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Chapter 1 History and Etiological Models of Addiction

David Capuzzi Walden University Mark D. Stauffer Walden University Chelsea Sharpe Multisystemic Therapy Therapist

Athens, Georgia The specialists serving the highest proportion of clients with a primary addiction diagnosis are professional counselors (20%), not social workers (7%), psychologists (6%), or psychiatrists (3%) (Lee, Craig, Fetherson, & Simpson, 2013, p. 2)

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The history of addictions counseling, a specialization within the profession of counseling, follows a pattern of evolution similar to that witnessed in many of the helping professions (social work, psychology, nursing, medicine). Early practitioners had more limited education and supervision (Astromovich & Hoskins, 2013; Iarussi, Perjessy, & Reed, 2013), were not licensed by regulatory boards, did not have well defined codes of ethics upon which to base professional judgments, may not have been aware of the values and needs of diverse populations, and did not have access to a body of research that helped define best practices and treatment plans (Hogan, Gabrielsen, Luna, & Grothaus, 2003).

It is interesting to watch the evolution of a profession and specializations within a profession. For example, in the late 1950s, the profession of counseling was energized by the availability of federal funds to prepare counselors. The impetus for the U.S. government to provide funds for both graduate students and university departments was Russia’s launching of Sputnik. School counselors were needed to help prepare students for academic success, especially in math and science, so the United States could “catch up” with its “competitors.”

As noted by Fisher and Harrison (2000), in earlier times, barbers who also did “bloodletting” practiced medicine, individuals who were skilled at listening to others and making suggestions for problem resolution became known as healers, and those who could read and write and were skilled

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at helping others do so became teachers with very little formal education or preparation to work with others in such a capacity. Fifty years ago nursing degrees were conferred without completing a baccalaureate (today a baccalaureate is minimal and a master’s degree is rapidly becoming the standard), a teacher could become a school counselor with 12 to 18 credits of coursework (today a two-year master’s is the norm), and 20 years ago an addictions counselor was an alcoholic or addict in recovery who used his or her prior experience with drugs as the basis for the addictions counseling done with clients.

Until the middle 1970s, there was no such thing as licensure for counselors, and those wishing to become counselors could often do so with less than a master’s degree. In 1976, Virginia became the first state to license counselors and outline a set of requirements that had to be met in order to obtain a license as a counselor. It took 33 years for all 50 states to pass licensure laws for counselors; this achievement took place in 2009 when the state of California passed its licensure law for counselors.

The purpose of this chapter is threefold: first, to provide an overview of the history of substance abuse prevention in the United States; second, to describe the most common models for explaining the etiology of addiction; and third, to overview and relate the discussion of the history of prevention and the models for understanding the etiology of addiction to the content of the text.

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Approaches to the Prevention of Addiction in the United States Alcoholic beverages have been a part of this nation’s past since the landing of the Pilgrims. Early colonists had a high regard for alcoholic beverages because alcohol was regarded as a healthy substance with preventive and curative capabilities rather than as an intoxicant. Alcohol played a central role in promoting a sense of conviviality and community until, as time passed, the production and consumption of alcohol caused enough concern to precipitate several versions of the “temperance” movement (Center for Substance Abuse Prevention, 1993). The first of these began in the early 1800s, when clergymen took the position that alcohol could corrupt both mind and body and asked people to take a pledge to refrain from the use of distilled spirits.

In 1784, Dr. Benjamin Rush argued that alcoholism was a disease, and his writings marked the initial development of the temperance movement. By 1810, Rush called for the creation of a “sober house” for the care of what he called the “confirmed drunkard.”

The temperance movement’s initial goal was the replacement of excessive drinking with more moderate and socially approved levels of drinking. Between 1825 and 1850, thinking about the use of alcohol began to change from temperance-as-moderation to temperance-as-abstinence (White, 1998). Six artisans and workingmen started the “Washingtonian Total

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Abstinence Society” in a Baltimore tavern on April 2, 1840. Members went to taverns to recruit members and, in just a few years, precipitated a movement that inducted several hundred thousand members. The Washingtonians were key in shaping future self-help groups because they introduced the concept of sharing experiences in closed, alcoholics only meetings. Another version of the temperance movement occurred later in the 1800s with the emergence of the Women’s Christian Temperance Movement and the mobilization of efforts to close down saloons. Societies such as the Daughters of Rechab, the Daughters of Temperance, and the Sisters of Sumaria are examples of such groups. (Readers are referred to White’s discussion of religious conversion as a remedy for alcoholism for more details about the influence of religion in America on the temperance movement.) These movements contributed to the growing momentum to curtail alcohol consumption and the passage of the Volstead Act and prohibition in 1920 (Hall, 2010).

It is interesting to note that the United States was not alone during the first quarter of the 20th century in adopting prohibition on a large scale; other countries enacting similar legislation included Iceland, Finland, Norway, both czarist Russia and the

Soviet Union, the Canadian provinces, and Canada’s federal government. A majority of New Zealand voters approved national prohibition two times but never got the legislation to be effected (Blocker, 2006). Even though Prohibition was successful in reducing per capita consumption of alcohol, the law created such social turmoil and defiance that it was repealed in 1933.

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Shortly after the passage of the Volstead Act in 1920, “speakeasies” sprang up all over the country in defiance of prohibition. The locations of these establishments were spread by “word of mouth” and people were admitted to “imbibe and party” only if they knew the password. Local police departments were kept busy identifying the locations of such speakeasies and made raids and arrests whenever possible. Often the police were paid so that raids did not take place and so patrons would feel more comfortable in such establishments.

Following the repeal of Prohibition, all states restricted the sale of alcoholic beverages in some way or another to prevent or reduce alcohol- related problems. In general, however, public policies and the alcoholic beverage industry took the position that the problems connected with the use of alcohol existed because of the people who used it and not because of the beverage itself. This view of alcoholism became the dominant view and force for quite some time and influenced, until recently, many of the prevention and early treatment approaches used in this country.

Paralleling the development of attitudes and laws for the use of alcohol, the nonmedical use of drugs, other than alcohol, can be traced back to the early colonization and settlement of the United States. Like alcohol, attitudes toward the use of certain drugs, and the laws passed declaring them legal or illegal, have changed over time and often have had racial/ethnic or class associations based on prejudice and less than accurate information. Prohibition was in part a response to the drinking patterns of European immigrants who became viewed as the lower class. Cocaine and opium were legal during the 19th century and favored by the middle and upper class, but cocaine became illegal when it was associated with African Americans following the Reconstruction era in the United States. The use of opium was first restricted in California during the latter part of the 19th century when it became associated with Chinese immigrant

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workers. Marijuana was legal until the 1930s when it became associated with Mexican immigrants. LSD, legal in the 1950s, became illegal in 1967 when it became associated with the counterculture.

