Focusing on the models of addiction outlined in the module notes, develop a list of the pros and cons for each of the models, as you see it. Explain those items from each model that resonate with your

DAAC 1319 Intro to AOD

Module One Notes

Models of Addiction

Models of Addiction

Your beliefs, values, training and experience will affect what model of addiction you decide to believe in. One of the purposes of this module is to expose you to an overview of the major models of addiction currently used as explanations for addictive behavior and to explore how drugs are affecting our society today. This module may elicit many emotions from you and your classmates. The purpose of class discussion will be to stir things up and cause you to explore your own beliefs and values. Perhaps during this process you may decide to expand or even change your original beliefs on the subject. It is important that you remain open to a variety of explanations of addiction in order to become a flexible counselor, better able to meet the individual needs of your clients. Be careful about putting on blinders that may inhibit your own personal and professional growth. This module is designed to help you examine the theories that explain the causes of substance abuse. You will notice that some of these theories contradict each other; each has its values and limitations. The study of the cause of a disease is called etiology.

You will notice that the learning guide notes and text book do not match up in how this information is presented. The text book speaks from a theory standing and the module notes attempt to serve as a summary of key points from the text and other resources. These concepts are similar in focus though they differ slightly. Be sure to review the PowerPoint slides to fill in any gaps between these notes and the text.

Moral Model/Moral Theory

Many assumptions and beliefs about the causes of substance abuse have been espoused. As the amount of knowledge gained through research expands, some of these explanations have been discounted or proved false. For example, the Moral Model attributes the cause of drug and alcohol problems to moral weaknesses in the character of individuals. According to this model the individual by their own actions has chosen to behave in a way that is a danger to themselves and others. This is perhaps the longest standing view of AODA (Alcohol and Other Drug Abuse). From its viewpoint AOD is seen as an infringement of societal rules by the abuser. Proponents feel it is a punishable crime and the individual is responsible for his or her choices. Some religious groups take this viewpoint and criticize AOD use as a sinful act and a crime by the laws of society. Proponents of this model believe change is possible only through personal motivation and efforts. While there is currently little support for the moral model within the drug treatment community it is, unfortunately, still a widely held belief among significant segments of the general population.

Those who advance this model do not accept that there is any biological basis for addiction. They often have scant sympathy for people with serious addictions, believing either that a person with greater moral strength could have the force of will to break an addiction, or that the addict demonstrated a great moral failure in the first place by starting the addiction. The moral model is widely applied to dependency on illegal substances, perhaps purely for social or political reasons, but is no longer widely considered to have any therapeutic value.

Temperance Model

The temperance model has habitually been confused with the moral model. This perspective began with a prohibition movement in the late 19th century. The movement emphasized the idea of moderation as primary to the shortcoming of helping drinkers. The conviction was that moderation was an impractical task. Abstinence was asserted as the only alternative. The core assumption of the temperance movement was that the addictive and destructive power of the drug is strong and that it is the drug itself that is the problem.

Medical Model/Disease Concept/Disease Theory

Dating back to the 17th century, the Disease Model experienced a revival after the repeal of the Eighteenth Amendment in 1933 (repeal of prohibition). As the term suggest, the Disease or Medical Model upholds the view that alcoholism or drug addiction is an illness in which the addict loses control of the use of the drug. In 1935, the same year Alcoholics Anonymous was founded by Bill W. and Dr. Bob, the American Disease perspective was developed primarily from the assertion that AODA is a unique, irreversible and progressive disease.

An early proponent of the Disease Model was Dr. E. M. Jellinek who published research in the 1940s and 1950s. His work, in conjunction with the growth of the twelve step program of Alcoholics Anonymous which embraces its own version of this model, led to formal acknowledgment of “alcoholism” as a disease by the World Health Organization (WHO) in 1955.

The American Medical Association gave formal recognition to the disease concept of addiction in 1956. Their recognition of alcoholism and other drug addictions as an illness is based on the following medical model:

• The illness can be described.

