There are 7 drug categories - Stimulants, Depressants, Hallucinogens, Inhalants, Narcotics, Steroids, Cannabis. Each category impacts brain function and behavior, has particular ways of ingestion, and
Chapter 1 History and Etiological
Mode ls of Addiction
David Capuzzi
Walden University
Mark D. Stauffer
Walden University
Chelsea Sharpe
Multisystemic Therapy Therapist
Athens, Georgia
The specialists serving the highest proportion of clients with a primary addiction diagnosis
are professional counselors (20%), not social workers (7%), psychologists (6%), or
psychiatrists (3%) (Lee, Craig, Fetherson, & Simpson, 2013 , p. 2)
The history of addictions counseling, a specialization within the profession of counseling,
follows a pattern of evolution similar to that witnessed in many of the helping professions (social
work, psychology, nursing, medicine). Early practitioners had more limited education and
supervision (Ast romovich & Hoskins, 2013 ; Iarussi, Perjessy, & Reed, 2013 ), were not
licensed by regula tory boards, did not have well defined codes of ethics upon which to base
professional judgments, may not have been aware of the values and needs of diverse populations,
and did not have access to a body of research that helped define best practices and tr eatment
plans (Hogan, Gabrielsen, Luna, & Grothaus, 2003 ).
It is interesting to watch the evolution of a profession and specializations within a
profession. For example, in the late 1950s, the profession of co unseling was energized by the
availability of federal funds to prepare counselors. The impetus for the U.S. government to
provide funds for both graduate students and university departments was Russia’s launching
of Sputnik . School counselors were needed t o help prepare students for academic success,
especially in math and science, so the United States could “catch up” with its “competitors.”
As noted by Fisher and Harrison (2000) , in earlier times, barbers who also did “bloodletting”
practiced medicine, individuals who were skilled at listening to others and making suggestions
for problem re solution became known as healers, and those who could read and write and were
skilled at helping others do so became teachers with very little formal education or preparation to
work with others in such a capacity. Fifty years ago nursing degrees were conf erred without
completing a baccalaureate (today a baccalaureate is minimal and a master’s degree is rapidly
becoming the standard), a teacher could become a school counselor with 12 to 18 credits of
coursework (today a two -year master’s is the norm), and 2 0 years ago an addictions counselor
was an alcoholic or addict in recovery who used his or her prior experience with drugs as the
basis for the addictions counseling done with clients. Until the middle 1970s, there was no such thing as licensure for counselors, and those
wishing to become counselors could often do so with less than a master’s degree. In 1976,
Virginia became the first state to license counselors and outline a set of requirements that had to
be met in order to obtain a license as a counselor. It took 33 years for all 50 states to pass
licensure laws for counselors; this achievement took place in 2009 when the state of California
passed i ts licensure law for counselors.
The purpose of this chapter is threefold: first, to provide an overview of the history of substance
abuse prevention in the United States; second, to describe the most common models for
explaining the etiology of addiction; and third, to overview and relate the discussion of the
history of prevention and the models for understanding the etiology of addiction to the content of
the text.
Approaches to the Prevention of
Addiction in the United States
Alcoholic beverages have been a part of this nation’s past since the landing of the Pilgrims. Early
colonists had a high regard for alcoholic beverages because alcohol was regarded as a healthy
substance with preventive and curative capabilities rather tha n as an intoxicant. Alcohol played a
central role in promoting a sense of conviviality and community until, as time passed, the
production and consumption of alcohol caused enough concern to precipitate several versions of
the “temperance” movement (Center for Substance Abuse Prevention, 1993 ). The first of
these began in the early 1800s, wh en clergymen took the position that alcohol could corrupt both
mind and body and asked people to take a pledge to refrain from the use of distilled spirits.
In 1784, Dr. Benjamin Rush argued that alcoholism was a disease, and his writings
marked the initial development of the temperance movement. By 1810, Rush called for the
creation of a “sober house” for the care of what he called the “confirmed drun kard.”
