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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Running head: Treatment Providers‘ Beliefs About Addiction

Predictors of Addiction Treatment Providers‘ Beliefs in the Disease and Choice Models of Addiction

Christopher Russell, John B. Davies and Simon C. Hunter University of Strathclyde

Author Note Christopher Russell (M.Sc.), Department of Psychology, University of Strathclyde, 40 George Street, Glasgow, Scotland, UK, G1 1QE; John B. Davies (Ph.D., FBPsS.), Department of Psychology, University of Strathclyde, 40 George Street, Glasgow, Scotland, UK, G1 1QE; Simon C. Hunter (Ph.D.), Department of Psychology, University of Strathclyde, 40 George Street, Glasgow, Scotland, UK, G1 1QE.

Correspondence concerning this article should be addressed to Christopher Russell, Department of Psychology, University of Strathclyde, 40 George Street, Glasgow, Scotland, G1 1QE, UK. Email: [email protected] This is a pre-publication version of the following article: Russell, C., Davies, J., & Hunter, S.C. (2011). Predictors of treatment providers‘ beliefs in the disease model of addiction. Journal of Substance Abuse Treatment, 40, 150-164.

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Predictors of Addiction Treatment Providers‘ Beliefs in the Disease and Choice Models of Addiction ABSTRACT Addiction treatment providers working in the United States (n = 219) and the United Kingdom (n = 372) were surveyed about their beliefs in the disease and choice models of addiction, as assessed by the 18-item Addiction Belief Scale (ABS: Schaler, 1992). Factor analysis of item scores revealed a three factor structure, labelled ‗addictions is a disease‘, ‗addiction is a choice‘, and ‗addiction is a way of coping with life‘, and factor scores were analysed in separate hierarchical multiple regression analyses. Controlling for demographic and addiction history variables, treatment providers working in the US more strongly believe addiction is a disease whereas UK-based providers more strongly believe that addiction is a choice and a way of coping with life. Beliefs that addiction is a disease were stronger among those who provide treatment for-profit, have stronger spiritual beliefs, have had a past addiction problem, are older, and are members of a group of addiction professionals, and have been treating addiction for longer. Conversely, those who viewed addiction as a choice were more likely to provide public/not-for-profit treatment, be younger, have been treating addiction for fewer years, and have weaker spiritual beliefs. Additionally, treatment providers who have had a personal addiction problem in the past were significantly more likely to believe addiction is a disease the longer they attend a 12-step-based group and if they are presently abstinent.

Keywords: Addiction; treatment providers; beliefs; disease; choice.

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION

1. Introduction The question ―what is addiction?‖ has long polarised the medical, social science, legal and spiritual communities into those who view addiction as a disease (Jellinek, 1960; Vaillant, 1990; Maltzman, 1994; Leshner, 1997; Lyvers, 1998; Koob & Nestler, 1997; Ketcham & Asbury, 2000; Kalivas & Volkow, 2005; Benowitz, 2008) and those who view addiction as a cognisant choice (Merry, 1966; Szasz, 1972; Room, 1983; Fingarette, 1988a, 1988b; Peele, 1989; Playfair, 1991; Schaler, 2000; Heyman, 2009). Many professional and lay conceptions of addiction can be traced back to this dichotomy in causation – drug ‗addicts‘ are either ―responsible/moral agents who perpetrate acts of mayhem on themselves…or victims of a disorder which undermines their values and best intentions‖ (White, 2001). Regardless of the scientific credibility of the disease and choice (or ‗free will‘) models, research has shown that clients of addiction services tend to adopt the addiction ideology of their treatment service (Koski-Jannes, 2004). Therefore, the extent to which addiction treatment providers believe their clients‘ addictive behaviours are diseased or chosen should be expected to have a strong bearing on how clients will attribute the causes of their problems, seek to resolve these problems, and believe in their capacity to achieve a desired change. Extending research by Schaler (1992), we examined addiction treatment providers‘ beliefs about addiction and investigated the factors explaining variance in beliefs, with a specific interest in the importance of country in which treatment is provided.

1.1. Dichotomous and trichotomous thinking about addiction The disease and choice models of addiction are not the only perspectives of addiction in existence; they are only the two chosen for scrutiny in this study. Several other perspectives of addiction – such as an illness, disorder, malady, allergy, ailment, sickness,