It is interesting to witness the varying attitudes and laws concerning the use of marijuana. Many view marijuana as a “gateway” drug and disapprove of the medical use of marijuana; others think that the use of marijuana should be legalized and that access should be unlimited and use monitored only by the individual consumer.

It is interesting to note that it was not until the end of the 19th century (Center for Drug Abuse Prevention, 1993) that concern arose with respect to the use of drugs in patent medicines and products sold over the counter (cocaine, opium, and morphine were common ingredients in many potions). Until 1903, believe it or not, cocaine was an ingredient in some soft drinks. Heroin was even used in the 19th century as a nonaddicting treatment for morphine addiction and alcoholism. Gradually, states began to pass control and prescription laws and, in 1906, the U.S. Congress passed the Pure Food and Drug Act designed to control addiction by requiring labels on drugs contained in products, including opium, morphine, and heroin. The Harrison Act of 1914 resulted in the taxation of opium and coca products with registration and record-keeping requirements.

Current drug laws in the United States are derived from the 1970 Controlled Substance Act (Center for Drug Abuse Prevention, 1993), under which drugs are classified according to their medical use, potential for abuse, and possibility of creating dependence. Increases in per capita consumption of alcohol and illegal drugs raised public concern so that by 1971 the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was established; by 1974, the National Institute on Drug Abuse (NIDA) had also been created. Both of these institutes conducted research and had strong

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prevention components as part of their mission. To further prevention efforts, the Anti-Drug Abuse Prevention Act of 1986 created the U.S. Office for Substance Abuse Prevention (OSAP); this office consolidated alcohol and other drug prevention initiatives under the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). ADAMHA mandated that states set aside 20% of their alcohol and drug funds for prevention efforts while the remaining 80% could be used for treatment programs. In 1992, OSAP was changed to the Center for Substance Abuse Prevention (CSAP) and became part of the new Substance Abuse and Mental Health Services Administration (SAMSHA) and retained its major program areas. The research institutes of NIAAA and NIDA were then transferred to the National Institutes of Health (NIH). The Office of National Drug Control Policy (ONDCP) was also a significant development when it was established through the passage of the Anti-Drug Abuse Act of 1988. It focused on dismantling drug trafficking organizations, on helping people to stop using drugs, on preventing the use of drugs in the first place, and on preventing minors from abusing drugs.

Time passed, and Congress declared that the United States would be drug free by 1995; that “declaration” has not been fulfilled. Since the mid-1990s, there have been efforts to control the recreational and nonmedical use of prescription drugs and to restrict the flow of drugs into the country. In 2005, Congress budgeted $6.63 billion for U.S. government agencies directly focused on the restriction of illicit drug use. However, as noted later in this text, 13–18 metric tons of heroin is consumed yearly in the United States (Department of Health and Human Services [DHHS], 2004). In addition, there has been a dramatic increase in the abuse of prescription opioids since the mid-1990s, largely due to initiation by adolescents and young adults. As noted by Rigg and Murphy (2013), the incidence of prescription painkiller abuse increased by more than 400%, from 628,000 initiates in 1990 to 2.7 million in 2000.

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There has been an attempt to restrict importation by strengthening the borders and confiscating illegal substances before they enter the United States. There has also been an attempt to reduce importation. The U.S. government uses foreign aid to pressure drug producing countries to stop cultivating, producing, and processing illegal substances. Some of the foreign aid is tied to judicial reforms, antidrug programs, and agricultural subsidies to grow legal produce (DHHS, 2004).

In an attempt to reduce drug supplies, the government has incarcerated drug suppliers. Legislators have mandated strict enforcement of mandatory sentences, resulting in a great increase in prison populations. As a result, the arrest rate of juveniles for drug-related crimes has doubled in the past 10 years while arrest rates for other crimes have declined by 13%. A small minority of these offenders (2 out of every 1,000) will be offered Juvenile Drug Court (JDC) diversionary programs as an option to prison sentences (CASA, 2004).

During the last few years, there has been much media attention focused on the drug cartels in Mexico and the drug wars adjacent to the U.S. border near El Paso, Texas. In April of 2010, the governor of Arizona signed into law legislation authorizing the police to stop anyone suspected of being an illegal immigrant and demand proof of citizenship.

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Current Policies Influencing Prevention

Addiction today remains as formidable a reality as it ever was, with 23 million Americans in substance abuse treatment and over $180 billion a year consumed in addiction-related expenditure in the United States (Hammer, Dingel, Ostergren, Nowakowski, & Koenig, 2012, pp. 713–714).

There are a number of current policies influencing the prevention of addiction that should be noted (McNeese & DiNitto, 2005) and are listed below.

All states in the United States set a minimum age for the legal consumption of alcohol and prescribe penalties for retailers who knowingly sell alcohol to minors and underage customers. There are some states that penalize retailers even when a falsified identification is used to purchase liquor. Even though the Twenty-First Amendment repealed prohibition, the “dry” option is still open to individual states and some states, mainly in the South, do have dry counties.

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Even though a few states still have “dry” counties, residents of those counties can often consume alcohol in restaurants that allow patrons to enter the establishment with a bottle of alcohol, usually wrapped or “bagged.” The restaurant then charges a fee for opening the bottle and allowing the liquor to be served. In addition, some counties allow liquor stores to be located just outside the county line, perhaps in a waterway accessed by a short walk across a connecting boardwalk or foot bridge. Many state governments influence the price of alcohol through taxation and through the administration of state-owned liquor stores. As part of the initial training of U.S. Air Force and Navy recruits, alcohol and tobacco use is forbidden during basic training and for a short time during advanced and technical training. This is because use of these substances usually has a negative effect on military readiness and performance (Bray et al., 2010). Besides taxation and the operation of state-owned liquor stores, government can attempt to regulate consumption by controlling its distribution. It accomplishes this through adopting policies regulating the number, size, location, and hours of business for outlets as well as regulating advertising. Perhaps no other area of alcohol policy has been as emotionally charged as the setting of the minimum legal age for consuming alcoholic beverages. Most states have adopted the age of 21 as the minimum legal age for unrestricted purchase of alcohol. This is a point of contention among many because at age 18 the young are eligible for military service. When a legally intoxicated individual (someone with a blood alcohol content [BAC] of 0.08 to 0.10) drives an automobile, in most states, a crime has been committed. Penalties can range from suspension of the driver’s license to a mandatory jail sentence, depending on the frequency of convictions.