• The course of the illness is predictable and progressive.

• The disease is primary - that is, it is not just a symptom of some other underlying disorder.

• It is permanent.

• It is terminal. If left untreated, it results in premature death.

Dr. Jellinek described alcoholism as a disease that progress through well-defined stages of development.

• The Prealcoholic Phase is one where alcohol is used for relief of normal social tensions. Over a period of time the frequency of such drinking increases, accounting for the development of physical tolerance to the drug. Now it takes more and more alcohol to feel the same relief that was once achieved with minimal amounts. This development of tolerance indicated the more advanced stage in this phase.

• Phase two is the Prodromal Phase and is marked by the onset of blackouts (periods of amnesia not associated with loss of consciousness). During this phase the drinker becomes preoccupied with alcohol. They gulp their first drinks and avoid talking about their drinking because of the guilt and shame they may feel. The advanced stage in this phase is the increase and duration of blackouts.

• The Crucial Phase is marked by loss of control over drinking, evidenced by an inability to abstain from drinking. Repeated attempts to stop drinking are marked by relapses with a quick return to the previous level of drinking. Significant social problems arise during this phase.

• The Chronic Phase marks the final phase in the addiction process. This phase is evidenced by the onset of prolonged intoxications, loss of alcohol tolerance, and serious physical and psychological functioning impairments. According to Jellinek this is where the alcoholic hits bottom (McNeece, DiNitto, 1998).

In addition Dr. Jellinek differentiated the types of alcoholics into one of six categories:

• Alpha alcoholic: mostly a psychological dependency on alcohol to bolster an inability to cope with life. The alpha type constantly needs alcohol and becomes irritable and anxious when it is not available.

• Beta alcoholic: a social dependency on alcohol. Often, though not exclusively this type is a heavy beer drinker who continues to meet social and economic obligations. Some nutritional deficiencies can occur, including organic damage such as gastritis and cirrhosis.

• Gamma alcoholic: the most severe form of alcoholism. This type of alcoholic suffers from emotional and psychological impairment. Jellinek believed this type of alcoholic suffered from a true disease and progresses from a psychological dependence to physical dependence. Loss of control over when alcohol is consumed and how much is taken characterizes the latter phase of this type of alcoholism.

• Delta alcoholic: this is the maintenance drinker, the individuals loses control over drinking and cannot abstain for even a day or two. Many wine-drinking countries such as France and Italy contain delta-type alcoholics who sip wine throughout most of their waking hours. Being “tipsy” but never completely inebriated is typical of the delta alcoholic.

• Epsilon alcoholic: is characterized as a binge drinker. They drink excessively for a certain period (for days sometimes weeks) but then abstains completely form alcohol until the next binge period. The dependence on alcohol is both physical and psychological. Loss of control over the amount consumed is another characteristic of this type of alcoholic.

• Zeta alcoholic: this drinker was added to Jellinek’s types to describe the moderate drinker who becomes abusive and violent. Although this type is also referred to as a “pathological drinker” or “mad drunk” they may not be physically addicted to alcohol.

Genetic/Biological Models

Research into the biological causes of addiction has resulted in convincing evidence that there is a hereditary vulnerability to alcoholism. Alcohol-related disorders have been found in multiple generations of families and have been studied over time. It is believed that many people with a genetic predisposition to alcoholism will progress to dependency if they begin using alcohol. Although a similar assumption is often made about other drugs of abuse, research evidence is much more difficult to obtain. Mood-altering drugs produce various pharmacological effects. The use of drugs over time is often influenced by fads and availability. Thus, different generations of families may be exposed to different types of drugs, whereas use of alcohol has been consistent over several generations. This makes the multigenerational study of drug abuse more difficult than similar studies of alcoholism.