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION condition, habit, functional attribution, and social construction among others – can be viewed as implicitly ascribing or alluding to the respective disease/choice model assumptions about addiction as a compelled versus chosen act, an involuntary versus voluntary act, and a problem inherent to the drug versus a problem inherent to the mind of the user. Alternatively, some theorists refute the suggestion that addiction can be fit to a disease-choice dichotomy, arguing addiction to be a complex, messy intertwining of the user‘s biology and sociology which subsumes elements of the disease and choice model without contradiction. Consequently, a disease-intermediate-choice trichotomy has emerged. White‘s (2001) ‗degrees of freedom‘ perspective, for example, argues addiction as a ―process disease‖ which should be discussed not in terms of complete control or complete loss of control, but in terms of degrees of diminishment and enhancement of volitional control. The problem with an intermediate perspective, however, is that it must logically presume there exists a critical, discrete point along the freedom continuum at which drug use becomes no longer governed by phenomenological wants but by physiological needs. This ‗tipping point‘ has survived as a core hypothesis of 19th century disease conceptualisations of inebriety – Joseph Parrish suggested in 1888 that ―a line could be crossed where drunkenness evolves into a disease that is no longer under the conscious control of the drinker‖ (cited in White, 2000) – through to the modern disease concept – ―the non-addicted brain is distinctly different from the addicted brain... A metaphorical switch in the brain seems to be thrown as a result of prolonged drug use. Initially, drug use is voluntary, but when that switch is thrown, the individual moves into the state of addiction characterized by compulsive drug seeking and use‖ (Leshner1, 1997: 46). To create an intermediate perspective would, therefore, be redundant for the purposes of asking whether drug seeking and use is willed or determined. Thus, though the validity of a trichotomous model of the governing factors in addiction, and the mechanisms of change at

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Director of National Institute of Drug Abuse at time of publication.

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION the boundary of each state will continue to be debated, this study was concerned only with treatment providers‘ beliefs in the disease and choice models.

1.2. The disease and choice models The disease and choice models of addiction emerged from different assumptions about the origins of behaviour; namely, whether behaviour is determined by physical mechanism or willed by an emergent force which transcends direct physical mechanism (Davies, 1997). Consequently, they hold divergent but equally powerful assumptions about how people become addicted to drugs and alcohol, their capacity for control during consumption, and their prospects for change without medical treatment. That the different sets of fundamental assumptions driving each model are philosophically irreconcilable also necessitate, we argue, proponents of one model to be equally passionate critics of the other. The disease model posits addiction/substance dependency as a primary, progressive, chronic relapsing disease which is either genetically transmitted or acquired through excessive consumption (Leshner, 1997; Ketcham & Asbury, 2000). Here, initial drug use occurs voluntarily. As repeated drug use changes neural and brain function, however, the user progressively loses control over their initial voluntary behaviour to the point that further drug seeking and use become acts of compulsion, not choice (Ochoa, 1994; Foulds & Ghodse 1995). Thus, getting drug users who are in the early or latter stages of an addiction into treatment with medical experts often represents their best hope for arresting but never curing the addiction (Milam & Ketcham, 1983). In response to criticism, however, that a large body of scientific evidence on alcoholism and alcohol problems has contradicted the view of addiction as ―an incurable, unitary, all-or-nothing disorder caused solely by hereditary physical abnormalities‖ (Miller, 1993: 133), a more scientifically defensible disease model has been sought in recent years. Miller proposed that research, treatment, and education about

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION alcoholism should be based on a disease model which describes alcohol problems on continua of severity and an aetiological model comprising interactions of drug properties, drug user, and drug setting. The alternative model describes addiction as a motivated choice. Here, drug taking is at all times something individuals do voluntarily, usually when life is going badly or to avoid coping with problems-in-living (Schaler, 2000). When these problems-in-living are resolved, individuals normally find that the addiction resolves with them, while others individuals mature out of their addiction in time (Peele, Brodsky, & Arnold, 1991) or learn to control their consumption (Heather & Robertson, 1989). In this way, addiction is seen as more to do with the environments people live in than with brain pharmacology (Cohen, Liebson, Faillace, & Allen, 1971; Robins, Helzer & Davis, 1975; Alexander, Hadaway, & Coambs, 1980). With regard to the issue of control, choice proponents argue that not only do drug users never lose control over their drug use but that the best way to get curb problem drug use is to make and implement better decisions, which does not require them to seek medical treatment. Choice proponents tend to allow discussion of addiction as a metaphorical disease, but refute that it is a literal brain disease (McMurran, 1994). They note that a large body of scientific evidence contradicts disease model claims regarding heritability, loss of control, and effectiveness of treatment, and they denounce the disease model‘s inference of a critical discrete event discriminating addicted and non-addicted drug users‘ as myth. They argue that drug users are always free to choose to stop, and that drug users‘ difficulty in effecting change should not be mistaken for a lack of freedom to do so.