The temperance movement’s initial goal was the replacement of excessive drinking with more
moderate and socially approved levels of drinking. Between 1825 and 1850, thinking about the
use of alcohol began to change from temperance -as -moderation to t emperance -as-abstinence
(White, 1998 ). Six artisans and workingmen started the “Washing tonian Total Abstinence
Society” in a Baltimore tavern on April 2, 1840. Members went to taverns to recruit members
and, in just a few years, precipitated a movement that inducted several hundred thousand
members. The Washingtonians were key in shaping fut ure self -help groups because they
introduced the concept of sharing experiences in closed, alcoholics only meetings. Another
version of the temperance movement occurred later in the 1800s with the emergence of the
Women’s Christian Temperance Movement and the mobilization of efforts to close down
saloons. Societies such as the Daughters of Rechab, the Daughters of Temperance, and the
Sisters of Sumaria are examples of such groups. (Readers are referre d to White’s discussion of
religious conversion as a remedy for alcoholism for more details about the influence of religion in America on the temperance movement.) These movements contributed to the growing
momentum to curtail alcohol consumption and the p assage of the Volstead Act and prohibition in
1920 (Hall, 2010). It is interesting to note that the United States was not alone during the first
quarter of the 20th century in adopting prohibition on a large scale; other countries enacting
similar legislat ion included Iceland, Finland, Norway, both czarist Russia and the Soviet Union,
the Canadian provinces, and Canada’s federal government. A majority of New Zealand voters
approved national prohibition two times but never got the legislation to be effected (Blocker,
2006). Even though Prohibition was successful in reducing per capita consumption of alcohol,
the law created such social turmoil and defiance that it was repealed in 1933. Shortly after the
passage of the Volstead Act in 1920, “speakeasies” sprang up all over the country in defiance of
prohibition. The locations of these establishments were spread by “word o f mouth” and people
were admitted to “imbibe and party” only if they knew the password. Local police departments
were kept busy identifying the locations of such speakeasies and made raids and arrests
whenever possible. Often the police were paid so that r aids did not take place and so patrons
would feel more comfortable in such establishments. Following the repeal of Prohibition, all
states restricted the sale of alcoholic beverages in some way or another to prevent or reduce
alcohol -related problems. In g eneral, however, public policies and the alcoholic beverage
industry took the position that the problems connected with the use of alcohol existed because of
the people who used it and not because of the beverage itself. This view of alcoholism became
the dominant view and force for quite some time and influenced, until recently, many of the
prevention and early treatment approaches used in this country. Paralleling the development of
attitudes and laws for the use of alcohol, the nonmedical use of drugs, o ther than alcohol, can be
traced back to the early colonization and settlement of the United States. Like alcohol, attitudes
toward the use of certain drugs, and the laws passed declaring them legal or illegal, have changed
over time and often have had rac ial/ethnic or class associations based on prejudice and less than
accurate information. Prohibition was in part a response to the drinking patterns of European
immigrants who became viewed as the lower class. Cocaine and opium were legal during the
19th ce ntury and favored by the middle and upper class, but cocaine became illegal when it was
associated with African Americans following the Reconstruction era in the United States. The
use of opium was first restricted in California during the latter part of t he 19th century when it
became associated with Chinese immigrant workers. Marijuana was legal until the 1930s when it
became associated with Mexican immigrants. LSD, legal in the 1950s, became illegal in 1967
when it became associated with the countercultu re. It is interesting to witness the varying
attitudes and laws concerning the use of marijuana. Many view marijuana as a “gateway” drug
and disapprove of the medical use of marijuana; others think that the use of marijuana should be
legalized and that acc ess should be unlimited and use monitored only by the individual
consumer. It is interesting to note that it was not until the end of the 19th century (Center for
Drug Abuse Prevention, 1993) that concern arose with respect to the use of drugs in patent
me dicines and products sold over the counter (cocaine, opium, and morphine were common
ingredients in many potions). Until 1903, believe it or not, cocaine was an ingredient in some
soft drinks. Heroin was even used in the 19th century as a nonaddicting trea tment for morphine
addiction and alcoholism. Gradually, states began to pass control and prescription laws and, in
1906, the U.S. Congress passed the Pure Food and Drug Act designed to control addiction by
requiring labels on drugs contained in products, i ncluding opium, morphine, and heroin. The
Harrison Act of 1914 resulted in the taxation of opium and coca products with registration and
record -keeping requirements. Current drug laws in the United States are derived from the 1970 Controlled Substance Act (Center for Drug Abuse Prevention, 1993), under which drugs are
classified according to their medical use, potential for abuse, and possibility of creating
dependence. Increases in per capita consumption of alcohol and illegal drugs raised public
concern s o that by 1971 the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was
established; by 1974, the National Institute on Drug Abuse (NIDA) had also been created. Both
of these institutes conducted research and had strong prevention components as p art of their
mission. To further prevention efforts, the Anti -Drug Abuse Prevention Act of 1986 created the
U.S. Office for Substance Abuse Prevention (OSAP); this office consolidated alcohol and other
drug prevention initiatives under the Alcohol, Drug Ab use, and Mental Health Administration
(ADAMHA). ADAMHA mandated that states set aside 20% of their alcohol and drug funds for
prevention efforts while the remaining 80% could be used for treatment programs. In 1992,
OSAP was changed to the Center for Subst ance Abuse Prevention (CSAP) and became part of
the new Substance Abuse and Mental Health Services Administration (SAMSHA) and retained
its major program areas. The research institutes of NIAAA and NIDA were then transferred to
the National Institutes of H ealth (NIH). The Office of National Drug Control Policy (ONDCP)
was also a significant development when it was established through the passage of the Anti -Drug
Abuse Act of 1988. It focused on dismantling drug trafficking organizations, on helping people
to stop using drugs, on preventing the use of drugs in the first place, and on preventing minors
from abusing drugs.
