AS A CHRONIC, BIOPSYCHOSOCIAL PHENOMENON
WHAT CAUSES ADDICTION?
What causes addiction? Is it a disease? Is it a product of our environment? Is it a symptom of an underlying problem? No one theory has adequately explained the nature of addiction so, as a result, a number of treatment models have been created, each with different approaches.
Margolis and Zweben ¹ identified four theoretical models that have been developed to explain this complex condition:
- the disease model
- the learning theory model
- the psychoanalytic model
- the family theory model
As an addiction progresses, its impact extends to all aspects of functioning including health, relationships, career, and lifestyle. Treatment and prevention efforts have responded to this complexity by oversimplifying the origin and solution of addiction, and arguing with those who forward a competing theory. Historically, the disease model has been championed by physicians while learning theory and psychoanalysis supporters include psychologists: two groups of professionals not known for collaboration. To compound the problem, addiction treatment is chronically under-funded, long treated as an orphan in our health and human services system ².
However, the good news is that collaboration in the field of addiction is on a general upswing. Evidence of this fresh approach to treatment is best exemplified by the rise of the Biopsychosocial model which attempts to unify competing addiction theories into an integrated conceptual framework. The Biopsychosocial model recognizes that there are multiple pathways to addiction and that the significance of these individual pathways depends on the individual. Furthermore, the Biopsychosocial model was one of the first models to recognize the importance of treating the whole person, not just the addiction.
To fully appreciate the recent arrival of the Biopsychosocial model, however, an examination of its parts is necessary. These parts are discussed in the sections that follow.
(1) Source: Treating Patients with Alcohol and Other Drug Problems: An Integrated Approach (2001) pp. 42-87, Robert D. Margolis, Joan E. Zweben
(2) Source: Substance Abuse in Canada: Youth in Focus (September 2007) Canadian Centre on Substance Abuse, pg. 39.
Typically, addiction treatment providers, regardless of the setting (residential, outpatient, etc.) adhere to a particular model based on their personal belief of what causes addiction or marketplace expectations. The most common models are as follows:
A. THE DISEASE MODEL
The disease model has been the dominant model of treatment in the United States since the 1960s. In its purest form, the disease model contends that certain individuals have a distinct physical or psychological condition that renders them incapable of drinking or using drugs in moderation.
As part of a treatment approach, the disease model endorses working with the individual to “accept” their diagnosis and be persuaded to follow a life of abstinence from alcohol and other mood-altering drugs.
In most treatment centers, the disease model has been blended with other models. This has led to much confusion, even among clinicians and people in recovery. For example, Alcoholics Anonymous (AA) is often considered the basis for the disease model, when in fact the Big Book of AA makes little reference to the cause of alcoholism but, rather, the solution to alcoholism, which AA asserts is spirituality ¹.
Another model with which the disease model has often been associated with, to its own detriment, is the moral model. The moral model emphasizes personal choice as the main reason why individuals become addicts. Use of the moral model in treatment appears when clients fail to observe house rules or are struggling with coming to terms with their addiction. The characterization of clients as “non-compliant” or “not done yet” are examples of the moral model in practice. Treatment centers that have failed to identify and weed out the practice of passing moral judgment of clients tend to kick clients out or treat clients as second-class citizens.
A third model that the disease model is also confused with is a more recent arrival, the biological model. The biological model is the result of recent advances in genetic research, pharmacology and neuroscience. This has led supporters of the biological model to suggest that addiction is, to varying degrees depending on the individual, a hereditary brain disorder that can be treated with medication. However, it is important to note that the disease model was established well before science was capable of brain scanning and DNA mapping.
One final model that is often confused with the disease model is the characterological model which asserts that there is an addictive personality and that addiction is a personality disorder. Individuals who manifest this personality defect show heightened character defense mechanisms such as denial. Typically, treatment providers who subscribe to this belief often set themselves up for power struggles with clients, trying to break down a client’s denial and replacing resistance with compliance.