1.3. Milestones in the evolution of the disease model Treatment providers‘ support for each of the competing models may vary depending on whether treatment is provided in the United States or not. Though the idea of alcoholism

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION as a disease did not originate in the US, the modern disease concept of alcoholism has been 200 years in the making2, during which time the US has presided over the most significant events in changing public conceptions of drunkenness and drug use from voluntary choices to involuntary compulsions (Levine, 1978; Peele, 1989). Benjamin Rush first medicalised the problem of drunkenness in the early 19th century, his definition of a ―disease of the will‖ becoming a central message of the American Temperance Movement (Levine, 1978). The term ‗inebriety‘ was introduced in the late 19th century to explain the seeking and problem use of a variety of drugs as due to a common underlying pathology. Interest turned to the effects of drugs‘ effects on the host, and doctors began to hypothesise that the inebriate‘s apparent loss of control and other symptoms could be traced to rogue hereditary and/or self-impaired biological mechanisms which mark a primary disease of the nervous system. In particular, the work of the Drs Parrish (1883) and Crothers (1893) – prominent leaders of the American Association for the Cure of Inebriety – described inebriety as a disease; which is curable in the sense that other diseases are curable; and as inherited or acquired through excessive consumption. This disease concept of inebriety began a movement to treat inebriates at specialised institutions in medical and scientific ways similar to other diseases, i.e. through the development of vaccines. During this period, Dr Norman Kerr (1888) was advocating a comparable disease concept in England. Consequently, disease thinking about inebriety soon spread throughout the US and UK. Public thinking about the disease of drunkenness took off in 1935 with the inception and rapid growth of Alcoholics Anonymous (A.A.), a spiritual self-help fellowship made up of self-described recovering alcoholics committed to helping one another maintain sobriety (Kurtz, 1988). Though A.A literature does not refer to alcoholism as a literal disease, Kurtz (2002) states that A.A. and A.Aers do use medical terms – illness, sickness, malady – and the

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Levine (1978) and White (2000) provide a comprehensive history of the disease concept of alcoholism.

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION disease concept to reflect their belief about the solution to alcoholism – abstinence – and to convey the hopelessness of alcoholics to change themselves. Ragge (1998), for example, traces seven features of the modern disease concept of alcoholism (e.g., beliefs that ―an intense physical craving is responsible for alcoholics‘ loss of control‖, and ―physiology, not psychology, determines whether one drinker will become addicted and another will not‖) to the Big Book of A.A. (Alcoholics Anonymous World Services, 1939), the fellowship‘s core publication. A.A., through its public relations campaigns, been instrumental in spreading and popularising the disease concept of alcoholism while avoiding discourse of alcoholism as a literal disease. Addiction as a disease in the US gained momentum in the mid-1990s with significant increases in public funding of research into the genetic and neurobiological foundations of addiction (Institute of Medicine, 1996). This research agenda, accompanied by a public education campaign which used a basic vocabulary to teach a basic level of understanding about brain reward circuitry, sought to ―move ‗addiction is a disease‘ from the status of an ideological proclamation by policy activists and an organizing metaphor for individuals seeking to resolve alcohol and other drug problems to a science-grounded conclusion‖ (White, 2007). In recent years, former and current Directors of the National Institute of Drug Abuse, Alan Leshner (1997) and Nora Volkow have used high profile, highly respected academic outlets to summarise twenty years of evidence from the neurosciences and behavioural sciences which they claim prove addiction is a brain disease. Leshner, additionally, called for public policy, education, and addiction treatment to catch up with these scientific facts. Volkow‘s keynote speech followed on from a special issue of Nature Neuroscience (multiple authors, 2005) in which a group of renowned neuroscientists reported the latest evidence on the neurobiology of addiction. Their findings described addiction as a fundamentally neurobiological disorder.

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Finally, as a vehicle for the dissemination of this new neuroscientific evidence base to the public, the IOM (1996) recommended that education about addiction should explain in basic language that drugs can alter neural or brain function, how these changes impair the user‘s ability to make choices about using drugs, and that treatment is effective. The ‗brain hijacking‘ metaphor – ―the concept that these drugs can capture control of brain mechanisms that control motivations and emotions‖ – was proposed as an effective device to increase understanding about a common effect of some drugs on the brain. This device has since featured prominently in major media pieces such as a TIME Magazine (2007) feature article entitled ―How We Get Addicted‖ and a 14-part TV special by HBO Documentary Films (2007) entitled, ―Addiction: Why Can‘t They Just Stop?‖. Today, the American Medical Association (Morse & Flavin, 1992), APA (2000), and NIDA (2009) continue to define as the essence of addiction uncontrollable, compulsive drug seeking and use. Consequently, the use of the word ―addiction‖ in public discourse has come to describe the activities which people engage in because they are physically unable to avoid doing so (Levine, 1978; Mercadante, 1996; Schaler, 2000). Though the disease model now dominates addiction discourse internationally, the prominent role played by the US‘ psychiatric, medical, research, media, and spiritual communities in shaping the modern disease concept of addictive behaviours suggests that support for the view that addiction is a disease may be stronger within the US than UK treatment community.