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Insurance and liability laws can also be used to influence lower consumption of alcohol because those drivers with DUI convictions may face higher insurance premiums or may be unable to purchase insurance. In addition, in a majority of states, commercial establishments that serve alcoholic beverages are civilly liable to those who experience harm as a result of an intoxicated person’s behavior. Public policies regarding the use of illicit drugs have not reached the same level of specificity as those regulating the use of alcohol (and, for that matter, tobacco). Since 1981 and the election of Ronald Reagan as president, federal policy has been more concerned with preventing recreational use of drugs than with helping habitual users. The approach chosen by the George H. Bush administration was one of zero tolerance. The George H. Bush administration did increase treatment funding by about 50%. Simultaneously, the administration continued to focus its attention on casual, middle-class drug use rather than with addiction or habitual use. In 1992, the presidential candidates, George H. Bush and Bill Clinton, rarely mentioned the drug issue except as related to adolescent drug use. In the year 2000, the major issue in the campaign of George W. Bush was whether Mr. Bush ever used cocaine. The administration of George W. Bush made very few changes in drug policy. Of major significance is the fact that SAMHSA was reauthorized in the year 2000 (Bazelon Center for Mental Health Law, 2000). That reauthorization created a number of new programs, including funding for integrated treatment programs for co-occurring disorders for individuals with both mental illness and a substance abuse disorder. Currently, a very controversial option for policy is being considered and discussed by policy makers (Fish, 2013). In short, replacing current assumptions and causal models underlying the war on drugs and punishment of drug users with alternative points of view could lead to a different way of understanding drug use and abuse and to different drug policy options. These alternatives could include refocusing our primary

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emphasis from attacking drugs to shrinking the black market through a targeted policy of legalization for adults, and differentiating between problem users (who should be offered help) and nonproblem users (who should be left alone). We could shift from a policy of punishing and marginalizing problem users to one of harm reduction and reintegration into society and shifting from a mandatory treatment policy to one of voluntary treatment. Abstention need not be the only acceptable treatment outcome because many (but not all) problem users can become occasional, nonproblematic users.

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Models For Explaining The Etiology of Addiction

Historically, addiction has been understood in various ways—a sin, a disease, a bad habit—each a reflection of a variety of social, cultural, and scientific conceptions (Hammer et al., 2012, p. 713).

Substance use and abuse has been linked to a variety of societal issues and problems (crime and violence, violence against women, child abuse, difficulties with mental health, risks during pregnancy, sexual risk-taking, fatal injury, etc.). Given the impact the abuse of substances can have on society in general and the toll it often levies on individuals and families, it seems reasonable to attempt to understand the etiology or causes of addiction so that diagnosis and treatment plans can be as efficacious as possible. There are numerous models for explaining the etiology of addiction (McNeese & DiNitto, 2005); these models are not always mutually exclusive and none are presented as the correct way of understanding the phenomena of addiction. The moral, psychological, family, disease, public health, developmental, biological, sociocultural, and some multicausal models will be described in the subsections that follow.

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The Moral Model

The moral model is based on beliefs or judgments of what is right or wrong, acceptable or unacceptable. Those who advance this model do not accept that there is any biological basis for addiction; they believe that there is something morally wrong with people who use drugs heavily.

The moral model explains addiction as a consequence of personal choice, and individuals who are engaging in addictive behaviors are viewed as being capable of making alternative choices. This model has been adopted by certain religious groups and the legal system in many states. For example, in states in which violators are not assessed for chemical dependency and in which there is no diversion to treatment, the moral model guides the emphasis on “punishment.” In addition, in communities in which there are strong religious beliefs, religious intervention might be seen as the only route to changing behavior. The moral model for explaining the etiology of addiction focuses on the sinfulness inherent in human nature (Ferentzy & Turner, 2012). Since it is difficult to establish the sinful nature of human beings through empirically based research, this model has been generally discredited by present-day scholars. It is interesting to note, however, that the concept of addiction as sin or moral weakness continues to influence many public policies connected with alcohol and drug abuse (McNeese & DiNitto, 2005). This may be part of the reason why needle/syringe exchange programs have so often been opposed in the United States.

Although the study of the etiology of alcoholism and other addictions has made great strides in moving beyond the moral model, alcoholics are not immune to social stigma, and other types of addiction have yet to be widely viewed as something other than a choice. But as we move further

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away from the idea that addiction is the result of moral failure, we move closer to providing effective treatment and support for all those who suffer.

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Psychological Models

Another explanation for the reasons people crave alcohol and other mind- altering drugs has to do with explanations dealing with a person’s mind and emotions. There are several different psychological models for explaining the etiology of alcoholism and drug addiction, including cognitive- behavioral, learning, psychodynamic, and personality theory models.

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Cognitive-Behavioral Models Cognitive-behavioral models suggest a variety of motivations and reinforcers for taking drugs. One explanation suggests that people take drugs to experience variety (Weil & Rosen, 1993). Drug use might be associated with a variety of experiences such as self-exploration, religious insights, altering moods, escape from boredom or despair, and enhancement of creativity, performance, sensory experience, or pleasure (Lindgren, Mullins, Neighbors, & Blayney, 2010). If we assume that people enjoy variety, then it can be understood why they repeat actions that they enjoy (positive reinforcement).

The use of mind-altering drugs received additional media attention in the 1960s, when “flower children” sang and danced in the streets of San Francisco and other cities, sometimes living together in communities they created. Much press was given to the use of drugs to enhance sensory experience in connection with some of the encounter groups led by facilitators in southern California.

The desire to experience pleasure is another explanation connected with the cognitive-behavioral model. Alcohol and other drugs are chemical surrogates of natural reinforcers such as eating and sex. Social drinkers and alcoholics often report using alcohol to relax even though studies show that alcohol causes people to become more depressed, anxious, and nervous (NIAAA, 1996). Dependent behavior with respect to the use of alcohol and other drugs is maintained by the degree of reinforcement the person perceives as occurring; alcohol and other drugs may be perceived as being more powerful reinforcers than natural reinforcers and set the stage for addiction. As time passes, the brain adapts to the presence of the drug or alcohol, and the person experiences unpleasant withdrawal

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symptoms (e.g., anxiety, agitation, tremors, increased blood pressure, seizures). To avoid such unpleasant symptoms, the person consumes the substance anew and the cycle of avoiding unpleasant reactions (negative reinforcement) occurs and a repetitive cycle is established. In an interesting review of the literature on the etiology of addiction (Lubman, Yucel, & Pantelis, 2004), it was proposed that in chemically addicted individuals, maladaptive behaviors and high relapse rates may be conceptualized as compulsive in nature. The apparent loss of control over drug-related behaviors suggests that individuals who are addicted are unable to control the reward system in their lives and that addiction may be considered a disorder of compulsive behavior very similar to obsessive compulsive disorder.