The observation that alcoholism runs in families is one of the most documented facts in the field of substance abuse. Research studies consistently demonstrate that the rates for alcoholism among first-degree relatives are significantly higher than among others in the population. One comparative study demonstrates that the offspring of alcoholics are approximately three to five times more likely to develop alcoholism than offspring of non-alcoholics. And estimated 20-25% of sons of alcoholics become alcoholics and about 5% of daughters. Similarly, about 20-25% of male siblings of alcoholics become alcoholic and about 5% of female siblings. Studies such as these provide incontrovertible evidence that a family history of alcoholism represents the strongest know risk factor for alcoholism (Goodwin, 1990).

Sociocultural Model

“Styles of drinking and attitudes toward alcohol vary tremendously across cultures. The United States has been a battleground of warring conceptions of drinking. Such diversity is not as apparent in contemporary American views of alcoholism, because alcohol problems are now widely considered to be primarily the results of an uncontrollable response to alcohol among those who are classified as alcoholic (Peele, 1985)”.

The Sociocultural Model of addiction looks at the similarities and differences between cultural groups and subgroups use of alcohol and drugs. There may be a great diversity regarding use within the same cultural group related to age, sex, socioeconomic class, religion, and family background (McNeece, DiNitto, 1998). Cultural attitudes regarding where, when and how much someone may drink, plays a significant role in determining acceptable drinking behaviors. This includes cultural norms regarding drunkenness. When a society imposes strong sanctions against drunkenness and encourages drinking low-proof alcoholic beverages in moderation; there appears to be a lower rate of alcoholism among that population. An example of this would be the Italians who drink most often with their families at meals, drinking mostly wine. The French on the other hand, while similar to the Italians in regards to many cultural factors, differ greatly in the attitude and use of alcohol. The French drink both wine and spirits in a variety of settings and consider it rude to refuse a drink. They do not strongly sanction drunkenness. The difference between these two cultural groups, according to the Sociocultural Model explains the fact that the French have one of the highest alcoholism rates in the world, while the Italians have a rate only 1/5th as great (Kinney, Leaton, 1987).

Another position within this model indicates that the most powerful predictor of drinking problems is not social background, but the current social environment of the drinker.

A distinct advantage of the Sociocultural model is that it views substance abusers within the larger context of their environment, and acknowledges the importance of social pressure in the development of substance abuse. Like the Systems theory discussed in the text, the sociocultural model sees the user as only part of the picture.

Psychological Model

The psychological explanation of addiction includes the paradigm that addiction is secondary to a primary mental health disorder. In other words the addict has used alcohol and drugs to self-medicate the pain caused by the primary, often undiagnosed condition. The use of alcohol and drugs serves to temporarily reduce the emotional pain. The second primary premise of this model is that an “addictive personality” predisposes the addict to compulsive behaviors. In fact this explanation is often used to understand why some addicts merely replace one addiction with another, perhaps more socially accepted behavior.

Biopsychosocial-spiritual Model

The Biopsychosocial-spiritual Model views addiction as a complex, progressive pattern having biological, psychological, sociological, spiritual and behavioral components. This model sees addiction as the result of a multitude of factors that may develop in anyone. Addicts differ in their patterns of consumption, family history, current environmental stressors, self-esteem and self-efficacy, coping skills, educational achievements, social supports, financial resources, physical and mental health, and beliefs and attitudes, including those around their drug use. An important aspect of this model is the recognition that the whole person must be treated not just the physical, social and psychological components. It is important to understand that the spiritual component does not refer to any particular religious practice, but rather to the concept of a higher power, whatever that may be to the individual. One clear advantage of this model is that it addresses more than one problem at a time (G. Miller, 2005). This model serves as an organizational framework to view the client and their presenting issues in. It does not attempt to explain the origins of addiction.

The text Concepts of Chemical Dependency has a chapter which refers to substance use disorders as a disease of the human spirit. Please refer to the PowerPoint slides for a review.

Stages of Change Model

This model describes the development of addiction in similar terms as the preparation for any behavior or major life change. This model describes five stages that occur in the process of such behavior change. First we will discuss the change process as it applies to developing an addiction then we will discuss it as a counseling tool.