1.4. Previous research Investigation of these questions was motivated by Schaler (1992) who found that treatment providers tended to believe that addiction is a disease from which only about 25% of people recover without medical or 12-step based treatment. Treatment providers who reported stronger beliefs that addiction is a disease were significantly more likely to be

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION female; members of the National Association for Alcoholism and Drug Abuse Counselors (NAADAC); present or past members of A.A.; certified addiction counsellors/therapists; abstinent at present; and have stronger spiritual beliefs as defined in A.A. philosophy. Strength of spiritual beliefs, as measured by the Spiritual belief Scale (SBS; Schaler, 1992) accounted for most variance (41%) in disease beliefs. However, though Schaler‘s sample comprised treatment providers working in the United States, Canada, and Australia, differences across these locations were not investigated. This precludes offering conclusions about support for the disease model in the US relative to out-with the US and the hypothesised significance of the country of treatment as a predictor of addiction beliefs. Data were also not collected on the profit status of treatment provided. Furthermore, there are a number of reasons to suspect that addiction beliefs may have changed since 1992. These include: high staff turnover rates; new pharmacological and psychotherapeutic treatment approaches to addiction; policy changes regarding public funding of addiction treatment and insurance coverage; new laboratory and field evidence on treatment effectiveness including the much publicised findings of Project MATCH (1997) and UKATT (2005); the aforementioned US-led research drive to emphasise the neuronal mechanisms and heritability of addiction; and the transmission of the basic facts of addiction neuroscience to the public, policy makers, and treatment providers. Thus, we examined whether a similar factorial structure emerged from ABS scores, and whether factors found by Schaler to explain variance remain potent 18 years on.

1.5. Current study aims The purpose of this study was to assess (a) whether belief in the disease model of addiction is stronger among treatment providers who work in the US versus the UK; and (b)

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION the variance in disease and choice beliefs explained by demographic and personal and professional addiction history variables.

2. Materials and method 2.1. Recruitment methods Treatment providers were recruited in three ways. First, a survey pack was sent to designated persons at each of the 21 and 94 regional Drug and Alcohol Action Teams (DAATs) in Scotland and England respectively. As part of regional NHS Health Boards, DAATs are responsible for the top-down and bottom-up communication of substance misuserelated data between addiction treatment services and local and central government and, therefore, have excellent access to voluntary and statutory addiction treatment providers within their region. DAATs were asked to forward the survey pack to managers of local addiction treatment services. In turn, managers were asked to forward the survey to all staff who are directly involved in the provision of addiction treatment. Second, survey packs were sent via email to 785 persons who could be identified as Chief Executive Officers/Managers of addiction treatment services on the websites of several large associations and online databases of addiction treatment professionals. These were: NAADAC, the Association for Addiction Professionals; Federation of Drug and Alcohol Professionals (a U.K. branch of NAADAC); European Federation of Therapeutic Communities; European Association for the Treatment of Addiction; Association of Intervention Specialists; Recover Now; Time for New Beginnings; Sober Recovery; Addiction Treatment Center Directory; Substance Abuse and Mental Health Services Administration, Substance Abuse Treatment Facility Locator (SAMHSA, U.S. Department of Health and Human Services); and Alcohol Focus Scotland. Treatment providers typically provide contact information for public viewing on these websites for the benefit of persons

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION seeking help for an addiction problem, though they are assumed to not oppose being contacted in this way by other interested parties. Indeed, no treatment providers objected to being contacted in this way and many were quite happy to know they were accessible in this way. Third, survey packs were circulated to subscribers of the following e-newsletter mailing lists: (1) U.K. lists: Alcohol Misuse, Drug Misuse Research, Drug Day Programmes, Wired In, and Therapeutic Community Open Forum; (2) US/Canadian Lists: Addict-L, Addiction Medicine, and Apolnet; (3) European Lists: Therapeutic Communities and European Working Group on Drugs Oriented Research; and (4) International Lists: the Kettil Bruun Society, and Gambling Issues International. These lists cover approximately 2,500 subscribers in total. The e-survey was closed two months after the final survey pack was sent out. 2.2. Sample characteristics The survey received 854 responses. Of these, 164 were excluded because the Addiction Belief Scale (ABS) was incomplete (n = 160) or because respondents were not providers of addiction treatment/were no longer actively treating clients (n = 14). We had initially planned to compare the strength of disease beliefs in the United States versus several countries. However, the majority of survey responses came from treatment providers working in the United Kingdom (n = 372) and the United States (n = 219) with the remaining 99 respondents representing 21 other countries. Thus, comparing disease beliefs in the US to those in several countries was not possible and creating a ―US versus Not US‖ variable was considered misleading given that 53% of the ―Not US‖ respondents came from the UK. Purely due to the geographical distribution of our sample, it was decided to exclude the 99 non-UK and non-US respondents so as to compare the strength of disease beliefs of treatment providers working in the US versus the UK. This left a final sample of 591. Due to the

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION opportunistic sampling method, it was impossible to calculate a survey return rate. Professional characteristics of the sample by country are summarised in Table 1. Table 1 near here

2.3. Materials Treatment providers were invited by email to complete an e-survey of their addiction beliefs. This email gave a brief explanation of the study, confirmed that local ethical approval had been granted, assured respondents of confidentiality, and gave contact information for the primary and secondary authors. The survey comprised three parts; the Addiction Belief Scale (ABS); the Spiritual Belief Scale (SBS); and questions about their personal and professional addiction history. Other information collected included age (in years) and gender.