Time passed, and Congress declared that the United States would be drug free by 1995; that
“declaration” has not been fulfilled. Since the m id-1990s, there have been efforts to control the
recreational and nonmedical use of prescription drugs and to restrict the flow of drugs into the
country. In 2005, Congress budgeted $6.63 billion for U.S. government agencies directly focused
on the restric tion of illicit drug use. However, as noted later in this text, 13 –18 metric tons of
heroin is consumed yearly in the United States (Department of Health and Human Services
[DHHS], 2004). In addition, there has been a dramatic increase in the abuse of pres cription
opioids since the mid -1990s, largely due to initiation by adolescents and young adults. As noted
by Rigg and Murphy (2013), the incidence of prescription painkiller abuse increased by more
than 400%, from 628,000 initiates in 1990 to 2.7 million i n 2000.
There has been an attempt to restrict importation by strengthening the borders and confiscating
illegal substances before they enter the United States. There has also been an attempt to reduce
importation. The U.S. government uses foreign aid to pressure drug producing countries to stop
cultivating, producing, and processing illegal substances. Some of the foreign aid is tied to
judicial reforms, antidrug programs, and agricultural subsidies to grow legal produce (DHHS,
2004).
In an attempt to reduce drug supplies, the government has incarcerated drug suppliers.
Legislators have mandated strict enforcement of mandatory sentences, resulting in a great
incre ase in prison populations. As a result, the arrest rate of juveniles for drug -related crimes has
doubled in the past 10 years while arrest rates for other crimes have declined by 13%. A small
minority of these offenders (2 out of every 1,000) will be offer ed Juvenile Drug Court (JDC)
diversionary programs as an option to prison sentences (CASA, 2004).
During the last few years, there has been much media attention focused on the drug cartels in
Mexico and the drug wars adjacent to the U.S. border near El Pas o, Texas. In April of 2010, the
governor of Arizona signed into law legislation authorizing the police to stop anyone suspected
of being an illegal immigrant and demand proof of citizenship. Current Policies Influencing Prevention Addiction
today remains a s formidable a reality as it ever was, with 23 million Americans in substance
abuse treatment and over $180 billion a year consumed in addiction -related expenditure in the
United States (Hammer, Dingel, Ostergren, Nowakowski, & Koenig, 2012, pp. 713 –714).
There are a number of current policies influencing the prevention of addiction that should be
noted (McNeese & DiNitto, 2005) and are listed below.
All states in the United States set a minimum age for the legal consumption of alcohol and
prescribe penalti es for retailers who knowingly sell alcohol to minors and underage customers.
There are some states that penalize retailers even when a falsified identification is used to
purchase liquor.
Even though the Twenty -First Amendment repealed prohibition, the “d ry” option is still open to
individual states and some states, mainly in the South, do have dry counties.
Even though a few states still have “dry” counties, residents of those counties can often consume
alcohol in restaurants that allow patrons to enter t he establishment with a bottle of alcohol,
usually wrapped or “bagged.” The restaurant then charges a fee for opening the bottle and
allowing the liquor to be served. In addition, some counties allow liquor stores to be located just
outside the county line , perhaps in a waterway accessed by a short walk across a connecting
boardwalk or foot bridge.
Many state governments influence the price of alcohol through taxation and through the
administration of state -owned liquor stores.
As part of the initial traini ng of U.S. Air Force and Navy recruits, alcohol and tobacco use is
forbidden during basic training and for a short time during advanced and technical training. This
is because use of these substances usually has a negative effect on military readiness and
performance (Bray et al., 2010).
Besides taxation and the operation of state -owned liquor stores, government can attempt to
regulate consumption by controlling its distribution. It accomplishes this through adopting
policies regulating the number, size, lo cation, and hours of business for outlets as well as
regulating advertising.
Perhaps no other area of alcohol policy has been as emotionally charged as the setting of the
minimum legal age for consuming alcoholic beverages. Most states have adopted the age of 21
as the minimum legal age for unrestricted purchase of alcohol. This is a point of contention
among many because at age 18 the young are eligible for military service.
When a legally intoxicated individual (someone with a blood alcohol content [BAC] of 0.08 to
0.10) drives an automobile, in most states, a crime has been committed. Penalties can range from
suspension of the driver’s license to a mandatory jail sentence, depending on the frequency of
convictions.
Insurance and liability laws can also be used to influence lower consumption of alcohol because
those drivers with DUI convictions may face higher insurance premiums or may be unable to
purchase insurance. In addition, in a majority of states, commercial establishments that serve
alcoholic bever ages are civilly liable to those who experience harm as a result of an intoxicated
person’s behavior.
Public policies regarding the use of illicit drugs have not reached the same level of specificity as
those regulating the use of alcohol (and, for that ma tter, tobacco). Since 1981 and the election of
Ronald Reagan as president, federal policy has been more concerned with preventing
recreational use of drugs than with helping habitual users. The approach chosen by the George H. Bush administration was one o f zero tolerance. The George H. Bush administration did
increase treatment funding by about 50%. Simultaneously, the administration continued to focus
its attention on casual, middle -class drug use rather than with addiction or habitual use. In 1992,
the p residential candidates, George H. Bush and Bill Clinton, rarely mentioned the drug issue
except as related to adolescent drug use. In the year 2000, the major issue in the campaign of
George W. Bush was whether Mr. Bush ever used cocaine. The administratio n of George W.
