The legal model of addiction
The legal model of addiction states that taking any illegal drugs or alcohol is an “illegal act” and hence “a crime”. Again, using drugs or alcohol is a freely chosen behaviour for which punishment needs to be meted out. Such punishment is likely to include fines or even jail sentences. Relapse into drug and alcohol use is simply seen as “a criminal act by a criminal person”. This model advocates that no treatment is necessary. It rather calls for punishment and stricter control as a way to curb the addiction problem. Thus, people addicted to drugs and alcohol are again blamed and discriminated against.
Unfortunately, such a legalistic view on addictions is also not particularly useful in assisting drug users in their struggle to overcome their addiction and move towards recovery. Punishing drug- and alcohol-addicted individuals is ineffective and is likely to cause more suffering, unhappiness, blame and discrimination for the individual and their families. Similar to the moral model, the legal model also lends itself to an all-or-nothing pattern of thinking. It legitimises an overly simplistic view that using drugs and alcohol is clearly “wrong”, while abstaining from drugs and alcohol is clearly “right”. There is no space for reasonable and sensible debate, thought or discussion.
The sociocultural model of addiction
The sociocultural model of addiction states that alcohol and drug dependence is a sociocultural construct. It states that society as a whole, along with the prevailing norms and culture, has declared that certain actions and behaviours (such as addiction) are not acceptable. It is therefore the sociocultural view as a whole that defines and changes concepts and definitions of drugs and addictions. Different patterns of drug and alcohol use may be acceptable to different societies, for example the moderate consumption of red wine in Mediterranean countries is acceptable to their culture, while binge drinking hard liquor may not be. This can be contrasted with the European “pub culture” where individuals consume large amounts of alcohol within a short period of time in a specific social setting. Similarly, smoking used to be fashionable but it is now frowned upon in most cultures. Lastly, cannabis used to be illegal, but has become less restricted in certain societies in Europe, while it has generally always been acceptable to use cannabis in the Caribbean.
Based on the prevailing social and cultural views, certain alcohol- and drug-using behaviours may be contrary to accepted norms. Using alcohol and drugs outside these established norms is likely to lead to sanction and resultant problems. Remaining within the prevailing norms is unlikely to cause any distress or repercussions.
The psychological model of addiction
The psychological model of addiction refers to addictive behaviour as a maladaptive, learnt behaviour. Addiction is seen to be similar to other learnt behaviours. In this sense, it can also be unlearnt. The addictive behaviour is under the influence of numerous psychological factors, including conditioning, reinforcement and punishment. Treatment of substance abuse is based on recognising such psychological factors, unlearning them and developing new skills aimed at remaining abstinent. A relapse is not seen as moral weakness or an illegal act, but rather as a learning opportunity. The individual can learn from such errors and apply this newly learnt knowledge to help prevent future relapses.
The psychological model of addiction is generally easy to understand, learn and implement. It provides a reasonably good explanation for most addictive thoughts and behaviours. It is also supported by good research evidence. This model can be applied successfully to numerous addictions and various situations. It makes intuitive sense once the basics of the psychological theory are grasped. However, this model is very time consuming and relies on active patient motivation and participation. Furthermore, many healthcare professionals are not adequately trained in its practical application. Based on current evidence, psychological theory and practice should be incorporated into the assessment, detoxification, rehabilitation and recovery plans of all substance abusers.
The medical model of addiction
The medical model of addiction suggests that the “disease of addiction” is caused by an external agent – the consumed drug or alcohol in this case. The disease of addiction has characteristic symptoms and behaviours which cause pain, discomfort, suffering and impaired functioning. This disease is marked by a loss of control, craving for the drug and a compulsion to continue using it. The medical model therefore suggests that the “disease of addiction” is a specific clinical condition that anyone who is dependent on drugs or alcohol suffers from. There may be an underlying predisposition or genetic vulnerability that makes an individual susceptible to becoming dependent as soon as an external agent, such as drugs or alcohol, is used.
Proponents of this theory see patients suffering from addiction as “victims” of an illness, that is they are sick or ill. A person suffering from addiction did not freely choose their addiction, but rather became addicted through no choice of their own. Hence, patients suffering from drug- and alcohol-related problems “deserve” help and treatment. According to this model, the disease of addiction is progressive, irreversible and may ultimately cause death if the patient does not remain abstinent or receive adequate treatment. The only successful treatment is complete abstinence. Benjamin Rush conceptualised alcoholism as a disease as early as 1784. Throughout the centuries much evidence has accumulated to support this view. More recently, modern technologies such as specialised brain scans seem to support the view that addiction is a brain disease. Despite some criticism in the academic literature, this model has good evidence in its favour and is likely to become more dominant as the neuroscience of addiction is further examined.
As can be seen, each of these models is based on a different view and may have a different contribution to make. Each model is likely to have some truths relevant to the addiction problem. However, it is of no use to cling mindlessly to one particular model and totally disregard the others. Such tunnel vision is only likely to cause more problems. Much heartache can be avoided if everyone keeps an open mind and remains tolerant of the views of others in order to avoid unnecessary confrontations with patients, families or healthcare professionals.
It is imperative that healthcare professionals and the public become aware of the different models of addiction. We should also all remain flexible in our thinking in order to use the advantages of the different theories so that we can help substance abusers and their families optimally. We need to work collaboratively in order to assist substance abusers and their families where we can. This would have to include a medical, psychological, social and spiritual approach. Such interdisciplinary collaboration is known as a “biopsychosociospiritual” approach.
It has to be recognised, however, that certain healthcare professionals and certain models predominate in particular phases of treatment. It is clearly important that the emergency treatment and detoxification phase be medically supervised. Similarly, the process of rehabilitation certainly requires a psychologist and social worker. In a routine, non-urgent setting the process of assessment, preparation for change and aftercare should be multidisciplinary. A spiritual component can provide motivation and guidance throughout the entire treatment period. While certain practitioners and thus models may claim dominance in some treatment phases and settings, the overall treatment approach should be collaborative and based on a team effort with a substance abuser and their family at the centre.
The best ultimate outcome for a substance abuser’s recovery and their family’s wellbeing is achieved when a substance abuser is engaged as regularly as possible, using numerous different treatment methods, from various backgrounds. Such multiple contacts should be incorporated into a tailor-made recovery plan for each individual.
CHAPTER 3