2.3.1. The Addiction Belief Scale The eighteen items of this scale comprise statements about addiction as described in the disease (nine items) and choice (nine items) models regarding aetiology, the need for treatment and addicts‘ capacity for self-control, insofar as these assumptions can be dichotomised. An example of a statement which reflects the disease model is ―Physiology, not psychology, determines whether one drinker will become addicted to alcohol and another will not‖ (item 11). An example of an item reflecting the choice model is ―People can stop relying on drugs or alcohol as they develop new ways to deal with life‖ (item 6). Respondents rate on a 5-point Likert scale the extent to which they agree with each statement (1 = strongly disagree to 5 = strongly agree) and the nine choice model items are reverse scored. The highest possible score is 90 (min. = 18) with a conceptual median of 54. A score higher or lower than 54 on the ABS indicates a belief in the disease or choice model of addiction respectively. Schaler (1995) reported strong internal consistency for the ABS (α = .91,

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION standardized item, α = .91, n = 266) and a three-factor structure described as ―power‖ (α = .91, n =274), ―dichotomous thinking‖ (α = .83, n = 285), and ―addiction as a way of coping with life‖ (α = .47, n = 286). High construct validity was evidenced by a strong negative correlation (r = -.67, p = .01) between respondents‘ ABS scores and their beliefs about the percentage of individuals able to recover from an addiction without any form of medical or 12-step-type treatment, i.e. the stronger their belief in addiction as a disease (higher ABS score), the lower the percentage of individuals they believed are able to recover without treatment. The full ABS and factorial analysis can be found in Schaler (1995). Despite reporting a three-factor structure, Schaler initially scored ABS items in accordance with a single factor, bipolar in nature, with endorsement of the disease model at one end and endorsement of the choice model at the other end. As such, the nine items designed to represent beliefs in the choice model were reverse scored. To determine whether this scoring system was appropriate for current data, a factor analysis of current ABS data was conducted to check whether addiction beliefs load on a single ‗disease-choice‘ factor (and so choice items can be reverse scored and ABS total scores used as a dependent measure of belief in the disease model) or whether addiction beliefs conform to a multi-factorial structure. Results of this analysis are reported in section 3.2.

2.3.2. The Spiritual Belief Scale The eight items of this scale measure spiritual thinking as defined in the philosophy of A.A. as belief in a metaphysical power which can influence personal experience. Items were adapted from how spirituality is discussed in the Big Book of A.A to form statements about God and ―spiritual health‖. Items reflect the four spiritual characteristics of A.A. – release, gratitude, humility, and tolerance – identified by Kurtz (1988). Respondents rate on a 5-point Likert scale the extent to which they agree with each statement (1 = strongly disagree to 5 =

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION strongly agree). Higher scores indicate stronger spiritual beliefs. The highest possible score is 40 (min. = 8). Schaler (1996) reported strong internal consistency for the SBS (α = .92, standardised item, α = .91, n = 280) and a two-factor structure described as ―releasegratitude-humility‖ (six items, α = .95, n = 281) and ―tolerance‖ (two items, α = .53, n = 290). The full SBS and factorial analysis can be found in Schaler (1996).

2.3.3. Addiction history questions Questions regarding respondents‘ professional addiction history were: whether they are an addiction treatment provider; job title; the country and state/county in which they provide treatment; the profit status of their treatment facility; number of years experience as an addiction treatment provider; whether they are a member of any professional group of addiction treatment providers; whether they are a certified counsellor or therapist for treating an addiction; and which types of addiction problems they treat. Regarding personal addiction history, respondents were asked if they have personally had a problem with an addiction in the past. If ―yes‖ was indicated they were then asked several follow-up questions: whether they have ever attended a treatment agency in the past; whether they have attended in the past or presently do attend A.A., Narcotics Anonymous (N.A.) or any other 12-step-based program; number of years in total they have been a member of a 12-step-based program; and whether they are abstinent at present. Respondents who indicated ―no‖ to the past addiction problem question did not answer these five followup questions. Finally, an empty text box at the end of the survey allowed respondents to comment on the survey.

3. Results 3.1. Power analysis

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Power analyses were performed to determine whether the planned multiple regression analysis would be sufficiently powered to detect meaningful effects (f² for multiple regression, see Cohen, 1988) given a sample of 591. The analysis showed that when N = 591 and α = .05 and with ten predictors, power = 1.00). Thus, it was concluded that the present analysis was sufficiently powered.