Bush made very few changes in drug policy.
Of major significance is the fact that SAMHSA was reauthorized in the year 2000 (Bazelon
Center for Mental Health Law, 2000). That reauthorization created a number of new programs,
including funding for integrated treatment programs for co -occurring disorders for individuals
with both mental illness and a substance abuse disorder.
Currently, a very controversial option for policy is being considered and discussed by policy
makers (Fish, 2013). In sho rt, replacing current assumptions and causal models underlying the
war on drugs and punishment of drug users with alternative points of view could lead to a
different way of understanding drug use and abuse and to different drug policy options. These
alter natives could include refocusing our primary emphasis from attacking drugs to shrinking the
black market through a targeted policy of legalization for adults, and differentiating between
problem users (who should be offered help) and nonproblem users (who should be left alone).
We could shift from a policy of punishing and marginalizing problem users to one of harm
reduction and reintegration into society and shifting from a mandatory treatment policy to one of
voluntary treatment. Abstention need not be th e only acceptable treatment outcome because
many (but not all) problem users can become occasional, nonproblematic users.
Models For Explaining The Etiology of Addiction
Historically, addiction has been understood in various ways — a sin, a disease, a bad ha bit — each
a reflection of a variety of social, cultural, and scientific conceptions (Hammer et al., 2012, p.
713).
Substance use and abuse has been linked to a variety of societal issues and problems (crime and
violence, violence against women, child abuse, difficulties with mental health, risks during
pregnancy, sexual risk -taking, fatal injury, etc.). Given the impact the abuse of substances can
have on society in general and the toll it often levies on individuals and families, it seems
reasonable to atte mpt to understand the etiology or causes of addiction so that diagnosis and
treatment plans can be as efficacious as possible. There are numerous models for explaining the
etiology of addiction (McNeese & DiNitto, 2005); these models are not always mutuall y
exclusive and none are presented as the correct way of understanding the phenomena of
addiction. The moral, psychological, family, disease, public health, developmental, biological,
sociocultural, and some multicausal models will be described in the subs ections that follow.
The Moral Model
The moral model is based on beliefs or judgments of what is right or wrong, acceptable or
unacceptabl e. Those who advance this model do not accept that there is any biological basis for
addiction; they believe that there is something morally wrong with people who use drugs
heavily. The moral model explains addiction as a consequence of personal choice, an d
individuals who are engaging in addictive behaviors are viewed as being capable of making
alternative choices. This model has been adopted by certain religious groups and the legal system
in many states. For example, in states in which violators are not assessed for chemical
dependency and in which there is no diversion to treatment, the moral model guides the emphasis on “punishment.” In addition, in communities in which there are strong religious beliefs,
religious intervention might be seen as the only route to changing behavior. The moral model for
explaining the etiology of addiction focuses on the sinfulness inherent in human nature (Ferentzy
& Turner, 2012). Since it is difficult to establish the sinful nature of human beings through
empirically bas ed research, this model has been generally discredited by present -day scholars. It
is interesting to note, however, that the concept of addiction as sin or moral weakness continues
to influence many public policies connected with alcohol and drug abuse (Mc Neese & DiNitto,
2005). This may be part of the reason why needle/syringe exchange programs have so often been
opposed in the United States. Although the study of the etiology of alcoholism and other
addictions has made great strides in moving beyond the m oral model, alcoholics are not immune
to social stigma, and other types of addiction have yet to be widely viewed as something other
than a choice. But as we move further away from the idea that addiction is the result of moral
failure, we move closer to p roviding effective treatment and support for all those who suffer.
Psychological Models
Another explanation for the reasons people crave alcohol and other mind -altering drugs has to do
with explanations dealing with a person’s mind and emotions. There are several different
psychological models for explaining the etiology of alcoholism and drug addiction, including
cognitive -behavioral, learning, psychodynami c, and personality theory models.
Cognitive -Behavioral Models
Cognitive -behavioral models suggest a variety of motivations and reinforcers for taking drugs.
One explanation suggests that people take drugs to experience variety (Weil & Rosen, 1993 ).
Drug use might be associated with a variety of experiences such as self -exploration, religious
insights, altering moods, escape from boredom or despair, and enhancement of creativity,
performance, sensory experience, or pleasure (Lindgren, Mullins, Neighbors, & Blayney,
2010 ). If we assume that people enjoy variety, then it can be underst ood why they repeat actions
that they enjoy (positive reinforcement).
The use of mind -altering drugs received additional media attention in the 1960s, when
“flower children” sang and danced in the streets of San Francisco and other cities, sometimes
living together in communities they created. Much press was given to the use of drugs to
enhance sensory experience in connection with some of the encounter groups led by facilitators
in southern California.
