____________________________________ Substance Use Disorders: Assessment and Treatment, 2nd Edition
THE DISEASE MODEL The disease model of addiction actually refers to two separate models, both of which are controversial. The older of these models forms the basis for the many traditional addiction treatment programs and 12-step approaches and is often referred to as the medical model of addiction (CASA Columbia, 2012). This model views addiction, in particular alcoholism, as a progressive disease in which some individuals are predis- posed to being or become “allergic” to the substance and thus cannot stop drinking or using the substance once they start. In this model, the disorder is seen as analogous to the disease of diabetes, which the individual can attempt to control with diet and behavioral changes, but which is lifelong, progressive, and incurable. Similarly, an “alcoholic” or “drug addict” has a lifelong disorder that requires lifelong abstinence to control it. In the words of the American Society of Addiction Medicine (https://www.asam.org/resources/definition-of-addiction, 2020), “Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engage- ment in recovery activities, addiction is progressive and can result in disability or premature death.” The more recent perspective is the “brain disease model of addiction” (BDMA; Barnett et al., 2020). Based on the concep- tualization of Alan Leshner, then director of NIDA, in 1997, and continuing today under the current NIDA director, Nora Volkow, this model views addiction as a “chronic, relapsing, brain disease” (Barnett et al., 2020). Although the initial use of a substance may be voluntary, the result is a changed brain, with the individual losing control of his or her drug use and its consequences. The acceptance of the medical disease model of addiction has resulted in the increase of insurance coverage for this problem and the growth of the substance abuse treatment industry, while the acceptance of BDMA has resulted in mil- lions of dollars spent on research focusing on identifying the brain areas affected by this disease and the medications that may help alleviate or cure it in the future (Volkow & Baler, 2014). The view of substance abuse as a disease is seen as valuable in helping individuals who abuse drugs and alcohol alleviate extreme feelings of guilt without absolving them from responsibility for their future behavior. This perspective also diminishes the usually negative countertransference reactions of clinicians. However, a growing number of professionals consider these models to be based on questionable science, and several effec- tive therapies for substance use disorder—including harm reduction techniques—do not adhere to the disease model. Actually, criticism of the disease model of addiction goes back to its earliest proposal in the 18th century. Initially, the criti- cism came from people who believed that what is now called substance use disorder was a moral failing (Fingarette, 1991). More recently, criticism has centered on the observation that the consumption of substances exists along a continuum, and selecting some point along that continuum as the point at which disease occurs is arbitrary (Fingarette, 1991). Other criticism emerges from the stripping of any social or cultural
context from the symptoms that indicate a substance use dis- ease state, when, in fact, the meaning and significance of any human behavior can be understood only within its social and cultural context (Barnett et al., 2020). FAMILIAL FACTORS Although research is limited, many clinicians view substance use problems, especially among adolescents, as the result of family dynamics. Family dynamics that may increase an ado- lescent’s risk of engaging in alcohol use include parent-child conflict, poor communication, and lack of oversight. As shown in the classic study on adverse childhood experiences (ACE study; Khalil et al., 2023), many people with SUDs were physi- cally, sexually, or otherwise abused during childhood (Khalil et al., 2023), and/or grew up in families with high incidences of multigenerational abuse of alcohol or other drugs (Straussner, 2013). Substance abuse also has been viewed as serving as an important stabilizing force in dysfunctional families (Stein- glass, 2013). For example, a child who has a substance use disorder may carry the symptoms of the larger family system dysfunction, thus helping to maintain family homeostasis. The symptomatic child then becomes the “battlefield” that keeps the problematic issues of the mother-father relationship closeted, generating intergenerational alliances that ultimately separate parents, stimulate the competition between them, and predispose the child to continued alcohol and drug use (Lander et al., 2013). However, although many clinicians believe that family dynamics play a role in adolescents’ sub- stance use disorders, treating the family dynamic alone may not be sufficient to reduce substance use, and evidence-based treatments are likely needed. PSYCHOLOGICAL FACTORS Theoretical explanations of psychological factors associated with SUDs range from psychoanalytic theories to cognitive- behavioral theories (Straussner, 2014). Psychoanalytic theo- ries posit that substance use may be a defense against sexual and aggressive drives. However, it is important to note that psychoanalysis is not an evidence-based treatment for SUDs. Therefore, this theory may not have practical implications for treatment. One of the most commonly held theories regarding substance use is the self-medication hypothesis. This theory posits that individuals engage in substance use to alleviate negative symp- toms that an individual is experiencing. The symptoms can include those of other mental health disorders such as mood or anxiety disorders, or they can include feelings of general stress or low mood (CASA Columbia, 2012; Melaku et al., 2021). This theory is consistent with the negative reinforce- ment model, suggesting that when an individual finds that engaging in a particular behavior (in this case, using substances) takes away the negative symptoms, he or she is more likely to continue that behavior because it has been reinforced. Evi- dence for the self-medication hypothesis certainly includes the high rates of mental health disorders, including PTSD,
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