3.2. Factor analysis of the Addiction Belief Scale Separate factor analyses were conducted to compare the ABS factor structures for the UK (n = 372) and US-based (n = 219) samples. Despite the ABS‘s apparent bi-polar content on a single dimension of addiction beliefs, extremely similar four-factor solutions were found for each country. Within the UK sample, five disease items (1 (.73); 2 (.75); 3 (.76); 5 (.61); and 10 (.57)) loaded on factor 1; four disease items (9 (.53); 11 (.57); 14 (.68); and 17 (.49) and one choice item (12 (-.66) loaded on factor 1; six choice items (4 (.66); 7 (.60); 8 (.50); 13 (.54); 15 (.61); and 16 (.48)) loaded on factor 3; and two choice items (6 (.70) and 18 (.62)) loaded on factor four. The only differences in the composition of the four factors extracted from US-based scores were that item 12 switched from being negatively correlated with disease items in factor 2 to strongly positively correlated with the choice items in factor 3, and items 13 and 15 switched from factor 3 (all choice items) to factor 4 (all choice items). Given these extremely similar factor solutions found in separate analyses, all ABS scores (N = 591) were factor analysed using varimax rotation with Kaiser Normalisation. Three factors were extracted, which we labelled ‗addiction is a disease‘; ‗addiction is a choice‘; and ‗addiction is a way of coping with life‘ respectively. These factors together explained 50.13% of common variance. Factor 1 had an eigenvalue of 6.08 and explained 33.80% of variance. Ten items loaded on this factor, nine of which were designed to represent the disease model

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION of addiction (items 1 (.67)3; 2 (.74); 3 (.66); 5 (.70); 9 (.72); 10 (.68); 14 (.65); and 17 (.66)) and one item designed to represent the choice model of addiction (12: ―Alcoholics can learn to moderate their drinking or cut down on their drug use‖) which was strongly negatively correlated (-.55). Disagreement with item 12 implied the belief that ‗alcoholics‘ are unable to learn to moderate drinking/drug use, which is consistent with the disease perspective. The item with the strongest correlation value reads: ―Addicts cannot control themselves when they drink or take drugs‖. Factor 2 had an eigenvalue of 1.83 and explained 10.19%. Six of the remaining eight items designed to represent the choice model loaded on this factor (items 4 (.58); 7 (.72); 8 (.50); 13 (.54); 15 (.62); and 16 (.54)). The item with the strongest correlation value reads: ―Addiction has more to do with the environments people live in than the drugs they are addicted to‖. Factor 3 had an eigenvalue of 1.11 and explained 6.14% of variance. The two remaining choice model items (6 (.65) and 18 (.69)) loaded on this factor. The item with the strongest correlation reads: ―Drug addiction is a way of life people rely on to cope with the world‖. However, the overall pattern mirrored that revealed by the factor analysis of the entire sample: items designed to represent the disease and choice models correlated positively with their own kind and correlated negatively with items representing the alternative model. Therefore, scores were summed for each of the three factors extracted by the main factor analysis (‗addiction is a disease‘, ‗addiction is a choice‘, and ‗addiction is a way of coping with life‘) and used as criterion variables in subsequent regression analyses. These factors had maximum scores of 50, 30, and 10 respectively, with higher scores reflecting stronger beliefs in each factor. Each factor had good-very good internal consistency and correlated strongly with each other, as shown in table 2.

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Correlation values in parentheses.

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Table 2 near here.

3.3. Hierarchical multiple regression models To investigate the variables which explain variance in addiction treatment providers‘ belief in the disease model of addiction, three separate hierarchical multiple linear regression analyses were conducted, each in three steps, with score on factor 1 (‗addiction is a disease‘), factor 2 (‗addiction is a choice‘), and factor 3 (addiction is a way of coping with life‘) of the ABS used respectively as the criterion variables. To control for their effects, eight variables were entered at step one of each regression equation: sex (0 = Male, 1 = Female); age; number of years as an addiction treatment provider; certification as an addiction treatment provider (0 = No, 1 = Yes); member of a group of addiction treatment professionals (0 = No, 1 = Yes); had a personal addiction problem in the past (0 = No, 1 = Yes); the profit status of treatment provision (0 = public/not-for-profit, 1 = private/for-profit); and SBS score. The country in which treatment is provided (0 = UK, 1 = US) was added at step 2. Finally, to assess any moderation of an effect of profit status on ABS score by country, an interaction term for profit status and country was regressed on ABS score at step 3. Data satisfied assumptions of linearity, multicollinearity, and homoscedasticity of residuals. Mean scores and standard deviations for the three ABS factors are presented in table 3. Table 3 near here