The desire to experience pleasure is another explanation connected with the cognitive -behavioral
model. Alcohol and other drugs are chemical surrogates of natural reinforcers such as eating and
sex. Socia l drinkers and alcoholics often report using alcohol to relax even though studies show
that alcohol causes people to become more depressed, anxious, and nervous (NIAAA, 1996 ).
Dependent behavior with respect to the use of alcohol and other drugs is maintained by the
degree of reinforcement the person perceives as occurring; alcohol and other drugs may be perceived as being more powerful reinforcers than natural reinforcers and set the stage for
addiction. As time passes, the brain adapts to the presence of the drug or alcohol, and the person
experiences unpleasant withdrawal symptoms (e.g., a nxiety, agitation, tremors, increased blood
pressure, seizures). To avoid such unpleasant symptoms, the person consumes the substance
anew and the cycle of avoiding unpleasant reactions (negative reinforcement) occurs and a
repetitive cycle is established. In an interesting review of the literature on the etiology of
addiction (Lubman, Yucel , & Pantelis, 2004 ), it was proposed that in chemically addicted
individuals, maladaptive behaviors and high relapse rates may be conceptualized as compulsive
in nature. The apparent loss of control over drug -related behaviors suggests that individuals who
are addicted are unable to control the reward system in their lives and that addiction may be
considered a disorder of compulsive behavior very similar to obsessive compulsive disorder.
Learning Models
Learning models are closely related and somewhat over lap the explanations provided by
cognitive -behavioral models. Learning theory assumes that alcohol or drug use results in a
decrease in uncomfortable psychological states such as anxiety, stress, or tension, thus providing
positive reinforcement to the use r. This learned response continues until physical dependence
develops and, like the explanation provided within the context of cognitive -behavioral models,
the aversion of withdrawal symptoms becomes a reason and motivation for continued use.
Learning mode ls provide helpful guidelines for treatment planning because, as pointed out
by Bandura (1969) , what has been learned can be unlearned; the earlier the intervention occurs
the better, since there will be fewer behaviors to unlearn.
Psychodynamic Models
Psychodynamic models link addiction to ego deficiencies, inadequate parenting, attachment
disorders, hostility, homosexuality, masturbation, and so on. As noted by numerous researchers
and clinicians, such models are difficult to substantiate through research since they deal with
concepts difficult to operationalize and with events that occurre d many years prior to the
development of addictive behavior. A major problem with psychodynamic models is that the
difficulties linked to early childhood development are not specific to alcoholism or addiction, but
are reported by nonaddicted adults with a variety of other psychological problems (McNeese &
DiNitto, 2005 ). Nevertheless, curre nt thinking relative to the use of psychodynamic models as a
potential explanation for the etiology of addiction has the following beliefs in common (Dodgen
& Shea, 2000 ):
1. Substance abuse can be viewed as symptomatic of more basic psychopathology.
2. Difficulty with an individual’s regulation of affect can be seen as a core problem or
difficulty.
3. Disturbed object relations may be central to the development of substance abuse.
Readers are referred to Chapter 12 of Slaying the Dragon: The History of Addiction Treatment
and Recovery in America by Willi am L. White (1998) for a more extensive discussion of
psychodynamic models in the context of the etiology of addiction.
Personality Theory Models These theories make the assumption that certain personality traits predispose the individual to
drug use. An “ alcoholic personality” is often described by traits such as dependent, immature,
impulsive, highly emotional, having low frustration tolerance, unable to express anger, and
confused about their sex role orientation (Catanzaro, 1967 ; Milivojevic et al.,
2012 ; Sc huckit, 1986 ).
Although many tests have been constructed to attempt to identify the personality traits of a drug -
addicted person, none have consistently distinguished the traits of the addicted individual from
those of the nonaddicted individual. One of th e subscales of the Minnesota Multiphasic
Personality Inventory does differentiate alcoholics from the general population, but it may only
be detecting the results of years of alcoholic abuse rather than underlying personality traits
(MacAndrew, 1979 ). The consensus among those who work in the addictions counseling arena
seems to be that pers onality traits are not of much importance in explaining addiction because an
individual can become drug dependent irrespective of personality traits (Raistrick & Davidson,
1985 ).
Family Models
As noted in Chapter 14 , during the infancy of the field of addictions counseling, addictions
counselors were used to working only with the addict. Family members were excluded.
However, it soon became clear that family members were influential in mo tivating the addict to
get sober or in preventing the addict from making serious changes.
There are at least three models of family -based approaches to understanding the development of
substance abuse (Dodgen & Shea, 2000 ).
Behavioral Models
A major theme of the behavioral model is, that within the context of the family, there is a
member (o r members) who reinforces the behavior of the abusing family member. A spouse or
significant other, for example, may make excuses for the family member or even prefer the
behavior of the abusing family member when that family member is under the influence of
alcohol or another drug. Some family members may not know how to relate to a particular
family member when he or she is not “under the influence.”