In the precontemplation phase, the person is often unaware, uninterested or unwilling to make a change. This is the phase prior to the behavior change whether that change can be understood in terms of the development of the addiction or, having become addicted, the seeking of treatment. Many prevention programs, for example will target children when they are in the precontemplation phase, proving arguments and ammunition to fight the temptations of addiction that are inevitably to come. In the contemplation phase, the person may be faced with the temptation to use drugs or alcohol, and will consider their response. The preparation (or determination) phase is the time in which the person makes the actual decision and preparation to act, in the case of addiction to begin to use the substance. The next phase is the action phase which encompasses attempts to maintain the new behavior over time. The maintenance phase of addiction is complicated and dominated with negative consequences and progression of the addiction.

For our purposes the stages of change model is better understood as a counseling devise. It is important for the counselor to match their intervention strategies with where the client is at in the change process. If your client is still in precontemplation “I don’t have a drug problem” it makes little since to base your interventions in the action stage. A saying by Stephen Covey comes to mind here: “people will not change until the pain of staying the same exceeds the pain of change” (Covey, 19). You have to be prepared to meet the client where they are, not where you want them to be. The art is in identifying where they are and providing a counseling climate conducive for change, thus giving you and environment where you can begin to move them forward.

Stage One: Precontemplation

In the precontemplation stage, people are not thinking seriously about changing and are not interested in any kind of help. People in this stage tend to defend their current bad habit(s) and do not feel it is a problem. They may be defensive in the face of other people’s efforts to pressure them to quit. They do not focus their attention on quitting and tend not to discuss their bad habit with others. 

The counselor’s intervention at this stage is designed to raise doubt by increasing the client’s perception of risks and problems with their current behavior. You want to build rapport so you can later provide information about the negative consequences or risks of maintaining the status quo. Get to know the client find out what they value the most. Find something they do well and affirm that.

Stage Two: Contemplation

In the contemplation stage people are more aware of the personal consequences of their bad habit and they spend time thinking about their problem. Although they are able to consider the possibility of changing, they tend to be ambivalent about it. In this stage, people are on a teeter-totter, weighing the pros and cons of quitting or modifying their behavior. Although they think about the negative aspects of their bad habit and the positives associated with giving it up (or reducing), they may doubt that the long-term benefits associated with quitting will outweigh the short-term costs.

It might take as little as a couple weeks or as long as a lifetime to get through the contemplation stage. (In fact, some people think and think and think about giving up their bad habit and may die never having gotten beyond this stage) On the plus side, people are more open to receiving information about their bad habit, and more likely to actually use educational interventions and reflect on their own feelings and thoughts concerning their bad habit.

The counselor’s focus at this stage is to tip the balance; find reasons to change and emphasize the cost of not changing. Confront the client’s ambivalence head on. It is important to show the client how committing to change can help them realign their life to their values (Field, 2010).

Stage Three: Preparation/Determination

In the preparation/determination stage, people have made a commitment to make a change. Their motivation for changing is reflected by statements such as: “I’ve got to do something about this — this is serious. Something has to change. What can I do?” This is sort of a research phase: people are now taking small steps toward cessation. They are trying to gather information (sometimes by reading things like this) about what they will need to do to change their behavior. Or they will call a lot of clinics, trying to find out what strategies and resources are available to help them in their attempt. Too often, people skip this stage: they try to move directly from contemplation into action and fall flat on their faces because they haven’t adequately researched or accepted what it is going to take to make this major lifestyle change.

The counselor’s job at this stage of change is to help the client determine the best source of action to take.

Stage Four: Action/Willpower

This is the stage where people believe they have the ability to change their behavior and are actively involved in taking steps to change their bad behavior by using a variety of different techniques. This is the shortest of all the stages. The amount of time people spend in action varies. It generally lasts about 6 months, but it can literally be as short as one hour! This is a stage when people most depend on their own willpower. They are making overt efforts to quit or change the behavior and are at greatest risk for relapse.