Learning Models Learning models are closely related and somewhat overlap the explanations provided by cognitive-behavioral models. Learning theory assumes that alcohol or drug use results in a decrease in uncomfortable psychological states such as anxiety, stress, or tension, thus providing positive reinforcement to the user. This learned response continues until physical dependence develops and, like the explanation provided within the context of cognitive-behavioral models, the aversion of withdrawal symptoms becomes a reason and motivation for continued use. Learning models provide helpful guidelines for treatment planning because, as pointed out by Bandura (1969), what has been learned can be unlearned; the earlier the intervention occurs the better, since there will be fewer behaviors to unlearn.

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Psychodynamic Models Psychodynamic models link addiction to ego deficiencies, inadequate parenting, attachment disorders, hostility, homosexuality, masturbation, and so on. As noted by numerous researchers and clinicians, such models are difficult to substantiate through research since they deal with concepts difficult to operationalize and with events that occurred many years prior to the development of addictive behavior. A major problem with psychodynamic models is that the difficulties linked to early childhood development are not specific to alcoholism or addiction, but are reported by nonaddicted adults with a variety of other psychological problems (McNeese & DiNitto, 2005). Nevertheless, current thinking relative to the use of psychodynamic models as a potential explanation for the etiology of addiction has the following beliefs in common (Dodgen & Shea, 2000):

1. Substance abuse can be viewed as symptomatic of more basic psychopathology.

2. Difficulty with an individual’s regulation of affect can be seen as a core problem or difficulty.

3. Disturbed object relations may be central to the development of substance abuse.

Readers are referred to Chapter 12 of Slaying the Dragon: The History of Addiction Treatment and Recovery in America by William L. White (1998) for a more extensive discussion of psychodynamic models in the context of the etiology of addiction.

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Personality Theory Models These theories make the assumption that certain personality traits predispose the individual to drug use. An “alcoholic personality” is often described by traits such as dependent, immature, impulsive, highly emotional, having low frustration tolerance, unable to express anger, and confused about their sex role orientation (Catanzaro, 1967; Milivojevic et al., 2012; Schuckit, 1986).

Although many tests have been constructed to attempt to identify the personality traits of a drug-addicted person, none have consistently distinguished the traits of the addicted individual from those of the nonaddicted individual. One of the subscales of the Minnesota Multiphasic Personality Inventory does differentiate alcoholics from the general population, but it may only be detecting the results of years of alcoholic abuse rather than underlying personality traits (MacAndrew, 1979). The consensus among those who work in the addictions counseling arena seems to be that personality traits are not of much importance in explaining addiction because an individual can become drug dependent irrespective of personality traits (Raistrick & Davidson, 1985).

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Family Models

As noted in Chapter 14 , during the infancy of the field of addictions counseling, addictions counselors were used to working only with the addict. Family members were excluded. However, it soon became clear that family members were influential in motivating the addict to get sober or in preventing the addict from making serious changes.

There are at least three models of family-based approaches to understanding the development of substance abuse (Dodgen & Shea, 2000).

Behavioral Models A major theme of the behavioral model is, that within the context of the family, there is a member (or members) who reinforces the behavior of the abusing family member. A spouse or significant other, for example, may make excuses for the family member or even prefer the behavior of the abusing family member when that family member is under the influence of alcohol or another drug. Some family members may not know how to relate to a particular family member when he or she is not “under the influence.”

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Family Systems There have been many studies demonstrating the role of the family in the etiology of drug abuse (Baron, Abolmagd, Erfan, & El Rakhawy, 2010). As noted in Chapter 14 , the family systems model focuses on the way roles in families interrelate (Tafa & Baiocco, 2009). Some family members may feel threatened if the person with the abuse problem shows signs of wanting to recover since caretaker roles, for example, would no longer be necessary within the family system if the member began behaving more responsibly. The possibility of adjusting roles could be so anxiety producing that members of the family begin resisting all attempts of the “identified patient” to shift relationships and change familiar patterns of day-to-day living within the family system.

Family Disease This model is based on the idea that the entire family has a disorder or disease, and all must enter counseling or therapy for improvement to occur within the addicted family member. This is very different from approaches to family counseling in which the counselor is willing to work with whichever family members will come to the sessions, even though every family member is not present.

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The Disease Model

The disease concept follows the medical model and posits addiction as an inherited disease that chemically alters the body in such a way that the individual is permanently ill at a genetic level (Lee et al., 2013, p. 4).

E. M. Jellinek (1960) is generally credited with introducing this controversial and initially popular model of addiction in the late 1930s and early 1940s (Stein & Foltz, 2009). However, it is interesting to note that, as early as the later part of the 18th century, the teachings and writings of Benjamin Rush, the Surgeon General of George Washington’s revolutionary armies, actually precipitated the birth of the American disease concept of alcoholism as an addiction (White, 1998). In the context of this model, addiction is viewed as a primary disease rather than being secondary to another condition (reference the discussion, earlier in this chapter, of psychological models). Jellinek’s disease model was originally applied to alcoholism but has been generalized to addiction to other drugs. In conjunction with his work, Jellinek also described the progressive stages of the disease of alcoholism and the symptoms connected with each stage. These stages (prodromal, middle or crucial, and chronic) were thought to be progressive and not reversible. Consistent with this concept of irreversibility is the belief that addictive disease is chronic and incurable. Once the individual has this disease, according to the model, it never goes away, and there is no treatment method that will enable the individual to use again without the high probability that the addict will revert to problematic use of the drug of choice. One implication of this philosophy is that the goal for an addict must be abstinence, which is the position taken by Alcoholics Anonymous (Fisher & Harrison, 2005). In addition, the idea that addiction is both chronic and incurable is the reason that addicts who are maintaining sobriety refer to themselves as “recovering” rather than as “recovered.”

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The vocabulary of recovery was first used by Alcoholics Anonymous in 1939. It is significant because we use the term recovery in the context of disease or illness rather than in connection with moral failure or character deficits. This reinforces the disease model to explain the etiology of addiction.

