those who are familiar and not so familiar—including mediating bodies such as organisations and governments.

Importantly, the concept of social capital provides a positive counterpoint to deficit models of problem identification and problem solving (such as those with a prime focus on treating pathological gamblers) that fail to embrace the rich supportive connections, strengths, aspirations, creative responses, and visions of people in their communities and their everyday worlds. (See also Coleman [1990], often credited with the invention of the notion of social capital, having picked it up from Bourdieu [1980]; Putnam [1993], the main source for Cox's elaboration of the concept; and, more critically but positively, Trigilia [2002]; finally, with an attempt at sorting out the various usages, Foley and Edwards [1999].)

In relation to research on problem gambling, particularly research undertaken in the qualitative mode, it is probably not so surprising that it emerges in relationship to a variety of contemporary social malaises, many related to social isolation, boredom, loneliness, feelings of meaninglessness, a need to escape from difficult life circumstances, lack of a feeling of belonging, an unfulfilled need to be valued by others, etc. In fact, much social research initially came about as a response to the massive dislocations occasioned by the effects of industrialisation and mass production from the middle of the nineteenth century onwards.

Thus, a model—such as provided by social capital approaches—would seem timely in increasing our understanding of the directions that we are taking, and of the best means by which to support and promote what is most meaningful and valuable for us as individuals and collectively as a society.


Conclusion

In this paper we have argued for the need to broaden our conception of aetiology and causality of problem gambling to include various social processes associated with the life-world of the individuals said to be afflicted with the “disorder” of problem gambling. The “life-world of individuals” includes not only their immediate and proximate environment, but equally refers to such societal and ecological processes as condition the life-worlds of both individuals and communities in a more mediated fashion; for example, political and economic processes and their multifarious interrelationships, often summarily referred to as social structure or society. We have further argued that the insertion of a widened concept of culture, mediating between the microsettings in which individuals live their daily lives and the macro structures referred to before, may help us to better ground understandings of problem gambling (as a “mental disorder”). It may also help us develop social approaches to prevention of problem gambling (and other addictions) and, indeed, lead to a precautionary approach in the planning of local provisions of leisure and recreation, rather than—in the words of the previously mentioned Mr. Williams—practicing harm minimisation when the “horse has bolted,” the horse, that is, of the uncontrolled spread of pokies into our communities.


References
Alexander, B. K.. ( 2000). The globalisation of addiction. Addiction Research, 8 (6), 501-526.
Bauman, Z.. ( 1973). Culture as praxis. London: Routledge and Keegan Paul.
Bauman, Z.. ( 1976). Towards a critical sociology. London: Routledge and Keegan Paul.
Borrell, J.. ( 2000). Critique of some VLGA research. VLGA Gambling Research Newsletter, 1 (2). Retrieved from http://www.vlga.org.au/issues/grn/2000%20October_GRN.pdf
Borrell, J.. ( 2002). Research on the impact of gaming machine modifications. VLGA Gambling Research Newsletter, 2 (7).
Borrell, J.. ( in press). Alcohol consumption and problem gambling as acts of resistance.
Boulet, J.. ( 1985). Action-theoretical reflections for social and community intervention. Unpublished doctoral dissertation, University of Michigan, Ann Arbor.
Boulet, J.. ( 1988). “Áction” as the core concept for social work epistemology, theory and practice. In Chamberlain, E.. (Ed.), Change and continuity in Australian social work (pp. 56–68). Melbourne, Victoria: Longman Cheshire.
Bourdieu, P.. ( 1977). Outline of a theory of practice. U.K.: Cambridge University Press.
Bourdieu, P.. ( 1980). Le capital social: Notes provisoires. Actes de la Recherche en Sciences Sociales, 31, 2-3.
Coleman, J.. ( 1990). Foundations of social theory. Cambridge, MA: Harvard University Press.
Cooper, B.. ( 2001). Constructivism in social work: Towards a participative practice viability. British Journal of Social Work, 31, 721-738.
Cox, E.. ( 1995). A truly civil society(Boyer Lectures). Sydney, New South Wales: ABC Books.
Denzin, N.. Lincoln, Y.. ( 2003). Handbook of qualitative research (3rd edition). Thousand Oaks, CA: Sage.
Foley, M.. Edwards, B.. ( 1999). Is it time to disinvest in social capital?Journal of Public Policy, 19, 141-173.
Giddens, A.. ( 1979). Central problems in social theory: Action, structure and contradiction in social analysis. Berkeley, CA: University Of California Press.
Giddens, A.. ( 1982). Profiles and critiques in social theory. Berkeley, CA: University Of California Press.
Horbay, R.. ( 2004). Slot tutorial treatment guide. The Problem Gamblers Help Network of West Virginia.
Inglis, F.. ( 1993). Cultural studies. Oxford, U.K.: Blackwell, U.K. Publishers.
Kickbusch, I.. ( 1989). Good planets are hard to find. Keynote address at Workshop on Sustainable Development and Health, Melbourne, Victoria.
Parke, J.. Griffiths, M.. ( in press). The psychology of the fruit machine: The role of structural characteristics (revisited).
Putnam, R.. ( 1993). Making democracy work. Princeton, NJ: Princeton University Press.
Qualitative Inquiry. Thousand Oaks, CA: Sage.
Trigilia, C.. ( 2001). Social capital and local development. European Journal of Social Theory, 4 (4), 427-442.
Wadsworth, Y.. , ( 1997). Do-it-yourself social research. St. Leonard's, New South Wales: Allen & Unwin.
Wadsworth, Y.. , ( 1997). Everyday evaluation on-the-run. St. Leonard's, New South Wales: Allen & Unwin.
Willis, P.. ( 1977). Learning to labour: How working class kids get working class jobs. London: Routledge & Kegan Paul.


Copyright © 2017 | Centre for Addiction and Mental Health
Editor-in-chief: Sherry Stewart, Ph.D.
Managing Editor: Vivien Rekkas, Ph.D. (contact)