Mentally, they review their commitment to themselves and develop plans to deal with both personal and external pressures that may lead to slips. They may use short-term rewards to sustain their motivation, and analyze their behavior change efforts in a way that enhances their self-confidence. People in this stage also tend to be open to receiving help and are also likely to seek support from others (a very important element).

Stage Five: Maintenance

Maintenance involves being able to successfully avoid any temptations to return to the bad habit. The goal of the maintenance stage is to maintain the new status quo. People in this stage tend to remind themselves of how much progress they have made.

People in maintenance constantly reformulate the rules of their lives and are acquiring new skills to deal with life and avoid relapse. They are able to anticipate the situations in which a relapse could occur and prepare coping strategies in advance.

They remain aware that what they are striving for is personally worthwhile and meaningful. They are patient with themselves and recognize that it often takes a while to let go of old behavior patterns and practice new ones until they are second nature to them. Even though they may have thoughts of returning to their old bad habits, they resist the temptation and stay on track.

The counselor’s focus in the action stage is to help the client develop and implement a plan. In most cases this is when you can really develop a functional treatment plan. Always assess and focus on what the client is willing to do. You can write the best treatment plan in the world but if the client has no buy in it is worthless. Don’t forget to begin work on a relapse prevention plan.

Relapse

Along the way to permanent cessation or stable reduction of a bad habit, most people experience relapse. In fact, it is much more common to have at least one relapse than not. Relapse is often accompanied by feelings of discouragement and seeing oneself as a failure.

While relapse can be discouraging, the majority of people who successfully quit do not follow a straight path to a life time free of self-destructive bad habits. Rather, they cycle through the five stages several times before achieving a stable life style change. Consequently, the Stages of Change Model considers relapse to be normal.

There is a real risk that people who relapse will experience an immediate sense of failure that can seriously undermine their self-confidence. The important thing is that if they do slip and say, have a cigarette or a drink, they shouldn’t see themselves as having failed. Rather, they should analyze how the slip happened and use it as an opportunity to learn how to cope differently. In fact, relapses can be important opportunities for learning and becoming stronger.

It is important to help the client understand that relapsing is like falling off a horse — the best thing you can do is get right back on again. However, if you do “fall off the horse” and relapse, it is important that you do not fall back to the precontemplation or contemplation stages. Rather, restart the process again at preparation, action or even the maintenance stages.

People who have relapsed may need to learn to anticipate high-risk situations (such as being with their family) more effectively, control environmental cues that tempt them to engage in their bad habits (such as being around drinking buddies), and learn how to handle unexpected episodes of stress without returning to the bad habit. This gives them a stronger sense of self control and the ability to get back on track (S Miller, 1991).

References

Reference materials used in this module have been taken from the following sources:

• A Moral Vision of Addiction: How People’s Values Determine Whether They Become and Remain Addicts by Stanton Peele published in the Journal of Drug Issues, Vol 17(2)(1987):

@ www.peele.net/lib/vision.html

• The Cultural Context of Psychological Approaches to Alcoholism by Stanton Peele in the American Psychologist, 39, 1984:

@ www.peele.net/lib/approach.html

• Covey, Stephen R., 1989, The 7 Habits of Highly Effective People, Free Press, NY

• Fields, Richard, 2010, Drugs in Perspective 7th Edition, McGraw Hill, NY

• Hanson, Venturelli, Fleckenstein, 2009, Drugs and Society, 10th Edition, Jones and Bartlett Publishers, Sudbury, MA.

• McNeece, Aaron & DiNitto, Diana, 1998, Chemical Dependency A Systems Approach, 2nd Edition, Allyn and Bacon, Needham Heights, MA.

• Miller, G., 2005, Learning the Language of Addiction Counseling, 2nd Edition, Hoboken, NJ: Wiley.

• Miller, W and Rollnick, S, 1991, Motivational Interviewing: Preparing People to Change Addictive Behaviors, Gilford Press, NY

• Kinney, Jean & Leaton, Gwen, 1987, Loosening the Grip: A Handbook of Alcohol Information, C.V., St. Louis, MO.

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