Models of Addiction can be aids or barriers to getting a handle on addiction and drug use in general. In my experience, the first thing a client or counselor needs to do is figure out how they see addiction. I can’t imagine progressing in therapy without that as a starting point.
For most counselors I’ve worked with over the past few years, there is a tendency to see drug use as a static “Thing.” It’s an almost intuitive sense of what drug use, and consequently addiction, is.
The problem is that the practice of substance abuse counseling is not intuitive. Intuition is what we learn on the street, with our families, in our schools, and with our friends. Intuition is a shortcut that bypasses clinical thinking. We all have it, we all do it. It’s not inherently wrong, bad, or ineffective. Until you’re confronted with a clinical case that doesn’t fit into the neatly compartmentalized reaction to the idea of drug use and addiction, that is.
For the rest of society and culture, we all have our own ideas about drug use and addiction. Those ideas soemtimes fall apart when confronted with a family member, a friend, or a loved one who has crossed the line from substance use, misuse, and abuse into a full-fledged addiction, or more accurately dependence.
In this piece, I’ll be taking a look at some of the most common Models of Addiction. Well most of us can make it through our day today without knowing or understanding the differences, for a counselor preparing to take a certification or license exam, it’s highly suggested that you be familiar with most of the concepts listed below. This list is neither comprehensive nor exhaustive and merely introduces the concepts. In other words, reading this isn’t going to help you pass the exam as much as introduce you to the basic concepts. For non-counselors, this might be an interesting inside peak into the profession of addiction counseling.
How do You View Drug Use and Addiction
1. The Moral Model
Contrary to what many undergraduate programs may teach you, The Moral Model remains the dominant model when it comes to drug use, alcohol use, and addiction. Technically, it’s the oldest model of addction. Basically, this model states that drug and alcohol use is bad, and people who indulge are equally bad. While current academic and professional thinking has shifted this somewhat, culturally and politically, the Moral Model still dominates. Even 12-Step theory, despite claims that they have moved beyond the Moral Model, still contain elements of it in the fourth step, taking a fearless and thorough moral inventory, through the 9th step, which is making amends, and beyond. In the Moral Modal, the drug/alcohol user is always in the wrong, and it’s always a choice. Extreme as it may seem, it has permeated our cultural DNA.
The Moral Model is closely linked to other models explored later in this piece. When utilized compassionately, the Moral Model sets limits and constraints and defines acceptable versus non-acceptable behavior. However, compassion seems to be the exception rather than the rule. Many substance abuse facilities, under the guise of “doing the right thing” and “tough love,” employ morality without mindfulness and wind up distributing punishment for “non-compliant” patients.
2. The Behavioral Model
With the Behavioral Model, the underlying concept is trigger/response, similar to Classical Conditioning. Drug use, through learned behavior, evolves into addiction. Contemporary thought and research links dopamine to the process. For example, when smoking a cigarette, the nicotine triggers a release of dopamine, which is pleasurable. The cigarette smoker “learns” that certain activities such as early morning coffee, eating, and socializing are more pleasurable when smoking during or after the activity. They then become “triggered” and begin craving a cigarette because the brain is conditioned to certain dopamine levels.
Professionally, I’m very critical of this theory. Behaviorism tends to deny free will and consciousness. While it certainly has merit, and I can’t deny the existence of triggers, I think it’s unnecessarily reductive. Nicotine is every bit as powerful as dopamine, and there are effects from nicotine that go beyond the pleasurable effects of dopamine. The same can be said about other vital neurotransmitters such as gabba, endorphins, glutamate, serotonin, oxytocin, and about a dozen others. Regardless, the Behavioral Model is essential for any would-be counselor to know. It’s also the basis for other theories and models that are equally important. It’s very difficult to pass the exam if you don’t have at least a basic understanding of it.
3. The Disease Model (A): A Disease of the Brain
Of the Models of Addiction, this one dominates the world of academia and research. Many facilities and institutions consider it an ethical imperative to utilize The Disease Model as part of “best practices.” On the surface, it appears diametrically opposed to the Moral Model and closely aligned with the Behavioral Model, but with distinct differences. Very simply, this model views addiction as a disease of the brain. There are differences of opinion regarding genetic predisposition and biological factors but the bottom line remains the same. Similar to the 12-Step Model which will be discussed next, this disease of the brain is chronic and likely terminal if not arrested. Treatment approaches vary, from cognitive/behavioral to medically assisted treatment such as methadone or Vivitrol.
While it is absurd to even contemplate practicing as an addiction counselor without a thorough understanding of the Disease Model, it does have its limitations. There are serious objections to the disease model, mostly articulated by Stanton Peele and his book The Diseasing of America. The biggest objection is that, like the Behavioral Model, The Disease Model removes the idea of agency and free will. There are also serious issues with the disease process itself, which are outside the scope of this commentary. The bottom line: learn it, know it, love it. It’s doubtful that you can pass the exam without understanding it, and it’s essential for people entering recovery or treatment to know about.
4. The Disease Model (B): A Spiritual Disease
When it comes to the Models of Addiction Treatment, 12-Step reigns supreme. Roughly 90% of all addiction treatment centers utilize 12 Step theory, either directly or indirectly. It’s not an exaggeration to state that when American society or culture thinks about drug treatment, they think about 12-Step programs. Put simply, alcoholism and addiction is a disease. Unlike the first Disease Model I looked at above, it is not essentially a brain disease. 12-Step theory specifies that addiction is a spiritual disease, and the only way to overcome it is by surrendering our will to a God of our understanding, undergowing a spiritual awakening, and abstaining completely. “Half measures availed us nothing.” You must seek God, and only He (or She) can help.