Interestingly, although Jellinek’s disease model of addiction has received wide acceptance (Ferentzy & Turner, 2012), the research from which he derived his conclusions has been questioned. Jellinek’s data were gathered from questionnaires. Of the 158 questionnaires distributed, 60 were discarded; no questionnaires from women were used. The questions about the original research, which led to the conceptualization of the “disease” model, have led to controversy. On the one hand, the articulation of addiction as a disease removes the moral stigma attached to addiction and replaces it with an emphasis on treatment of an illness, results in treatment coverage by insurance carriers, and sometimes encourages the individual to seek assistance much like that requested for diabetes, hypertension, or high cholesterol. On the other hand, the progressive, irreversible progression of addiction through stages does not always occur as predicted, and the disease concept may promote the idea for some individuals that one is powerless over the disease, is not responsible for behavior, may relapse after treatment, or may engage in criminal behavior to support the “habit.”

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The Public Health Model

It is interesting to note that the public health model was not originally conceptualized to focus on psychobehavioral ailments since, from its early beginnings, the emphasis has been on promoting healthy behaviors. As noted by Ferentzy and Turner (2012), the 20th-century psychiatrist Paul Lemkau, founding chairperson of the Mental Hygiene department in the Johns Hopkins University School of Public Health, was one of the first to apply a public health model to mental disorders. Lemkau promoted the establishment of community, rather than residential, treatment centers because he believed that mental health, including the treatment of addiction, was a public rather than a private issue. Lemkau believed that when individuals did not engage in healthy behaviors and became addicted, it was because of the impact of social issues. He viewed addiction as a societal disease, in direct contrast to the more dominant, individualistic conceptions associated with the disease model.

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The Developmental Model

As noted by Sloboda, Glantz, and Tarter (2012), the etiology of addiction can also be explicated by applying a developmental framework to understand the factors that increase or decrease risks for the individual to use or misuse drugs. They posited that vulnerability is never static or unchanging, but varies across the life span. Sloboda and her colleagues examined some of the key developmental competencies associated with the following developmental stages: prenatal through early childhood, middle childhood, adolescence, late adolescence/early adulthood, and adulthood. This research provided detailed examples of competencies that must be mastered during each of these developmental stages to decrease the possibility of engaging in risky behavior that includes the use and misuse of drugs. Readers interested in exploring the developmental model for understanding the etiology of addiction will find the Sloboda et al. (2012) an article excellent starting point for additional study.

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Biological Models

Biophysiological and genetic theories assume that addicts are constitutionally predisposed to develop dependence on drugs. These theories or models support a medical model of addiction, apply disease terminology, and often place the responsibility for treatment under the purview of physicians, nurses, and other medical personnel. Usually, biological explanations branch into genetic and neurobiological discussions.

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Genetic Models Although genetic factors have never really been established as a definitive cause of alcoholism, the statistical associations between genetic factors and alcohol abuse are very strong. For example, it has been established that adopted children more closely resemble their biological parents than their adoptive parents when it comes to their use of alcohol (Dodgen & Shea, 2000; Goodwin, Hill, Powell, & Viamontes, 1973); alcoholism occurs more frequently in some families than others (Cotton, 1979); concurrent alcoholism rates are higher in monozygotic twin pairs than in dizygotic pairs (Kaij, 1960); and children of alcoholics can be as much as seven times more likely to be addicted than children whose parents are not alcoholic (Koopmans & Boomsina, 1995). Because of such data, some genetic theorists have posited that an inherited metabolic defect may interact with environmental elements and lead, in time, to alcoholism. Some research points to an impaired production of enzymes within the body and yet other lines of inquiry point to the inheritance of genetic traits that result in a deficiency of vitamins (probably the vitamin B complex), which leads to a craving for alcohol as well as the accompanying cellular or metabolic changes.

There have been numerous additional lines of inquiry that have attempted to establish a genetic marker that predisposes a person toward alcoholism or other addictions (Bevilacqua & Goldman, 2010). Studies that examined polymorphisms in gene products and DNA, the D2 receptor gene, and even color blindness as factors have all been conducted and then later more or less discounted. Genetic research on addiction shows potential, but is a complex activity given the fact that each individual carries genes located on 23 pairs of chromosomes. The Human Genome Project, which is supported by the National Institutes of Health and the U.S. Department of Energy, is conducting some promising studies (NIAAA, 2000).

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Neurobiological Models Neurobiological models are complex (Jacob, 2013) and have to do with the neurotransmitters in the brain that serve as the chemical messengers of our brain (Hammer et al., 2012); Kranzler & Li, 2008; Wilcox, Gonzales, & Miller, 1998). Almost all addictive drugs, as far as we know, seem to have primary transmitter targets for their actions. The area of the brain in which addiction occurs is the limbic system or the emotional part of the brain. The limbic part of the brain refers to an inner margin of the brain just outside the cerebral ventricles, and the transmitter dopamine is key in its activity in the limbic system and the development of addiction. As a person begins to use a drug, changes in brain chemistry in the limbic system begin to occur and lead to addiction. Current thinking is that these changes can also be reversed by the introduction of other drugs in concert with counseling and psychotherapy.

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Sociocultural Models

Sociocultural models have been formulated by making observations of the differences and similarities between cultural groups and subgroups. As noted by Goode (1972), the social context of drug use strongly influences drug definitions, drug effects, drug-related behavior, and the drug experience. These are contextual models and can only be understood in relation to the social phenomena surrounding drug use. A person’s likelihood of using drugs, according to these models, the way he/she behaves, and the way abuse and addiction are defined are all influenced by the sociocultural system surrounding the individual.

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Supracultural Models The classic work of Bales (1946) provided some hypotheses connecting culture, social organization, and the use of alcohol. He believed that cultures that create guilt, suppress aggression and sexual tension, and that support the use of alcohol to relieve those tensions will probably have high rates of alcoholism. Bales also hypothesized that the culture’s collective attitude toward alcohol use could influence the rate of alcoholism. Interestingly, he categorized these attitudes as favoring (1) abstinence, (2) ritual use connected with religious practices, (3) convivial drinking in a social setting, and (4) utilitarian drinking (drinking for personal reasons). The fourth attitude (utilitarian) in a culture that produces high levels of tension is the most likely to lead to high levels of alcoholism; the other three attitudes lessen the probability of high alcoholism rates. Another important aspect of Bales’ thinking is the degree to which the culture offers alternatives to alcohol use to relieve tension and to provide a substitute means of satisfaction. A culture that emphasizes upward economic or social mobility will frustrate individuals who are unable to achieve at such high levels and increase the possibility of high alcoholism rates.

In 1974, Bacon theorized that high rates of alcoholism were likely to exist in cultures that combine a lack of indulgence toward children with demanding attitudes toward achievement and negative attitudes toward dependent behavior in adults. An additional important factor in supracultural models is the degree of consensus in the culture regarding alcohol and drug use. In cultures in which there is little agreement, a higher rate of alcoholism and other drug use can be expected. Cultural ambivalence regarding the use of alcohol and drugs can result in the weakening of social controls, which allows the individual to avoid being looked upon in an unfavorable manner.

