The basis of addiction is controversial. Professionals view it as a disease or a choice. One model is referred to as the Disease model of addiction. The second model is the Choice model of addiction. Researchers argue that the addiction process is like the disease model with a target organ being the brain, some type of defect, and symptoms of the disease. Addiction is like the choice model with a disorder of genes, a reward, memory, stress, and choice. Both models result in compulsive behaviour.
Substance addictions relate to drugs, alcohol, and smoking. Process addictions relate to non-substance-related behaviours such as gambling, spending, sexual activity, gaming, the internet, and food.
Psychologists‘ oldest definition of addiction is that the addict has a lack of self-control. The addicted party wants to abstain, but they can not resist the temptation. Addicts lose control over their actions. It is viewed that an addict battles with their addiction and wanting abstinence and gain control over their actions.
Refer to Addiction Psychiatry, Addiction Psychology, Addiction Medicine, American Academy of Addiction Psychiatry, Addictive Personality, Addiction Vulnerability, Addiction-Related Structural Neuroplasticity, and American Society of Addiction Medicine.
The word ‘addiction’ has successfully been traced to the 17th century. During this time period, addiction was defined as being compelled to act out any number of bad habits. Persons abusing narcotics were called opium and morphine ‘eaters.’ ‘Drunkard’ referred to abusers of alcohol. Medical textbooks categorised these ‘bad habits’ as dipsomania or alcoholism. However, it was not until the 19th century when the diagnosis was first printed in medical literature. In the 1880s, Sigmund Freud and William Halsted began experimenting with users of cocaine. Unaware of the drug’s powerful addictive qualities, they inadvertently became guinea pigs in their own research and, as a result, their contributions to psychology and medicine changed the world.
While working in Vienna General Hospital (Vienna Krankenhaus), in Austria, cocaine took possession over Freud’s life when he found cocaine to relieve his migraine. When the effect of cocaine decreased, the amount of cocaine Freud consumed increased. With information about the pain suppressing properties of cocaine, physicians began prescribing cocaine to their patients who required pain relief.
Unaware of Freud and Halsted’s experiments with cocaine, American Physician W.H. Bentley was conducting his own similar experiments. The Index Medicus published his article describing how he successfully treated patients with cocaine who were addicted to opium and alcohol. In the late 1800s the use of cocaine as a recreational drug spread like a worldwide epidemic.
As cocaine continued to spread physicians began looking for ways to treat patients with opium, cocaine, and alcohol addictions. Physicians debated the existence of the label ‘addictive personality’ but believed the qualities Freud possessed (bold risk taking, emotional scar tissue, and psychic turmoil) were of those that fostered the ‘addictive personality’.
Physician Sigmund Freud, born on 06 May 1856, in Freiberg, France (an area now known as Pribor in the Czech Republic), was instrumental in the field of psychology. Dream interpretation and psychoanalysis (also known as talk therapy) are two of his well-known contributions. Psychoanalysis is used to treat a multitude of conditions including addictions. As one of the most influential thinkers in the 20th century, he altered the way we perceive ourselves and communicate about our perceptions as a number of his theories have been popularised and terms he created have entered into general language.
Theories on mental health, personality development and illness that Freud developed are considered highly controversial. According to Freud, people are endowed with three levels of awareness: conscious, preconscious, and unconscious, where conscious level refers to what we are fully appreciative of, preconscious is what people could be aware of if they became more attentive, and unconscious level includes facts that humans cannot be aware of. The aim of the therapy is to turn unconscious into conscious.
William Halsted, born on 23 September 1852, in New York City, received his degree in medicine in 1877. Throughout his medical career as a surgeon he contributed surgical techniques that ultimately led to improvement of the patient’s outcome following surgery. During Halsted’s professional career, he (along with Freud) conducted experiments with the drug cocaine. While their research was in process they became guinea pigs for their own experiments when they became addicted to cocaine. In 1884 he became the first to describe how cocaine could be utilized as a localized anaesthetic when injecting into the trunk of a sensory nerve, and how the localized ischemia prolonged the anaesthetic properties of the drug.