Family Systems
There have been many studies demonstrating the role of the family in the etiology of drug abuse
(Baron, Abolmagd, Erfan, & El Rakhawy, 2010 ). As noted in Chapter 14 , the family
systems m odel focuses on the way roles in families interrelate (Tafa & Baiocco, 2009 ). Some
fami ly members may feel threatened if the person with the abuse problem shows signs of
wanting to recover since caretaker roles, for example, would no longer be necessary within the
family system if the member began behaving more responsibly. The possibility o f adjusting roles
could be so anxiety producing that members of the family begin resisting all attempts of the
“identified patient” to shift relationships and change familiar patterns of day -to-day living within
the family system. Family Disease
This model is based on the idea that the entire family has a disorder or disease, and all must enter
counseling or therapy for improvement to occur within the addicted family member. This is very
different from approaches to family counseling in which the counselor is willing to work with
whichever family members will come to the sessions, even though every family member is not
present.
The Disease Model
The disease concept follows the medical model and posits addiction as an inherited diseas e that
chemically alters the body in such a way that the individual is permanently ill at a genetic level
(Lee et al., 2013, p. 4). E. M. Jellinek (1960) is generally credited with introducing this
controversial and initially popular model of addiction in the late 1930s and early 1940s (Stein &
Foltz, 2009). However, it is interesting to note that, as early as the later part of the 18th century,
the teachings and writings of Benjamin Rush, the Surgeon General of George Washington’s
revolutionary armies, act ually precipitated the birth of the American disease concept of
alcoholism as an addiction (White, 1998). In the context of this model, addiction is viewed as a
primary disease rather than being secondary to another condition (reference the discussion,
ear lier in this chapter, of psychological models). Jellinek’s disease model was originally applied
to alcoholism but has been generalized to addiction to other drugs. In conjunction with his work,
Jellinek also described the progressive stages of the disease of alcoholism and the symptoms
connected with each stage. These stages (prodromal, middle or crucial, and chronic) were
thought to be progressive and not reversible. Consistent with this concept of irreversibility is the
belief that addictive disease is ch ronic and incurable. Once the individual has this disease,
according to the model, it never goes away, and there is no treatment method that will enable the
individual to use again without the high probability that the addict will revert to problematic use
of the drug of choice. One implication of this philosophy is that the goal for an addict must be
abstinence, which is the position taken by Alcoholics Anonymous (Fisher & Harrison, 2005). In
addition, the idea that addiction is both chronic and incurable is the reason that addicts who are
maintaining sobriety refer to themselves as “recovering” rather than as “recovered.” The
vocabulary of recovery was first used by Alcoholics Anonymous in 1939. It is significant
because we use the term recovery in the con text of disease or illness rather than in connection
with moral failure or character deficits. This reinforces the disease model to explain the etiology
of addiction. Interestingly, although Jellinek’s disease model of addiction has received wide
acceptanc e (Ferentzy & Turner, 2012), the research from which he derived his conclusions has
been questioned. Jellinek’s data were gathered from questionnaires. Of the 158 questionnaires
distributed, 60 were discarded; no questionnaires from women were used. The qu estions about
the original research, which led to the conceptualization of the “disease” model, have led to
controversy. On the one hand, the articulation of addiction as a disease removes the moral stigma
attached to addiction and replaces it with an emph asis on treatment of an illness, results in
treatment coverage by insurance carriers, and sometimes encourages the individual to seek
assistance much like that requested for diabetes, hypertension, or high cholesterol. On the other
hand, the progressive, i rreversible progression of addiction through stages does not always occur
as predicted, and the disease concept may promote the idea for some individuals that one is powerless over the disease, is not responsible for behavior, may relapse after treatment, or may
engage in criminal behavior to support the “habit.”
The Public Health Mode
l It is interesting to note that the public health model was not originally conceptualized to focus on
psychobehavioral ailments since, from its early beginnings, the emphasis has been on promoting healthy
behaviors. As noted by Ferentzy and Turner (2012), the 20th -century psych iatrist Paul Lemkau, founding
chairperson of the Mental Hygiene department in the Johns Hopkins University School of Public Health,
was one of the first to apply a public health model to mental disorders. Lemkau promoted the
establishment of community, rat her than residential, treatment centers because he believed that
mental health, including the treatment of addiction, was a public rather than a private issue. Lemkau
believed that when individuals did not engage in healthy behaviors and became addicted, i t was because
of the impact of social issues. He viewed addiction as a societal disease, in direct contrast to the more
dominant, individualistic conceptions associated with the disease model.
The Developmental Model
As noted by Sloboda, Glantz, and Tarter (2012), the etiology of addiction can also be explicated by
applying a developmental framework to understand the factors that increase or decrease risks for the
individual to use or misuse drugs. They posited that vulnerability is never static or unchangi ng, but varies
across the life span. Sloboda and her colleagues examined some of the key developmental
competencies associated with the following developmental stages: prenatal through early childhood,
middle childhood, adolescence, late adolescence/early adulthood, and adulthood. This research
provided detailed examples of competencies that must be mastered during each of these
developmental stages to decrease the possibility of engaging in risky behavior that includes the use and
misuse of drugs. Readers interested in exploring the developmental model for understanding the
etiology of addiction will find the Sloboda et al. (2012) an article excellent starting point for additional
study.