(1) Source: Models of alcoholism used in treatment: Contrasting AA and other perspectives with which it is often confused. Journal of Studies on Alcohol, 55, 159-166.
Source: Handbook of Alcoholism Treatment Approaches: Effective Alternatives (Second Edition). (1995) Reid Hester, William Miller, pp. 2 – 8.
B. LEARNING THEORY MODEL
The learning theory model focuses not so much on the internal workings of addiction such as physiology but, rather, on the thoughts (cognitions) and actions (behaviors) of individuals with addictions. The learning theory model asserts that addictive behaviors are developed in response to one’s environment. The learning theory model includes (a) behavioral modalities, (b) cognitive modalities, and (c) cognitive-behavioral modalities, which is an integration of behavioral and cognitive modalities.
C. PSYCHOANALYTIC MODEL
Psychoanalytic theory is the version of psychology made famous by Sigmund Freud, considered the “Father of Psychoanalysis.” While many of its concepts and techniques are found in other approaches, psychoanalysis (or “psychodynamic psychotherapy”) has often been criticized for treating uncontrolled drinking or drug use as a symptom of a deeper issue rather than as the central problem. Furthermore, opponents argue that this fixation on the “root” cause of addiction (especially in early stage addiction) results in clients ¹:
- wasting therapy time focusing on their life story instead of on the imminent danger posed by continued, uncontrolled drug or alcohol use
- avoiding personal accountability through denial, blame, & rationalization ²
- assuming that if they figure out the cause of their addiction that they can return to moderate drinking or drug use
- recalling past traumatic events which can trigger a relapse.
However, recent developments in psychodynamic therapy have addressed these concerns and have developed several modalities that are now making vital contributions to the treatment of addictions. These psychodynamic modalities include (a) interpersonal psychotherapy (IPT), modified dynamic group therapy (MDGT), and supportive-expressive psychotherapy (SE).
(1) Source: Treating Patients with Alcohol and Other Drug Problems: An Integrated Approach (2001) Robert D. Margolis, Joan E. Zweben, pg. 29-30.
(2) Source: Dangers of psychotherapy in the treatment of alcoholism. In M.H Bean & N.E. Zinberg (Eds.), Dynamic approaches to the understanding and treatment of alcoholism. George Vaillant. (pp. 36-54).
D. FAMILY THEORY MODEL
Family theory believes that an individual (or his addiction) cannot be understood without considering his/her relationship with his family. Family theory also asserts that families, as a whole, tend to resist change which, in turn, can affect the progress of the individual.
Defining the Term “Family” as in “Family Therapy”
The word “family” as in “family therapy” can mean:
- the immediate family (parents and their children)
- significant others (friends, extended family members, cousins, grandparents, and immediate family)
- couples (husband and wife, gay partners, common-law partners, etc.)
- multiple families
The significance of defining “family” by these four groups will become clearer in the discussion of family therapy models.
Family Therapy Models
In addiction treatment, three most common family therapy models are: (1) family systems model, (2) family behavioral model (or behavioral marital therapy), and (3) the family disease model.
Additional family therapy models include: (4) strategic family therapy, (5) structural family therapy, (6) Bowenian family therapy, (7) contextual family therapy, (8) network therapy, (9) community reinforcement approach (CRA), (10) community reinforcement and family training (CRAFT), and (11) multidimensional family therapy (MDFT).
For more information on family therapy modalities see the Help for Families & Partners section.
Source: Brief Intervention and Brief Therapies for Substance Abuse (1999) Ch. 8, Treatment Improvement Protocol (TIP) 34. DHHS Publication (SMA) 99-3353.
E. BIOPSYCHOSOCIAL (BPS) MODEL
In contrast to the traditional theories, a model called the Biopsychosocial (BPS) model has been developed to explain the complex interaction between the biological, psychological, and social aspects of addiction. It is the model most widely endorsed by treatment researchers because it can most adequately explain the intricate nature of addiction ¹. The term “Biopsychosocial” comes from combining the individual factors that contribute to the model: biological, psychological (thoughts, feelings, behaviors), and social. Many clinicians and treatment providers (particularly those in traditional addiction treatment) use the same term to include a fourth factor, spirituality.