G. Alan Marlatt was a pioneer in the field of addiction psychology. Born in Vancouver, British Columbia, in 1941, he spent his professional career as an addiction psychologist, researcher, and director of the University of Washington’s Addictive Behaviours Research Centre and professor in the Department of Psychology. Marlatt adopted the theory of harm reduction, and developed and scientifically tested ways to prevent an addict’s slip from becoming a relapse. He understood that expecting immediate and complete abstinence from addicts often deterred addicts from seeking the help they needed and deserved. Marlatt died on 14 March 2011.
A. Thomas McLellan was born in 1949 in Staten Island, New York. He is a professor at the University of Pennsylvania School of Medicine at the Centre for Studies of Addiction. McLellan serves or has served on editorial boards as a reviewer of medical and scientific journals, and as an advisor to government and non-profit organizations including the National Practice Laboratory of the American Psychiatric Association, and the World Health Organization. He is co-founder and chief executive officer of the Treatment Research Institute located in Philadelphia, Pennsylvania. McLellan has conducted decades of research for the efficacy of treatment for substance abuse patients, and is recognized both at the national and international level as an addiction psychologist. He is also known for the development of the Addiction Severity Index or ASI and serves as editor-in-chief of the Journal of Substance Abuse Treatment and the deputy officer of National Drug Control Policy, Research and Evaluation.
Arnold Washton has specialised in addiction since 1975 and is an addiction psychologist known for his work in the development of therapeutic approaches to the treatment of drug and alcohol abuse. He is the author of many books and professional journal articles on treatment and addiction. He is a lecturer, clinician, researcher, and has served on the advisory committee for the US Food and Drug Administration. Washton is the founder and executive director of Recovery Options, a private addiction treatment practice located in New York City and Princeton, New Jersey.
William L. White is a Senior Research Consultant at Chestnut Health Systems, an addiction counsellor, researcher and writer in the field of addiction for over 45 years. He wrote over 400 papers and 18 books. He received awards from the National Association of Addiction Treatment Providers (NAATP), the National Council on Alcoholism and Drug Dependence, (NAADAC), the Association of Addiction Professionals and the American Society of Addiction Medicine (ASAM).
Addiction is a progressive disease and psychiatric disorder that is defined by the American Society of Addiction Medicine as “a primary, chronic disease of brain reward, motivation, memory and related circuitry. It is characterized by the inability to control behaviour, it creates a dysfunctional emotional response, and it affects the users ability to abstain from the substance or behaviour consistently. Psychology Today defines addiction as “a state that can occur when a person either consumes a substance such as nicotine, cocaine, or, alcohol or engages in an activity such as gambling or shopping/spending.”
When a non-addict takes a drug or performs a behaviour for the first time he/she does not automatically become an addict. Over time the non-addict chooses to continue to engage in a behaviour or ingest a substance because of the pleasure the non-addict receives. The now addict has lost the ability to choose or forego the behaviour or substance and the behaviour becomes a compulsive action. The change from non-addict to addict occurs largely from the effects of prolonged substance use and behaviour activities on brain functioning. Addiction affects the brain circuits of reward and motivation, learning and memory, and the inhibitory control over behaviour.
There are different schools of thought regarding the terms dependence and addiction when referring to drugs and behaviours. One adopted belief is that “drug dependence” equals “addiction.” The second belief is that the two terms do not equal each other. According to the DSM, the clinical criteria for “drug dependence” (or what we refer to as addiction) include compulsive drug use despite harmful consequences; inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal.
The latter reflects physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs – including even appropriate, medically instructed use. Thus, physical dependence in and of itself does not constitute addiction, but often accompanies addiction. This distinction can be difficult to discern, particularly with prescribed pain medications, where the need for increasing dosages can represent tolerance or a worsening underlying problem, as opposed to the beginning of abuse or addiction.
There are some characteristics of addiction that regardless of the type share commonalities. The behaviour provides a rapid and potent means of altering mood, thoughts, and sensations of a person which occur because of physiology and learned expectations. The immediate precipitating factors of the relapse, the timing of the relapse and the rate of relapse following treatment is high.
American Psychological Association
The American Psychological Association (APA) is a professional psychological organisation and is the largest association of psychologists in the United States. Over 100,000 researchers, educators, clinicians and students support the association through their membership. Their mission “is to advance the creation, communication and application of psychological knowledge to benefit society and improve people’s lives.”
