Robin-Marie Shepherd and Tannis M. Laidlaw
This paper describes an undergraduate course in addictions within the health science sector linking theory with practice at a university in New Zealand. The essence of this addiction course includes both a strong theoretical basis and public health focus. The theoretical and practical content is described with examples of the students’ pedagogical journey in the course. Three conceptual elements lay at the foundation of this course and are easily explained by employing the symbolic allegory found in The Wizard of Oz(Baum, 1900): that of the heart (the Tin Woodman), the brain (the Scarecrow) and courage (the Cowardly Lion).
Keywords: addiction course, health science, undergraduates, public health approaches
This paper describes a course in addiction studies at the undergraduate level in the health sciences. It is offered in the final year as an elective to students studying for a health science degree, which provides an academic pathway for those students who are considering a health profession. A need to teach addictions within a health sciences curriculum has been identified (Rassool & Oyefesso, 1993) as it enhances confidence about approaching people with addictions as well as changes their attitudes towards those addicted (Miller, Sheppard, Lorinda, Colendra, Magen, 2001; Rassool & Rawaf, 2008).
The first author has been teaching the course ‘Communities and Addiction’ for the past eight years. Since there is no prerequisite to enrol in the course, it must contain the basics as well as more advanced theoretical content appropriate to final year undergraduate students. Three conceptual elements lay at the foundation of this course and are easily explained by employing the symbolic allegory found in The Wizard of Oz (Baum, 1900): that of the heart (the Tin Woodman), the brain (the Scarecrow) and courage (the Cowardly Lion).
The Yellow Brick Road is the path we follow, using the well-known story by Baum (1900), The Wizard of Oz, which was once used as a symbolic allegory of monetary populism in America (Littlefield, 1964). For those not familiar with it, The Wizard of Oz is a story for young people describing the unplanned journey of a girl (Dorothy) to the magical land of Oz where she meets a tin man who thinks he needs a heart, a scarecrow who desires a proper brain, and a lion who wishes he were more courageous. The symbolic allegory within the story: that of the heart (the Tin Woodman), the brain (the Scarecrow) and courage (the Cowardly Lion) describes the basic learning objectives which can be explained in a fun, but ultimately useful way, thus, laying a foundation of knowledge for students learning about addictions.
There is very little literature about teaching addictions at the undergraduate level of a health sciences degree, rather, publications concentrate on the teaching limited knowledge of addictive behavior to medical and nursing students (Glass, 1989; Handley, Plumber, Sullivan, Stanley, Hagemaster, 1993). These publications raise the importance of learning about substance abuse (yet ignore behavioral addictions e.g. eating disorders or gambling addiction) among future health professions. However, these courses on addiction mainly have a focus on the facts about addiction, and at times, serve the purpose of challenging the students’ attitudes towards people experiencing an addiction.
With this in mind, we invite you to take a trip along the famous yellow brick road, which will fill a gap in the addiction literature, emphasizing the added, and perhaps necessary, element of empathy.
The symbolic allegory of the heart stands for emotional reflections which are processed within each student. Arguably, developing empathy (heart) is the most important element for future professionals working with addictions. Rogers (2007) clearly posited that empathy is one of three core conditions necessary for therapeutic success (i.e. empathy, unconditional positive regard, and congruence). Empathy is defined as, ‘To sense the client’s private world as if it were your own, but without ever losing the “as if” quality – this is empathy, and this seems essential to therapy.’ (Rogers, 2007, p. 243.).
However, published studies describing courses on addictions aimed at nursing and medical students explore the students’ attitudes towards those addicted (Schroder, Sellman, & Elmslie, 2010). Attitude is, ‘a relatively enduring organization of beliefs, feelings, and behavioral tendencies towards socially significant objects, groups, events or symbols’ (Hogg, & Vaughan 2005, p. 150). There is no doubt that attitude is important, otherwise, for instance, some doctors could view those with a real disease as more worthy of treatment in comparison to a patient with the ‘disease’ of an addiction (Stuart, Burland, Ganju, Levounis & Kiosk, 2002). However, it’s important to widen the picture so that developing positive attitudes is treated as a precursor to developing a capacity for empathetic communication. Therefore, the learning process must not stop at challenging attitudes, but continue towards a full experience of empathy, which lies at the heart of therapeutic change, and in a more general sense healthy ways of living (Rogers, 2007).
In this paper, we posit that the development of empathy among students by also challenging their attitudes as a precursor as well as empathy. This process can be accomplished by using two routes within an undergraduate course on addictions. First, students are encouraged to examine addictions in their own lives (e.g. self, family or community) and understand that certain individuals, families and communities are vulnerable to addictions. This can be achieved through their assigned reflective practice exercise narratives of case studies, conventional lectures on the addiction, or guest speakers who share their journey of recovery (e.g. problem gambling, substance misuse or eating disorders).
Second, the process towards empathy can be developed or enhanced within the student by assigning them to attend a self-help meeting such as Alcoholics Anonymous (AA). Many undergraduates’ knowledge of AA is superficial at best (Shepherd, 2010; Shepherd & Pinder, 2012), with few students familiar with the 12 Steps (a spiritual process of recovery for those choosing the path of abstinence) or what the Big Book entails (it contains many inspirational stories of recovery) (Galanter, 2007; Smith & Wilson, 2013). Students become familiar with this basic knowledge known by all 12 step members, which promotes understanding of this multi-layered recovery programme.