First articulated by George Engel in 1977 ², The BPS model was originally designed as an alternative to the prevailing biomedical model, which tends to reduce illness to a single source, then treat the illness with little regard for other contributing factors such as a patient’s psychological experiences or social behaviors.
A decade later, Donovan ³ and Wallace 4 articulated a BPS model for addictive behaviors in recognition that drinking behavior and alcohol problems are multidimensional. Donovan recommended comprehensive assessment that could capture the biological, psychological and social aspects of the individual’s life that are affected by drinking. This information, Donovan hypothesized, would improve diagnosis and treatment.
Since then, others have expanded the concept of the BPS model to reflect the multiple pathways to addiction such as genetic predisposition, learned behaviour, the need for self-medication, and the impact of one’s family.
In their book, Theories on Alcoholism 5, editors Chaudron and Wilkinson incorporated eleven theories on alcoholism into three sections based on the Biopsychosocial model:
-systems theory (see the Help for Families & Partners section)
-availability theory (see the Drug Policy section)
-economic theory (see the Drug Policy section)
However, these competing theories are rarely integrated into a therapeutic program. Currently, the Biopsychosocial model in addiction remains limited in its application to assessment and treatment planning.
(1) Source: Causes of Addiction and Modalities for Treatment (1994) Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination. Technical Assistance Publication Series 11. Chapter 3. DHHS Publication (SMA) 94-2075.
(2) Source: The need for a new medical model: A challenge for biomedicine (1977) George Engle. Science 196:129‑136.
(3) Source: Assessment of addictive behaviors: Implications of an emerging biopsychosocial model (1988) In DM Donovan & GA Marlatt (eds.) Assessment of Addictive Behaviors. D M Dononvan.
(4) Source: The new disease model of alcoholism (1990) Western Journal of Medicine.152:502‑505. J Wallace.
(5) Source: Theories on Alcoholism (1988) C. Douglas Chaudron, D. Adrian Wilkinson, Alcoholism and Drug Addiction Research Foundation.
Typically, addiction treatment providers develop their programs or approaches based on one of the addiction models detailed above. This approach of exclusively following techniques suggested by one particular addiction model, however, may not be in the best interest of the client since each client may benefit from techniques offered by other treatment models.
Fortunately, the “tools not schools” movement, which endorses a range of treatment techniques and methods, is growing. The same idea described in more clinical terms was detailed by Reid and Hester who proposed that treatment providers follow an informed eclecticism ¹. This “client-centered” approach of considering the whole person is in stark contrast to the “one-size-fits-all” approach that prevails in many of today’s treatment programs.
(1) Source: Handbook of Alcoholism Treatment Approaches: Effective Alternatives (Second Edition). (1995) Reid Hester, William Miller, pp. 8-11.
FOR MORE INFORMATION
Printed Resources – General Information on Addiction Theory
The Dynamics and Treatment of Alcoholism: Essential Papers (1994)is a collection of papers that traces our understanding of alcoholism. Papers were chosen based on their insight, readability, historical relevance, and clinical utility.
Psychological Theories of Drinking and Alcoholism (1999) reviews established and emerging approaches that guide research into the psychological processes influences drinking and alcoholism. Kenneth E. Leonard, Howard T. Blane.
Theory of Addiction (2006) presents a digest of major existing theories in one volume and develops a new synthetic theory of addiction, recognizing the diversity of the experience of addiction. Robert West, Ainsley Hardy.
Theories on Alcoholism (1988) C. Douglas Chaudron, D. Adrian Wilkinson, Alcoholism and Drug Addiction Research Foundation.
Theories on Drug Abuse: Selected Contemporary Perspectives (March 1980) Dan J. Lettieri, Mollie Sayers, Helen Wallenstein Pearson, National Institute on Drugg Abuse. (Full text version available here).