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Culture-Specific Models Culture-specific models of addiction are simultaneously fascinating and hampered by the possibilities inherent in promoting stereotypes and overgeneralizing about the characteristics of those who “seem” to fit the specific culture under consideration. For example, there are many similarities between the French and Italian cultures since both cultures are profoundly Catholic and both cultures support wineries and have populations that consume alcohol quite freely (Levin, 1989). The French drink both wine and spirits, with meals and without, at home as well as away from the family. The French often consider it bad manners to refuse a drink, and the attitudes toward drinking too much are usually quite liberal. The Italians drink mostly wine, with meals and at home, and they strongly disapprove of public misconduct due to the overconsumption of wine. They do not pressure others into accepting a drink.

In some Italian American families children over the age of about 10 can drink wine with dinner, but are admonished never to drink large amounts of wine; wine is to be enjoyed in social situations and is never to be consumed in excess. As a result, these children usually become adults who drink wine in moderation and never have problems derived by too much consumption of alcoholic beverages.

As the reader might expect from prior discussion, the rate of alcoholism in France is much more problematic than that which exists in Italy. Although the authors would agree that the prevailing customs and attitudes relating to the consumption of alcohol in a specific culture can provide insight and have usefulness as a possible explanation of the etiology of addiction in the culture under consideration, readers should be cautious about cultural stereotyping and make every attempt to address diversity issues in

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counseling as outlined in the current version of the Code of Ethics of the American Counseling Association (ACA) as well as the ACA guidelines for culturally competent counseling practices. (See the ACA website at www.counseling.org.)

Subcultural Models It should also be briefly noted that there have been many investigations of both sociological and environmental causes of addiction and alcoholism at the subcultural level. Factors related to age, gender, ethnicity, socioeconomic class, religion, and family background can create different patterns within specific cultural groups (McNeese & DiNitto, 2005; White, 1998). They also can be identified as additional reasons why counselors and other members of the helping professions must vigilantly protect the rights of clients to be seen and heard for who they really are rather than who they might be assumed to resemble.

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Multicausal Models

The great challenge to understanding the etiology of drug use and drug use disorders is the complexity of the phenomenon itself (Sloboda et al., 2012, p. 954).

At this point in your reading you may be wondering which of these etiological models or explanations of addiction is the correct model. As you may have already surmised, although all of these models are helpful and important information for counselors beginning their studies in addiction counseling, no single model adequately explains why some individuals become addicted to a substance and others do not. An important advance in the study of addiction is the realization that addiction is probably not caused by a single factor, and the most likely models for increasing our understanding and our development of treatment options are multivariate (Buu et al., 2009; McNeese & DiNitto, 2005; Stevens & Smith, 2005). Even though there may be some similarities in all addicted individuals, the etiology and motivation for the use of drugs varies from person to person. For some individuals, there may be a genetic predisposition or some kind of a physiological reason for use and later addiction to a drug. For others, addiction may be a result of an irregularity or disturbance of some kind in their personal development without a known genetic predisposition or physiological dysfunction. The possible debate over which model is the correct model is valuable only because it assists the practitioner to see the importance of adopting an interdisciplinary or multicausal model.

An interesting example of a multicausal model that has been proposed is the syndrome model of addiction (Shaffer et al., 2004). This model suggests that the current research pertaining to excessive eating, gambling, sexual behaviors, shopping, substance abuse, and so on does not

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adequately capture the origin, nature, and processes of addiction. The researchers believe that the current view of addictions is very similar to the view held during the early days of AIDS awareness when rare diseases were not recognized as opportunistic infections of an underlying immune deficiency syndrome. The syndrome model of addiction suggests that there are multiple and interacting antecedents of addiction that can be organized in at least three primary areas: (1) shared neurobiological antecedents, (2) shared psychosocial antecedents, and (3) shared experiences and consequences. Another promising example of a multicausal model is the integral model (Amodia, Cano, & Eliason, 2005). This integral approach examines substance abuse etiology and treatment from a four-quadrant perspective adapted from the work of Ken Wilbur. It also incorporates concepts from integrative medicine and transpersonal psychology. Readers are referred to the references cited in this subsection for more complete information about both the syndrome and integral models.

The multicausal model is similar to the public health model recently adopted by health care and other human service professionals. This model conceptualizes the problem of addiction as an interaction among three factors: the “agent” or drug, the “host” or person, and the “environment,” which may be comprised of a number of entities. When the agent or drug interacts with the host, it is important to realize that there are a variety of factors within the host, including the person’s genetic composition, cognitive structure and expectations about drug experiences, family background, and personality traits, that must be taken into consideration as a treatment plan is developed. Environmental factors that need to be considered include social, political, cultural, and economic variables. When a counselor or therapist uses a multicausal model to guide the diagnosis and treatment planning process, the complex interaction of several variables must be taken into consideration.

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Summary and Some Final Notations This chapter provided an overview of the historical evolution of approaches to the prevention of addiction in the United States. It chronicled the movement from the rudimentary and unregulated approaches of early practitioners to the more carefully regulated, credentialed, and evidence- based methods in use today. The social and political influences on the attitudes toward the use of drugs for both recreational and medical purposes were also addressed. A brief review of the federal government’s role in funding agencies focused on the prevention of drug abuse as well as the provision of treatment for addicted individuals provided the background for some of the current policies influencing the prevention of addiction. Descriptions of the moral, psychological, family, disease, public health, developmental, biological, sociocultural, and multicausal models for understanding the etiology of addiction provided the reader with the background to understand topics covered in subsequent chapters of the text.

In addition to the first chapter on history and etiological models of addiction, Part I of our text, Introduction to Addictions Counseling, includes chapters on substance and process addictions, professional issues, interviewing clients, and assessment and diagnosis of addiction. These introductory chapters provide the background for Part II, The Treatment of Addictions, which provides a thorough examination of current treatment modalities. The seven chapters in this section address motivational interviewing, psychotherapeutic approaches, co-occurring disorders and addictions treatment, group work and addictions, pharmacological treatment of addictions, 12-step facilitation of treatment, and maintenance

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and relapse prevention. Part III, Addictions in Family Therapy, Rehabilitation, and School Settings, provides the reader with needed perspective regarding variations in treatment modalities so necessary for competent counseling in specific settings. The chapters in this section discuss interventions with couples and families, persons with disabilities and addictions, and prevention programs for children, adolescents, and college settings. Part IV, Cross-Cultural Counseling in Addictions, addresses ethnic diversity, gender and addictions, and gay, lesbian, bisexual affirmative addiction treatment.