AA/NA and the like are the most renowned methods of recovery today and for nearly a century. It is vital that the emerging counselor knows the theory behind it, knows the Steps, and knows how to use it in groups and sessions. However, there are severe limitations to the approach, and every year it seems to become more and more controversial. One thing to keep in mind: The Twelve Steps are not a scientifically developed treatment method like Cognitive/Behavioral, Motivational Enhancement or the Relapse Prevention Model. The science and research came decades after AA became a worldwide phenomenon.
5. The Cognitive/Behavioral Model
Aaron T Beck revolutionized counseling and therapy with his Cognitive/Behavioral Model (CBT). In 1993 he released Cognitive Therapy of Substance Abuse, developed as part of Project Match (I’ll be referring to Project Match a lot in future posts.) Today, it is one of the essential Models of Addiction. Like the Behavioral Model, CBT views addiction as a maladaptive pattern based on various forms of conditioning. What makes CBT exciting for someone like me is that it does not remove agency, but reinforces it. Ideally, it is presented in a manual approach, and the patient learns how to become their own counselor by identifying cognitive distortions, dysfunctional behavior, and countering them with opposing thoughts.
Go to almost any treatment center, and you’re likely to see CBT listed as one of the “evidence-based practices” mentioned in their literature. It’s also likely that your counselor will address “cognitive distortions” such as predictive thinking, catastrophizing, minimizing, and personalizing, among others. The thing is: this is NOT CBT, it’s a part of CBT. Cognitive Behavioral Therapy is an intensive practice with a rich grounding in theory. Practicing CBT, especially for new counselors, requires intense training and supervision. “CBT Light” as I call it isn’t destructive, but it’s not overly productive, either.
6. Biopyschosocial Model
For the first three years of my training and education, the Biopsychosocial Model was 90% of what I learned. It was so entrenched in me that when I started practicing in other states, at other kinds of facilities, I was shocked to find out that this wasn’t the dominant model of addiction. I still am. The Biopsychosicial Model (BPS) acknowledges that addiction is a complex diagnosis that involves multiple factors rather than having a single cause: it’s a medical AND psychological AND social issue.
That may seem simple to understand, but in practice it can be overwhelming. Other Models of Addiction have the benefit of being a single cause: one point of focus to account for substance abuse and dependency. BPS requires a high degree of awareness of multiple factors and causes, and is best practiced with an Interdisciplinary Treatment Team of social workers, addiction counselors, psychologists and doctors. However, its holistic nature makes room for all of the other models, just with the understanding that all (or none) of them may apply in any given situation.
7. The Life Process Model
AI Overview (with slight edits by Stanton Peele)
The life-process model of addiction is a theory that addiction is a habitual response and a source of security and gratification. The life process model is in contrast to the disease model of addiction.
Stanton Peele, along with Archie Brodsky and Mary Arnold, first proposed the life-process model in their 1991 book “The Truth About Addiction and Recovery.” Peele views drugs as one of many destructive entanglements. He believes that recovery is a gradual process that involves functioning in the real world, and that traditional disease treatments can undermine the optimism and agency that people need to improve their lives.
Proponents of the life-process model believe that people can overcome addiction by: Increasing their life options and coping mechanisms, Pursuing values and purpose, Repairing relationships, and Expressing personal agency.
Bonus: The Self-medication Hypothesis
The final Model of Addiction I’m addressing is the Self-medication Hypothesis. This seems to have faded a bit in recent years, but I predict it will gain more traction as our experiment with legalized personal and medical marijuana continues. The idea behind it is when a person uses or misuses a drug, they are trying to alleviate or cope with physical or mental health issues. We’ve all heard about people drinking a beer, smoking a joint, or taking a benzo to get over the stress, tension, or even anxiety of the day. Some people use drugs to deal with depression, some to deal with trauma.
I think you can pass the exam without knowing the self-medication hypothesis. I also think your clinical practice might be easier if you keep it in the back of your head, that the person in front of you is using drugs reasons that, for them, can actually be sound. If you’re a person currently experiencing difficulties around substances, it might be a good question for to ask yourself: am I taking or using this to get over something else I’m feeling? If so, this hypothesis might make sense.
In Conclusion
That it’s for my overview of the Models of Addiction. If you look at substance use, abuse, and addiction from the lens of anyone of these perspectives, it shapes your thinking and understanding. I am not four or against any particular model, do I do prefer the Biopsychosocial.
Another thing to keep in mind is that these are theories about why people use substances, these are not the same thing as treatment-related theories.
Whether you are a counselor, a patient, or someone researching the topic, I challenge you to identify which model do you relate to the most? Is there any model that you wish you believed in, but in actuality you act as if you believe in another? For example, many counselors I’ve known over the years will claim to be aligned with the Cognitive/Behavioral or Disease Model, but in practice they are clearly acting on the Moral Model. (Surprisingly, I’ve seen this more often in Methadone Clinics and other Harm Reduction environments, despite the best intentions of the personnel.)
In a future post, I will address the major therapeutic theories or models of addiction. But for now, I hope this has encouraged you to take a look at what you think, what do you believe, and challenge what you know.
If you live in North Carolina, and are in need of substance would be treatment or clinical supervision, you can visit my Psychology Today profile, or call me at (984) 249-2218
Thanks again for reading!!!