Treating Substance Abuse: Theory and Technique (2003) introduce the six most prominent psychosocial treatment approaches. For each approach, includes basic theories and clinical strategies. Frederick Rotgers, Jon Morgenstern, Scott T. Walters.
Printed Resources – The Biopsychosocial Model
Addiction Treatment: A Strengths Perspective (2007) covers the biological, psychological, and social aspects of alcoholism and other addictions. Katherine van Wormer, Diane Rae Davis, Diane Davis.
Preventing Relapse in the Addictions: A Biopsychosocial Approach (1991) Emil J. Chiauzzi.
Proven Holistic Treatment for Addiction & Chronic Relapse (2006) is a self-help tool from an individual in recovery that recommends both psychological and complementary therapies such as yoga, goal setting, positive affirmations, etc. Also discusses different emotions such as anger, loneliness, etc. John J. Giordano.
Printed Resources – the Disease Model
Current Issues in Alcohol/Drug Studies (1989) includes professionals from a very wide variety of disciplines--medicine and biochemistry, psychiatry and psychology, philosophy, anthropology, law, social work, and journalism--presenting their very differing points of view on the perception of alcoholism as a disease and on public policy issues like proposed legislative controls overalcoholic beverages. Edith Lisansky Gomberg.
This Strange Illness: Alcoholism and Bill W.(2004) at once an intellectual history of Bill W.'s vision; a short history of alcohol addiction and the culture of that addiction; a treatise on the psychological, biochemical, and spiritual aspects of the illness and its treatment; and a scientific research program for the future. Jared C. Lobdell
Printed Resources - Opponents of the Disease Model
Addiction is a Choice (2000) offers new approaches to understanding addiction and explains why current policies are ineffective by allowing people to feel blameless for the consequences of their choices. Jeffrey A. Schaler.
The Alcoholism and Addiction Cure (2005) is a protocol based on the Passages Malibu treatment center which approaches addiction as a curable condition. Chris Prentiss.
Coming Clean: Overcoming Addiction Without Treatment (1999) examines stories of untreated addicts who have recovered from a lifestyle of substance abuse without professional help. A critical analysis of the disease model of addiction treatment. Robert Granfield, William Cloud.
Fighting Firewater Fictions: Moving Beyond the Disease Model of Alcoholism in First Nations (2004) is essential reading for anybody working in, or seeking to understand, aboriginal communities that are experiencing problems with alcoholism. Richard W. Thatcher.
Heavy Drinking: The Myth of Alcoholism as a Disease(1989) argues that social and political responses to alcohol problems are neglected and research programs misdirected, because the disease model prevails so strongly. A highly referenced text for opponents of the disease model. Herbert Fingarette.
Sober for Good: New Solutions for Drinking Problems (2001) is for people who don’t want to go to AA meetings or be labeled an alcoholic. Contains interviews with people who have managed to stay sober. Anne M. Fletcher.
The Useful Lie: How the Recovery Industry has Entrapped America in a Disease Model of Addiction (2004) criticizes the disease model and advocates for a Christian-based approach. William L. Playfair
Printed Resources – The Learning Theory Model
The Myth of Addiction (1997) examines the “why?” of addiction by examining human desire and intention rather than something that just happens to people. John Booth Davies
Rational-Emotive Therapy with Alcoholics and Substance Abusers (1988) Albert Ellis
Printed Resources – The Psychoanalytic Model
The Heart of Addiction (2002) explores the “why?” question of alcoholism and other addictions. Lance M. DowdsII. ONLINE RESOURCES
Online Resources – Biopsychosocial Model
A Biopsychosocial Model of Addiction (June 2000) describes the AFM’s interpretation of a Biopsychosocial understanding of addiction, its program implications and perceived benefits. Addiction Foundation of Manitoba (AFM).