3.4. Variables explaining variance in treatment providers‟ beliefs that „addiction is a disease‟

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION The final regression model accounted for 35.6% of variance in treatment providers‘ beliefs in the disease model of addiction (see Table 4). Step 1 produced a significant model, F(8, 565) = 26.47, p < .001, and accounted for 27.3% of variance in factor 1 scores. Six of the eight variables made significant contributions. Score on the SBS and age were both positively associated (β = .40, p < .001, and β = .15, p < .001 respectively) with ABS score. These indicate that belief in the disease model strengthens with level of spiritual thinking and with age. Providing private/for-profit treatment was positively associated (β = .10, p < .01) with factor 1 score. Those who provide addiction treatment for-profit more strongly believe (M = 28.96, SD = 6.53) that addiction is a disease than those who provide public/not-for-profit treatment (M = 26.39, SD = 6.15). Being a member of a professional group of addiction treatment providers was positively associated (β = .11, p < .01) with factor 1 score. Professional group members more strongly believe (M = 29.61, SD = 6.09) that addiction is a disease than non-members (M = 26.27, SD = 6.17). Number of years of experience as a treatment provider was positively associated with factor 1 score (β = .13, p < .01), with disease beliefs strongest (M = 27.60, SD = 7.39) among those who have provided addiction treatment for the longest (21+ years). Finally, having had a personal problem with addiction in the past was positively associated (β = .10, p < .05) with factor 1 score. Those who have had a personal addiction problem more strongly believe (M = 29.15, SD = 6.39) that addiction is a disease than those who have not had an addiction problem (M = 26.23, SD = 6.16). Table 4 near here

Step 2 in the model accounted for a significant increase of 8.0% explained variance in factor 1 scores, Fchange(1, 564) = 68.55, p < .001. After partialling out variance explained by variables in step 1, providing addiction treatment in the US was positively associated (β =

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION .32, p < .001) with factor 1 score. Providers of addiction treatment in the US more strongly believe (M = 31.02, SD = 5.53) in the disease model of addiction than those who provide addiction treatment in the UK (M = 24.97, SD = 5.77). Step 3 in the model yielded a non-significant increase of 0.4% explained variance, Fchange(1, 563) = 3.84, p > .05. Therefore, the country of treatment did not moderate the effect of profit status on treatment providers‘ beliefs that addiction is a disease.

3.5. Variables explaining variance in treatment providers‟ beliefs that „addiction is a choice‟ The final regression model accounted for 23.6% of variance in treatment providers‘ beliefs that addiction is a motivated choice. Step 1 produced a significant model, F(8, 565) = 12.89, p < .001, and accounted for 15.4% of variance in factor 2 score. Four of the eight variables made significant contributions. In complete contrast to factor 1 scores, score on the SBS and age were both negatively associated (β = -.24, p < .001, and β = -.10, p < .05 respectively) with factor 2 scores. These indicate that beliefs that addiction is a choice weaken as strength of spiritual thinking increases and with age. Providing private/for-profit treatment was negatively associated (β = .14, p < .01) with factor 2 score. Those who provide public/not-for-profit addiction treatment more strongly believe (M = 17.47, SD = 3.45) that addiction is a choice than those who provide private/for-profit treatment (M = 15.70, SD = 3.46). Being a member of a professional group of addiction treatment providers was negatively associated (β = -.11, p < .01) with factor 2 score. Treatment providers whom are not members of a group of addiction professionals more strongly believe (M = 17.46, SD = 3.50) that addiction is a choice than group members (M = 15.70, SD = 3.23). Step 2 in the model accounted for a significant increase of 6.7% explained variance in factor 2 score, Fchange(1, 564) = 48.71, p < .001. After partialling out variance explained by

20

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION variables in step 1, providing addiction treatment in the US was negatively associated (β = .30, p < .001) with factor 2 score. Providers of addiction treatment in the UK more strongly believe (M = 17.96, SD = 3.22) that addiction is a choice than those who provide addiction treatment in the US (M = 15.24, SD = 3.39). Step 3 in the model yielded a significant increase of 1.5% explained variance in factor 3 score, Fchange(1, 563) = 10.80, p < .001. To interrogate this interaction, simple effects analyses were conducted (i.e., repeating the analysis with neither the country X profit status interaction term nor main effects of country), first for US-based treatment providers (n = 219) and then for UK-based treatment providers (n = 372). This revealed a significant negative association between profit status and factor 2 score among US-based treatment providers (β = -.40, p < .001) after controlling for seven variables entered at step 1, Fchange(1, 207) = 31.42, p < .001, R²change = .117. No significant association was found between profit status and factor 2 score among UK-based providers (see table 5). This indicates that country of treatment moderates the relationship between profit status and treatment providers‘ beliefs that addiction is a choice, with only US-based providers of public/not-for-profit treatment reporting significantly stronger beliefs (M = 16.23, SD = 3.28) than private/for-profit providers (M = 13.13, SD = 2.55) that addiction is a choice. Table 5 near here 3.6. Variables explaining variance in treatment providers‟ beliefs that „addiction is a way of coping with life‟ The final regression model accounted for 22.0% of variance in treatment providers‘ beliefs that addiction is a way of coping with life. Step 1 produced a significant model, F(8, 565) = 9.45, p < .001, and accounted for 11.8% of variance in factor 3 score. Four of the eight variables made significant contributions.