Biological Models
Biophysiological and genetic theories assume that ad dicts are constitutionally predisposed to develop
dependence on drugs. These theories or models support a medical model of addiction, apply disease
terminology, and often place the responsibility for treatment under the purview of physicians, nurses,
and o ther medical personnel. Usually, biological explanations branch into genetic and neurobiological
discussions.
Genetic Models
Although genetic factors have never really been established as a definitive cause of alcoholism, the
statistical associations betwe en genetic factors and alcohol abuse are very strong. For example, it has
been established that adopted children more closely resemble their biological parents than their
adoptive parents when it comes to their use of alcohol (Dodgen & Shea, 2000; Goodwin, Hill, Powell, &
Viamontes, 1973); alcoholism occurs more frequently in some families than others (Cotton, 1979);
concurrent alcoholism rates are higher in monozygotic twin pairs than in dizygotic pairs (Kaij, 1960); and
children of alcoholics can be as mu ch as seven times more likely to be addicted than children whose parents are not alcoholic (Koopmans & Boomsina, 1995). Because of such data, some genetic theorists
have posited that an inherited metabolic defect may interact with environmental elements an d lead, in
time, to alcoholism. Some research points to an impaired production of enzymes within the body and
yet other lines of inquiry point to the inheritance of genetic traits that result in a deficiency of vitamins
(probably the vitamin B complex), wh ich leads to a craving for alcohol as well as the accompanying
cellular or metabolic changes. There have been numerous additional lines of inquiry that have
attempted to establish a genetic marker that predisposes a person toward alcoholism or other
addict ions (Bevilacqua & Goldman, 2010). Studies that examined polymorphisms in gene products and
DNA, the D2 receptor gene, and even color blindness as factors have all been conducted and then later
more or less discounted. Genetic research on addiction shows p otential, but is a complex activity given
the fact that each individual carries genes located on 23 pairs of chromosomes. The Human Genome
Project, which is supported by the National Institutes of Health and the U.S. Department of Energy, is
conducting som e promising studies (NIAAA, 2000).
Neurobiological Models
Neurobiological models are complex (Jacob, 2013) and have to do with the neurotransmitters in the
brain that serve as the chemical messengers of our brain (Hammer et al., 2012); Kranzler & Li, 2008;
Wilcox, Gonzales, & Miller, 1998). Almost all addictive drugs, as far as we know, seem to have primary
transmitter targets for their actions. The area of the brain in which addiction occurs is the limbic system
or the emotional part of the brain. The limb ic part of the brain refers to an inner margin of the brain just
outside the cerebral ventricles, and the transmitter dopamine is key in its activity in the limbic system
and the development of addiction. As a person begins to use a drug, changes in brain chemistry in the
limbic system begin to occur and lead to addiction. Current thinking is that these changes can also be
reversed by the introduction of other drugs in concert with counseling and psychotherapy.
Sociocultural Models
Sociocultural models have been formulated by making observations of the differences and similarities
between cultural groups and subgroups. As noted by Goode (1972), the social context of drug use
strongly influences drug definitions, drug effects, drug -related behavior, and the d rug experience. These
are contextual models and can only be understood in relation to the social phenomena surrounding
drug use. A person’s likelihood of using drugs, according to these models, the way he/she behaves, and
the way abuse and addiction are de fined are all influenced by the sociocultural system surrounding the
individual.
Supracultural Models
The classic work of Bales (1946) provided some hypotheses connecting culture, social organization, and
the use of alcohol. He believed that cultures that create guilt, suppress aggression and sexual tension,
and that support the use of alcohol to relieve those tensions will probably have high rates of alcoholism.
Bales also hypothesized that the culture’s collective attitude toward alcohol use could influen ce the rate
of alcoholism. Interestingly, he categorized these attitudes as favoring (1) abstinence, (2) ritual use
connected with religious practices, (3) convivial drinking in a social setting, and (4) utilitarian drinking
(drinking for personal reasons) . The fourth attitude (utilitarian) in a culture that produces high levels of
tension is the most likely to lead to high levels of alcoholism; the other three attitudes lessen the
probability of high alcoholism rates. Another important aspect of Bales’ thi nking is the degree to which the culture offers alternatives to alcohol use to relieve tension and to provide a substitute means of
satisfaction. A culture that emphasizes upward economic or social mobility will frustrate individuals who
are unable to achi eve at such high levels and increase the possibility of high alcoholism rates. In 1974,
Bacon theorized that high rates of alcoholism were likely to exist in cultures that combine a lack of
indulgence toward children with demanding attitudes toward achieve ment and negative attitudes
toward dependent behavior in adults. An additional important factor in supracultural models is the
degree of consensus in the culture regarding alcohol and drug use. In cultures in which there is little
agreement, a higher rate of alcoholism and other drug use can be expected. Cultural ambivalence
regarding the use of alcohol and drugs can result in the weakening of social controls, which allows the
individual to avoid being looked upon in an unfavorable manner.