The final epilogue chapter presents an interesting discussion of the characteristics and issues connected with both inpatient and outpatient treatment of addiction.

Although it is impossible to include every conceivable topic that would be helpful to a counselor or therapist beginning the study of addictions counseling in a single text, we believe the information in this text is comprehensive enough in scope and sufficiently detailed to provide an excellent foundation for follow-up courses as well as supervised practicum and internship experiences for those wishing to develop a specialization in addictions counseling.

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MyCounselingLab

Visit the MyCounselingLab site for Foundations of Addictions Counseling, Third Edition to enhance your understanding of concepts. You'll have the opportunity to practice your skills through video- and case-based exercises. You will find sets of questions to help you prepare for your certification exam with Licensure Quizzes. There is also a Video Library that provides taped counseling sessions, ethical scenarios, and interviews with helpers and clients.

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Useful Websites The following websites provide additional information relating to the chapter topics:

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Funding Opportunities

NIMH

www.nimh.nih.gov/

NIDA Extramural Affairs

www.drugabuse.gov/funding/

NIAAA

www.niaaa.nih.gov/

NIH Grants and Funding Opportunities

grants.nih.gov/grants/index.cfm

Enhancing Practice Improvement in Community-Based Care for Prevention and Treatment of Drug Abuse or Co-occurring Drug Abuse and Mental Disorders.

grants.nih.gov/grants/guide/rfa-files/RFA-DA-06-001.html

HRSA

www.hrsa.gov/grants/default.htm

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Funding Sources For Prevention Programs

The Catalog of Federal Domestic Assistance (CFDA)

www.cfda.gov/

A database of all federal programs available to state and local governments (including the District of Columbia); federally recognized Indian tribal governments; territories (and possessions) of the United States; domestic public, quasi-public, and private profit and nonprofit organizations and institutions; specialized groups; and individuals.

Federal Register (FR)

www.gpoaccess.gov/fr/index.html

The Federal Register is the official daily publication for all federal agency funding notices. The bound version can be viewed at a local or university library.

The Foundation Center

www.fdncenter.org/

The Foundation Center’s mission is to support and improve institutional philanthropy by promoting public understanding of the field and helping grantseekers succeed.

Foundations & Grantmakers Directory

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www.foundations.org/grantmakers.html

This directory lists foundations and grantmakers by name.

The Grantsmanship Center

www.tgcigrantproposals.com

This resource is designed to help nonprofit organizations and government agencies write better grant proposals and develop better programs.

A starting point for accessing grant-related information and resources on the Internet.

GuideStar

www.guidestar.org/

GuideStar is a free information service on the programs and finances of more than 600,000 charities and nonprofit organizations. The database of nonprofit organizations is searchable by several different criteria. The site also offers news on philanthropy and other resources for donors and volunteers.

The Research Assistant

www.theresearchassistant.com/funding/index.asp

Resources for new and minority drug abuse researchers.

The Robert Wood Johnson Foundation (RWJF)

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www.rwjf.org/index.jsp

RWJF, the largest U.S. foundation devoted to improving the health and health care of all Americans, funds grantees through both multisite national programs and single-site projects.

U.S. Department of Education (DOE)

www.ed.gov/topics/topics.jsp?&top=Grants+%26+Contracts

DOE only posts those grants currently open for competition at this site.

U.S. Department of Housing and Urban Development

www.hud.gov/grants/index.cfm

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References Amodia, D. S., Cano, C., & Eliason, M. J. (2005). An integral approach to

substance abuse. Journal of Psychoactive Drugs, 37 (4), 363–371.

Astramovich, R. L., & Hoskins, W. J. (2013). Evaluating addictions counseling programs: Promoting best practices, accountability, and advocacy. Journal of Addictions & Offender Counseling, 34(2), 114–124. doi:10.1002/j.2161-1874.2013.00019.x

Bacon, M. K. (1974). The dependency-conflict hypothesis and the frequency of drunkenness. Quarterly Journal of Studies on Alcohol, 40, 863–876.

Bales, R. F. (1946). Cultural differences in rates of alcoholism. Quarterly Journal of Studies on Alcohol, 6, 480–499.

Bandura, A. (1969). Principles of behavior modification. New York, NY: Holt, Rinehart, and Winston.

Baron, D., Abolmagd, S., Erfan, S., & El Rakhawy, M. (2010). Personality of mothers of substance dependent patients. Journal of Multidisciplinary Healthcare, 3, 29–32.

Bazelon Center for Mental Health Law. (2000). Legislative Update: 2000 SAMHSA reauthorization. Retrieved January 2006 from http://www.bazelon.org/takeaction/alerts/10-17-00samhsa.htm

Bevilacqua, L., & Goldman, D. (2010). Geonomics of addiction. Current Psychiatry Reviews, 6, a22–134.

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Blocker, J. S. (2006). Did prohibition really work? Alcohol prohibition as a public health innovation. American Journal of Public Health, 96 (2), 233–243.

Bray, R. M., Brown, J. M., Jones, S. B., Pemberton, M. R., Vandermaas- Peeler, R., & Williams, J. (2010, January). Alcohol use after forced abstinence in basic training among United States Navy and Air Force trainees. Journal of Studies on Alcohol and Drugs, 71 (1), 15+.

Buu, A., DiPiazza, C., Wang, J., Puttler, L. I., Fitzgerald, H. E., & Zucker, R. A. (2009). Journal of Studies of Alcohol and Drugs, 70, 489–498.

CASA: National Center on Addiction and Substance Abuse at Columbia University. (2004). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York, NY: Author.

Catanzaro, P. (1967). Psychiatric aspects of alcoholism. In D. J. Pittman (Ed.), Alcoholism. New York, NY: Harper & Row.

Center for Substance Abuse Prevention. (1993). Prevention primer: An encyclopedia of alcohol, tobacco and other drug prevention terms (DHHS Publication No. SMA 2060). Rockville, MD: National Clearing House for Alcohol and Drug Information.

Cotton, N. A. (1979). The familial incidence of alcoholism. Journal of Studies on Alcohol, 40, 89–116.

Department of Health and Human Services. (2004). National drug control strategy. Washington, DC: Government Printing Office.

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Dodgen, C. E., & Shea, W. M. (2000). Substance use disorders: Assessment and treatment. San Diego, CA: Academic Press.

Ferentzy, P., & Turner, N. E. (2012). Morals, medicine, metaphors, and the history of the disease model of problem gambling. Journal of Gambling Issues, 27, 1–27. doi:10.4309/jgi.2012.27.4

Fish, J. M. (2013). Rethinking drug policy assumptions. Humanist, 73 (2), 12–15.