The Biopsychosocial Model: Application to the Addictions Field reviews the Biopsychosocial model and its historical roots in theory, specific applications to addictions, guiding principles, and research and clinical advantages. Controversies in the Addiction Field, Chapter 7, Karol Kumpfer, Eric Trunnell, Henry Whiteside.
Evolution of the Biopsychosocial Model: Prospects and Challenges for Health Psychology(2004) identifies four areas that need to be addressed to ensure the continued evolution of the Biopsychosocial model. Jerry Suls, Alex Rothman. Health Psychology, Vol. 23, No. 2, 119-125.
Online Resources - General Information on the Disease Model
Addiction Disease Concept: Advocates and Critics (February 2001) explores the typical argument between critics and advocates of the disease concept of addiction. William L. White, Counselor Magazine.
A Disease Concept for the 21st Century (April 2001) considers the concept of the disease model and some proposals for an improved disease model. William L. White, Counselor Magazine.
Online Resources - History of the Disease Model
Alcoholics Anonymous and the Disease Concept of Alcoholism suggests that the disease concept did not originate with Alcoholics Anonymous yet its members did have a large role in spreading and popularizing that understanding. Ernest Kurtz, Behavioral Health Recovery Management (BHRM).
Addiction as a Disease: Birth of a Concept(2000) explores the ways in which disease concepts of addiction emerged and co-existed alongside more popular perceptions of chronic intemperance. Also examined is the major role the concept played in 19th century addiction treatment. William L. White, Counselor Magazine.
The Rebirth of the Disease Concept of Alcoholism in the 20th Century (2000) traces the addiction-disease concept through the 20th century, depicting its hibernation, re-emergence, and commercialization. William L. White, Counselor Magazine.William White, Ernest Kurtz, and Caroline Acker document the disease concept of addiction in the media and print - The Combined Addiction Disease Chronologies:
5th Century B.C. to 1865
Online Resources - Opponents of the Disease Model
Addiction Disease Concept: Advocates and Critics (February 2001) explores the typical arguments between critics and advocates of the disease concept of addiction. William L. White, Counselor Magazine.
Online Resources – The Psychoanalytic Model
How AA and Psychotherapy can Work Together (July 1999) Edward J. Khantzian, Psychiatric Times, Vol. XVI, Issue 7.
Online Resources - Spirituality and the Disease Model
Spiritual Evocation(June 2004) focuses on the integration of spiritual direction with the counseling style of motivational interviewing, which was designed specifically for working through ambivalence. Expertise in spiritual direction is assumed. William R. Miller, Center on Alcoholism, Substance Abuse, and Addictions (CASAA).
Video Resources - General Information on Addiction Theory
Roots of Addiction is a 30 minute video that explores why we use drugs, alcohol, even gambling, eating, etc. Includes patient interviews. CNS Productions and Haight-Ashbury Clinic.
THE DISEASE MODEL
Video Resources – The Disease Model
Video Resources - General Information on the Disease Model
These are videos that have general information on the disease model.
Video Resources - Opponents and Alternatives to the Disease Model
Alcoholism is Not a Disease (2003) explains one opinion on why alcoholism is not a disease. Stanton Peele.
Doctors Doubt Addiction Disease (2003) discusses why medical doctors struggle with labeling addiction as a disease. Stanton Peele.
Drug Addiction & Alcoholism Can Be Cured (2011) is an interview with the founder of Passages Malibu Treatment Center in California. Chriss Prentiss.
Video Resources – Learning Theory Model
Video Resources – The Psychoanalytic Model
Psychology of Substance Abuse is a program aired on PBS with Philip Zimbardo, Ph.D. that profiles a young mother who was treated with psychotherapy for her drug addiction.
Video Resources – Biopsychosocial Model
Addiction and the Brain
The Mind: Brain Mechanisms of Pleasure and Addiction explores biological motivation and addictive behavior, and takes the viewer through scientists’ work on brain stimulation.
Addiction is a PBS medical series, Second Opinion, that explores addiction as a Biopsychosocial disease, which includes working with families, medications, therapy, etc.
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