Culture -Specific Models
Culture -specific models of addiction are simultaneously fascinating and hampered by the possibilities
inherent in promoting stereotypes and overgeneralizing about the characteristics of those who “seem”
to fit the specific culture under consideration. For example, there are many similarities between the
French and Italian cultures since both cultures are profoun dly Catholic and both cultures support
wineries and have populations that consume alcohol quite freely (Levin, 1989). The French drink both
wine and spirits, with meals and without, at home as well as away from the family. The French often
consider it bad manners to refuse a drink, and the attitudes toward drinking too much are usually quite
liberal. The Italians drink mostly wine, with meals and at home, and they strongly disapprove of public
misconduct due to the overconsumption of wine. They do not press ure others into accepting a drink.
In some Italian American families children over the age of about 10 can drink wine with dinner, but are
admonished never to drink lar ge amounts of wine; wine is to be enjoyed in social situations and is never
to be consumed in excess. As a result, these children usually become adults who drink wine in
moderation and never have problems derived by too much consumption of alcoholic bevera ges
. As the reader might expect from prior discussion, the rate of alcoholism in France is much more
problematic than that which exists in Italy. Although the authors would agree that the prevailing
customs and attitudes relating to the consumption of alco hol in a specific culture can provide insight and
have usefulness as a possible explanation of the etiology of addiction in the culture under consideration,
readers should be cautious about cultural stereotyping and make every attempt to address diversity
issues in counseling as outlined in the current version of the Code of Ethics of the American Counseling
Association (ACA) as well as the ACA guidelines for culturally competent counseling practices. (See the
ACA website at www.counseling.org .)
Subcultural Models It should also be briefly noted that there have been many investigations of both
sociological and environmental causes of addiction and alcoholism at the subcultural level. Factors
related to age, gender, ethnicity, socioeconomic class, religion, a nd family background can create
different patterns within specific cultural groups (McNeese & DiNitto, 2005; White, 1998). They also can
be identified as additional reasons why counselors and other members of the helping professions must
vigilantly protect the rights of clients to be seen and heard for who they really are rather than who they
might be assumed to resemble.
Multicausal Models The great challenge to understanding the etiology of drug use and drug use disorders is the complexity
of the phenomen on itself (Sloboda et al., 2012, p. 954).
At this point in your reading you may be wondering which of these etiological models or explanations of
addiction is the correct model. As you may have already surmised, although all of these models are
helpful and important information for counselors beginning their studies in addiction counseling, no
single model adequately explains why some individuals become addicted to a substance and others do
not. An important advance in the study of addiction is the realizat ion that addiction is probably not
caused by a single factor, and the most likely models for increasing our understanding and our
development of treatment options are multivariate (Buu et al., 2009; McNeese & DiNitto, 2005; Stevens
& Smith, 2005). Even tho ugh there may be some similarities in all addicted individuals, the etiology and
motivation for the use of drugs varies from person to person. For some individuals, there may be a
genetic predisposition or some kind of a physiological reason for use and la ter addiction to a drug. For
others, addiction may be a result of an irregularity or disturbance of some kind in their personal
development without a known genetic predisposition or physiological dysfunction. The possible debate
over which model is the cor rect model is valuable only because it assists the practitioner to see the
importance of adopting an interdisciplinary or multicausal model.
An interesting example of a multicausal model that has been proposed is the syndrome model of
addiction (Shaffer et al., 2004). This model suggests that the current research pertaining to excessive
eating, gambling, sexual behaviors, shopping, substance abuse, and so on does not adequately capture
the origin, nature, and processes of addiction. The researchers believe that the current view of
addictions is very similar to the view held during the early days of AIDS awareness when rare diseases
were not recognized as opportunistic infections of an underlying immune deficiency syndrome. The
syndrome model of addiction sug gests that there are multiple and interacting antecedents of addiction
that can be organized in at least three primary areas: (1) shared neurobiological antecedents, (2) shared
psychosocial antecedents, and (3) shared experiences and consequences. Another promising example of
a multicausal model is the integral model (Amodia, Cano, & Eliason, 2005). This integral approach
examines substance abuse etiology and treatment from a four -quadrant perspective adapted from the
work of Ken Wilbur. It also incorporate s concepts from integrative medicine and transpersonal
psychology. Readers are referred to the references cited in this subsection for more complete
information about both the syndrome and integral models.
The multicausal model is similar to the public hea lth model recently adopted by health care and other
human service professionals. This model conceptualizes the problem of addiction as an interaction
among three factors: the “agent” or drug, the “host” or person, and the “environment,” which may be
compri sed of a number of entities. When the agent or drug interacts with the host, it is important to
realize that there are a variety of factors within the host, including the person’s genetic composition,
cognitive structure and expectations about drug experie nces, family background, and personality traits,
that must be taken into consideration as a treatment plan is developed. Environmental factors that need
to be considered include social, political, cultural, and economic variables. When a counselor or
thera pist uses a multicausal model to guide the diagnosis and treatment planning process, the complex
interaction of several variables must be taken into consideration.