The experiential aspect of the course has the added advantage that students challenge stereotypes they may have, therefore, no one is excluded from an addiction, and this realization may extend the students’ empathy on a larger scale. Students gradually learn to dissect myths of addiction and their own stereotypes, an example being, ʻthe adult drug pusher at the school gates’ (Hammersley & Reid, 2002, p. 10). Such myths of addiction thrive through ‘social mechanisms’; and as a consequence, students reflect upon the experiential, their own life narratives, and guest speakers who are in recovery (Hammersley & Reid, 2002, p. 7). For example, many students are shocked when someone from Overeaters Anonymous (OA) comes to the class to share their journey of recovery and they are thin or a well-dressed and articulate lawyer discuss her journey in AA (Shepherd, 2010; Shepherd & Pinder, 2012).
The brain metaphor stands for the cognitive part of the course, not only the theoretical domain, learning about etiological models of addiction, but also becoming familiar with public health paradigms. As this is the conventional part of the academic process, the lecturer guides the students in their pedagogical journey to link addiction theories and public health approaches with addictive behaviors (e.g. substance abuse and harm reduction or gambling with best practice). Time and again, the biggest challenge for students is how to link theory with the addiction. Here again, the experiential, the presenters’ stories, and/or case studies aid this process, creating the needed link. For example, many do not consider the possibility that alcoholism could be a disease until they hear someone’s journey of recovery or a lecture on how the structural components of the brain can be damaged as a result of addiction. Consequently, more students seriously consider the validity of the Disease Model (as gauged informally by votes in the classroom).
To assess in a more formal format within the context of using the Scarecrow’s brain as a metaphor, reflective practice, for example, can be deployed as an assignment. Reflective practice, in particular, offers the space and time to integrate the theoretical concepts with the experiential within the academic medium (Shepherd, 2010; Shepherd & Pinder, 2012). The results of reflective practice can guide students away from superficial thinking and into a deeper level, leading to real insight (Kolb, 2013).
To further challenge and assess the academic process using the Scarecrow’s brain as a metaphor, the students are required to create a social marketing campaign. This project challenges their ability to apply public health approaches to potentially addictive behaviors. They must create a campaign, targeting a specific at-risk population (i.e. Maori and smoking), apply the four P’s of social marketing (product, place, price and promotion) and critically evaluate their social marketing campaign’s strengths and limitations. This assignment also demands theoretical knowledge to argue their points.
As for the symbolic allegory of the so-called Cowardly Lion’s search for courage, a special kind of courageousness is needed to sit among those recovering from addictions at a 12 step support group. Courage in the students is developed in terms of self-efficacy enabling them to learn about addictions outside the safety of power point slides and academic readings. It is important to address the fears of some students when they are asked to attend a treatment facility or a twelve-step group. Some are afraid it will be an intimidating process (and, in fact, one student brought a parent along for support to attend a 12 step group). Some commented that they were afraid that they would be labelled an ‘addict’ if seen at a self-help group. A challenge for the students is to have the courage to ask questions, which can be quite personal, yet are often answered openly and honestly, as is encouraged by the treatment process. Despite initial fears, the experience has proved to be invaluable for students in developing self-efficacy, seen year after year by the first author in student evaluations of the course.
The lion metaphor, courage, is also anticipated in other ways. For instance, the course encourages students to challenge the theoretical concepts of addiction and thoroughly discuss the merits and inconsistencies. Sometimes a student comes from a culture where challenging authority is not acceptable, for example, in Asian cultures (Littlewood, 2002). In relation to some cultural protocols, it is important the student receives the explanation that they are being encouraged to challenge the theory rather than view such behavior as confrontational towards the lecturer (i.e. as disrespectful).
In the Wizard of Oz, the characters all discover they already have the very characteristics they desire – the Tin Woodman is kind and shows he had no need for an artificial heart; the Scarecrow displays ingenuity from the use of his already very good brain; the Cowardly Lion shows plenty of bravery in the face of danger and Dorothy herself is already wearing magic shoes that can return her home to Kansas. So, too, our students discover they have such potential that will allow them to become caring, wise and courageous professionals in the future.
The symbolic allegory taken from The Wizard of Oz, offers one framework with which to outline an undergraduate paper in addiction studies using the symbolic allegories of heart, brain and courage to learn about addictions in a clear and succinct and ultimately useful way.
In developing their own sense of self as a future practitioner, each student, as they travel their pedagogical journey, can put into practice the three necessary elements delineated in this paper: having the courage to challenge everything they hear and experience, the brain to ask the correct questions (such as: ‘What are the limitations?’, ‘Is it applicable to everybody?’). Only someone who can open their heart, change one’s attitude and develop empathy, is interested in the answers, yet the heart is the least likely area to be a focus in academia. This needs to be further embedded within every addictions curriculum.
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Robin-Marie Shepherd, PhD., has been teaching and conducting research at the University of Auckland since 2004. She has moved on to private practice pursuing a clinical career in Mental Health and Addictive Disorders.
Tannis M. Laidlaw, PhD., is a retired Senior Lecturer in Primary Care Mental Health at the University of Auckland and former clinical practitioner and now, instead of writing academic papers, is currently concentrating on writing novels.