Fisher, G. L., & Harrison, T. C. (2000). Substance abuse: Information for school counselors, social workers, therapists and counselors (2nd ed.). Boston, MA: Allyn & Bacon.

Fisher, G. L., & Harrison, T. C. (2005). Substance abuse: Information for school counselors, social workers, therapists and counselors (3rd ed.). Boston, MA: Allyn & Bacon.

Goode, E. (1972). Drugs in American society. New York, NY: Alfred A. Knopf.

Goodwin, D. W., Hill, S., Powell, B., & Viamontes, J. (1973). The effect of alcohol on short-term memory in alcoholics. British Journal of Psychiatry, 122, 93–94.

Hall, W. (2010). What are the policy lessons of National Alcohol Prohibition in the United States, 1920–1933? Addiction (Abingdon, England), 105 (7), 1164–1173. doi:10.1111/j.1360-0443.2010.02926.x

Hammer, R. R., Dingel, M. J., Ostergren, J. E., Nowakowski, K. E., & Koenig, B. A. (2012). The experience of addiction as told by the addicted: Incorporating biological understandings into self-story. Culture,

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Medicine and Psychiatry, 36 (4), 712–734. doi:10.1007/s11013-012- 9283-x

Hogan, J. A., Gabrielsen, K. R., Luna, N., & Grothaus, D. (2003). Substance abuse prevention: The intersection of science and practice. Boston, MA: Allyn & Bacon.

Iarussi, M. M., Perjessy, C. C., & Reed, S. W. (2013). Addiction-specific CACREP Standards in clinical mental health counseling programs: How are they met? Journal of Addictions & Offender Counseling, 34 (2), 99– 113. doi:10.1002/j.2161-1874.2013.00018.x

Jacob, C. (2013). Peter Riederer “70th birthday” neurobiological foundations of modern addiction treatment. Journal of Neural Transmission, 120 (1), 55–64. doi:10.1007/s00702-012-0886-8

Jellinek, E. M. (1960). The disease concept of alcoholism. New Haven, CT: Hillhouse Press.

Kaij, L. (1960). Alcoholism in twins: Studies on the etiology and sequels of abuse of alcohol. Stockholm, Sweden: Almquist and Wiskell.

Koopmans, J. R., & Boomsina, D. L. (1995). Familiar resemblances in alcohol use: Genetic or cultural transmission. Amsterdam, The Netherlands: Department of Psychonomics, Vriji Univeriteit.

Kranzler, H. R., & Li, T. (2008). What is addiction? Alcohol Research and Health, 31, 93–95.

Lee, T. K., Craig, S. E., Fetherson, B. T. L., & Simpson, C. D. (2013). Addiction competencies in the 2009 CACREP Clinical Mental Health Counseling

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Program Standards. Journal of Addictions & Offender Counseling, 34 (1), 2–15. doi:10.1002/j.2161-1874.2013.00010.x

Levin, J. D. (1989). Alcoholism: A bio-social approach. New York, NY: Hemisphere.

Lindgren, K. P., Mullins, P. M., Neighbors, C., & Blayney, J. A. (2010). Curiosity killed the cocktail? Curiosity, sensation seeking, and alcohol- related problems in college women. Addictive Behaviors, 35, 513–516.

Lubman, D. L., Yucel, M., & Pantelis, C. (2004). Addiction, a condition of compulsive behaviour? Neuroimaging and neuropsychological evidence of inhibitory dysregulation. Society for the Study of Addiction, 99, 1491– 1502.

MacAndrew, C. (1979). On the possibility of the psychometric detection of persons who are prone to the abuse of alcohol and other substances. Journal of Addictive Behaviors, 4, 11–20.

McNeese, C. A., & DiNitto, D. M. (2005). Chemical dependency: A systems approach (3rd ed.). Boston, MA: Allyn & Bacon.

Milivojevic, D., Milovanovic, S. D., Jovanovic, M., Svrakic, D. M., Svrakic, N. M., Svrakic, S. M., & Cloninger, C. R. (2012). Temperament and character modify risk of drug addiction and influence choice of drugs. The American Journal on Addictions, 21(5), 462–467. doi:10.1111/j.1521- 0391.2012.00251.x

National Institute on Alcohol Abuse and Alcoholism. (1996). Alcohol alert (no. 33). Washington, DC: U.S. Government Printing Office.

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National Institute on Alcohol Abuse and Alcoholism (2000). Tenth special report on alcohol and health to the U.S. Congress. Washington, DC: U.S. Government Printing Office.

Raisitrick, D., & Davidson, R. (1985). Alcoholism and drug addiction. New York, NY: Churchill and Livingstone.

Rigg, K. K., & Murphy, J. W. (2013). Understanding the etiology of prescription opioid abuse: Implications for prevention and treatment. Qualitative Health Research, 23 (7), 963–975. doi:10.1177/1049732313488837

Schuckit, M. A. (1986). Etiological theories on alcoholism. In N. J. Estes & M. E. Heinemann (Eds.), Alcoholism; Development, consequences, and interventions (3rd ed., pp. 15–30). St. Louis, MO: C. V. Mosby.

Shaffer, H. J., LaPlante, D. A., LaBrie, R. A., Kidman, R. C., Donato, A. N., & Stanton, M. V. (2004). Toward a syndrome model of addiction: Multiple expressions, common etiology. Harvard Review of Psychiatry, 12, 367– 374.

Sloboda, Z., Glantz, M. D., & Tarter, R. E. (2012). Revisiting the concepts of risk and protective factors for understanding the etiology and development of substance use and substance use disorders: Implications for prevention. Substance Use & Misuse, 47(8/9), 944– 962. doi:10.3109/10826084.2012.663280

Stein, D. B., & Foltz, R. (2009). The need to operationally define “disease” in psychiatry and psychology. Ethical Human Psychology and Psychiatry, 11, 120–141.

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Stevens, P., & Smith, R.L. (Eds.). (2005). Substance abuse counseling: Theory and practice. Upper Saddle River, NJ: Merrill/Prentice Hall.

Tafa, M., & Baiocco, R. (2009). Addictive behavior and family functioning during adolescence. The American Journal of Family Therapy, 37, 388– 395.

Weil, A., & Rosen, W. (1993). Alcoholism: The nutritional approach. Austin, TX: The University of Texas Press.

White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems.

Wilcox, R. E., Gonzales, R. A., & Miller, J. D. (1998). Introduction to neurotransmitters, receptors, signal transduction and second messengers. In C. H. Nemeroff & A. E. Schatzberg (Eds.), Textbook of psychopharmacology (pp. 3–36). Washington, DC: American Psychiatric Press.