APA supports 54 divisions, two of which pertain to addictions. Division 50, Society of Addiction Psychology promotes advances in research, professional training, and clinical practice within the range of addictive behaviours. Addictive behaviours include problematic use of alcohol, nicotine, and other drugs as well as disorders involving gambling, eating, spending, and sexual behaviour. Division 28, Psychopharmacology and Substance Abuse promotes teaching, research, and dissemination of information regarding the effects of drugs on behaviour.
The College of Professional Psychology (CPP), hosted by the American Psychological Association Practice Organization, previously offered a certificate to psychologists whom demonstrated proficiency in the psychological treatment of alcohol and other substance-related disorders. The CPP maintains the certificate of proficiency for persons who acquired it prior to 2011. The Society of Addiction Psychology certificate will be re-instated while the Society examines other avenues for credentialing professionals in addiction treatment.
Addiction as a Disease
It seems that wherever one finds intoxication, one likely will find addiction. Recently researchers have argued that the addiction process is like the disease model, with a target organ, a defect, and symptoms of the disease. In other accounts, addiction is a disorder of genes, reward, memory, stress, and choice.
The Disease Model in Addiction
According to the new disease model, rather than being a disease in the conventional sense, addiction is a disease of choice. That is, it is a disorder of the parts of the brain necessary to make proper decisions. As one becomes addicted to cocaine, the ventral tegmentum nucleus accumbens in the brain is the organ. The defect is stress-induced hedonic regulation.
Understanding the impact that genes, reward, memory, stress, and choice have on an individual will begin to explain the Disease Model of Addiction.
- The genetic makeup of an individual determines how they respond to alcohol. What causes an individual to be more prone to addiction is their genetic makeup.
- For example, there are genetic differences in how people respond to methylphenidate (Ritalin) injections.
- Increased dopamine is correlated with increased pleasure. For that reason, dopamine plays a significant role in reinforcing experiences.
- It tells the brain the drug is better than expected.
- When an individual uses a drug, there may be a surge of dopamine in the midbrain, which can result in the shifting of that individual’s pleasure “threshold”.
- The neurochemical, glutamate is the most abundant neurochemical in the brain. It is critical in memory consolidation.
- When an addict discovers an addicting behaviour, glutamate plays a role by creating the drug cues.
- It is the neurochemical in motivation which initiates the drug seeking, thus creating the addiction.
- When under stress the brain is unable to achieve homeostasis.
- As a result, the brain reverts to allostasis, which in turn alters the brains ability to process pleasure, which is experienced at the hedonic “set point”.
- Thus, previous pleasures may become no longer pleasurable.
- This is also known as anhedonia, or “pleasure deafness.”
- When stressed, the addict may experience extreme craving – an intense, emotional, obsessive experience.
- An addict may incur damage to the orbitofrontal cortex (OFC), the anterior cingulate cortex (ACC), and the prefrontal cortex (PFC).
- This damage causes a tendency to choose small and immediate rewards over larger but delayed rewards, deficits in social responding due to decreased awareness of social cues, and a failure of executive function such as sensitivity to consequences.
Many degrees provide space for the treatment of addictions. The educational background that each professional obtains will contain similarities but the philosophy and the viewpoint from which the material is delivered may vary. The required amount of education prior to earning a certificate or degree also varies. A few of the more commonly recognised fields of study are included.
- Licensed Counsellor Social Worker.
- Licensed Social Worker.
- Licensed Professional Counsellor.
Recognised Certifications in the Field of Addiction Psychology
Many certifications are recognised in the field of addiction psychology. Each have their own requirements.
- Certification for Alcohol and Drug Counsellor Candidate.
- Credentialed Alcoholism and Substance Abuse Counsellor.
- A Certified Chemical Dependency Counsellor.
- Substance Abuse Counsellor/Certified Addiction Counsellor.
- The Certified Addiction Professional.
- Certified Addiction Treatment Counsellors.
- Combined Certifications With Other Degrees.
Both process addiction and behavioural addiction have many dimensions causing disarray in many aspects of the addicts’ life. Treatment programs are not a one size fits all phenomenon, hence there are different modalities or levels of care. Effective treatment programmes incorporate many components to address each dimension. The addict suffers from psychological dependence and some may suffer from physical dependence.
Helping an individual stop using drugs is not enough. Addiction treatment must also help the individual maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Addiction is a disease which alters the structure and function of the brain. The brain circuitry may take months or years to recover after the addict has recovered.
This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences. Research shows that most addicted individuals need a minimum of 3 months in treatment to significantly reduce or stop their drug use, however treatment in excess of 3 months has a greater success rate. Recovery from addiction is a long-term process.
Modalities of Care
The modality or level of care needed for a patient is decided by the treating professional in conjunction with the patient when feasible. As expected the patient receiving treatment will likely take steps forward and backward the level of care will likely to fluctuate. Common modalities are explained.
Detoxification and Medically Managed Withdrawal
The process when the body rids itself of drugs is referred to as detoxification, and is usually concurrent with the side effects of withdrawal which vary depending on the substance(s) and are often unpleasant and even fatal. Physicians may prescribe a medication that will help decrease the withdrawal symptoms while the addict is receiving care in an inpatient or outpatient setting. Detoxification is generally considered a precursor to or a first stage of treatment because it is designed to manage the acute and potentially dangerous physiological effects of stopping drug use.
Treatment is structured and operates 24 hours a day. Residents will remain in treatment from usually 6 to 12 months while developing accountability, responsibility and socialization skills. Activities are designed to help addicts recover from destructive behaviour patterns while adopting positive behavioural patterns. Constructive methods of interacting with others and improving self-esteem are other areas of focus. The therapeutic community model is an example of one treatment approach. Many therapeutic communities provide a more comprehensive approach to include employment training and other support services.
Short-term residential programmes are on average 3-6 weeks in a residential setting. The program is intensive followed by more extended outpatient treatment to include individual and/or group therapy, 12-step Anonymous programmes, or other forms of support. Because of the short duration of this modality it is even more important for individuals to remain active in outpatient treatment programmes to help decrease the risk of relapse following residential treatment.
Outpatient treatment programme vary regarding the services offered and the intensity. It is more affordable and may be more suitable for patients who are employed full-time and/or who have secured multiple social supports. Outpatient programmes may include group and/or individual therapy, intensive outpatient programme, and partial hospitalisation. Some outpatient programmes are also designed to treat patients with medical or other mental health problems in addition to their drug disorders.
Individualised Drug Counselling
Individualised drug counselling not only focuses on reducing or stopping illicit drug or alcohol use; it also addresses related areas of impaired functioning such as employment status, illegal activity, and family/social relations as well as the content and structure of the patient’s recovery program. Through its emphasis on short-term behavioural goals, individualised counselling helps the patient develop coping strategies and tools to abstain from drug use and maintain abstinence. The addiction counsellor encourages 12-step participation (at least one or two times per week) and makes referrals for needed supplemental medical, psychiatric, employment, and other services.
An outpatient treatment option facilitated by a treatment provider and used to expand on the support system the patient already has. Groups foster a non-judgmental environment allowing patients to meet and discuss difficulties and successes of their addiction while providing on-going support that is needed to be successful with recovery.
Intensive Outpatient Programme (IOP)
As the name implies this is an outpatient treatment option designed for addicts who for various reasons do not have the opportunity to attend an inpatient treatment programme, yet who otherwise would not be able to receive the level of support needed to recover from their addiction. Programs vary in duration based on the patients need. Because of the lower level of support offered IOP is frequently used as a step down approach from patients leaving inpatient treatment but who are still in need of intensive therapy.
Prevention, Relapse and Recovery
Therapeutic Orientations and Approaches
In 1878 the Index Medicus published research conducted and written by American physician W.H. Bentley. Bentley’s research described his success in treating patients addicted to the ‘opium habit’ w/cocaine. Two years later he reported success in treating both opium and alcohol abusers w/cocaine. Today, the swapping one addiction for another is referred to as crossover addiction.
A variety of treatment approaches are utilised by health professionals in order to provide their clients the highest possible level of success to overcome their addictions. There is no one specific approach and often therapists will use multiple techniques.
- Humanistic Therapy.
- Cognitive Behavioural Therapy (CBT).
- Dialectical Behavioural Therapy (DBT).
- Harm Reduction.
- Animal Assisted Therapy.