21

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Score on the SBS and age were again both negatively associated (β = -.14, p < .001, and β = -.12, p < .05 respectively) with factor 3 score. These indicate that beliefs that addiction is a way of coping with life weaken as strength of spiritual thinking increases and with age. Providing private/for-profit treatment was negatively associated (β = -.16, p < .001) with factor 3 score. Those who provide public/not-for-profit addiction treatment more strongly believe (M = 7.19, SD = 1.49) that addiction is a way of coping with life than those who provide private/for-profit treatment (M = 6.55, SD = 1.75). Being female was positively associated (β = .12, p < .01) with factor 3 score. Female treatment providers more strongly believe (M = 7.17, SD = 1.49) that addiction is a way of coping with life than male treatment providers (M = 6.76, SD = 1.47). Step 2 in the model accounted for a significant increase of 8.2% explained variance in factor 2 scores, Fchange(1, 564) = 57.80, p < .001. After partialling out variance explained by variables in step 1, providing addiction treatment in the US was negatively associated (β = .33, p < .001) with factor 3 score. Providers of addiction treatment in the UK more strongly believe (M = 7.40, SD = 1.35) that addiction is a choice than those who provide addiction treatment in the US (M = 6.28, SD = 1.48). Step 3 in the model yielded a significant increase of 2.0% explained variance in factor 3 score, Fchange(1, 563) = 14.40, p < .001. To interrogate this interaction, simple effects analyses were again conducted, first for US-based sample (n = 219) and then the UK-based sample (n = 372). This revealed a significant positive association between profit status and factor 3 score in the US (β = .47, p < .001) after controlling for seven variables entered at step 1, Fchange(1, 207) = 32.56, p < .001, R²change = .124. Again, no significant association was found between profit status and factor 2 score in the UK sample. This indicates that country of treatment moderates the relationship between profit status and treatment providers‘ beliefs in the disease model, with only US-based treatment providers reporting significantly stronger

22

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION beliefs (M = 6.68, SD = 1.36) than private/for-profit providers (M = 5.41, SD = 1.35) that addiction is a way of coping with life.

3.7. Hierarchical multiple regression models applied to data provided only by treatment providers who have had a past addiction problem Three separate hierarchical multiple linear regression analyses were then conducted to investigate the variance in addiction beliefs of treatment providers who have had a past addiction problem (n = 199) explained by five personal addiction history variables. Three ABS factor scores were again used as criterion variables. To control for their effects, sex, age, number of years as an addiction treatment provider, certification status as an addiction treatment provider, membership status of a group of addiction treatment professionals, country of treatment, profit status of treatment, and SBS score were all entered at step 1. A further five variables were entered at step 2 of the equation: attended treatment in past (0 = No, 1 = Yes); attended 12-step-based group in past (0 = No, 1 = Yes); attend 12-step-based group at present (0 = No, 1 = Yes); number of years in 12-step-based group; and abstinence status at present (0 = Not abstinent, 1 = Abstinent). Power analysis confirmed that with a sample of 199, α = .05, and with 13 predictor variables, power = .89, meaning this regression model was sufficiently powered to detect meaningful factor effects.

3.8. Variables explaining variance in „addiction is a disease‟ beliefs of treatment providers who have had a past addiction problem Controlling for the effects of the eight variables entered at step 1, step 2 in the model accounted for a significant increase of 12.2% explained variance in factor 1 scores, Fchange(5, 179) = 7.48, p < .001 (see table 6). Two of the five variables made significant contributions. Number of years as a member of a 12-step group was positively associated (β = .24, p < .001)

23

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION with factor 1 score. The longer treatment providers are members of a 12-step-based group, the more strongly they come to believe addiction is a disease. Being abstinent at present was also positively associated (β = .16, p < .05) with factor 1 score. Treatment providers who have had a personal addiction problem and are not presently abstinent more strongly believe (M = 29.90, SD = 6.32) that addiction is a disease than those who are presently abstinent (M = 23.78, SD = 3.74). Table 6 near here.

3.9. Variables explaining variance in „addiction is a choice‟ beliefs of treatment providers who have had a past addiction problem Controlling for the effects of the eight variables entered at step 1, step 2 in the model accounted for a significant increase of 5.3% explained variance in factor 1 scores, Fchange(5, 179) = 6.13, p < .001. Only one variable made a significant contribution. Number of years as a member of a 12-step group was negatively associated (β = .26, p < .001) with factor 2 score. The longer treatment providers are members of a 12-step-based group, the less they come to view addiction as a choice.

3.10. Variables explaining variance in „addiction is a way of coping with life‟ beliefs of treatment providers who have had a past addiction problem Controlling for the effects of the eight variables entered at step 1, step 2 in the model accounted for a non-significant increase of 1.8% explained variance in factor 3 scores, Fchange(5, 179) = 0.64, p > .05. Thus, treatment providers who had a personal addiction problem in the past did not vary significantly in their beliefs about addiction as a way of coping with life.

24

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION 4. Discussion 4.1. Key findings Addiction treatment providers in the United States and United Kingdom were surveyed on their beliefs about the aetiology of addiction, the need to receive treatment and addicts‘ capacity for self-control during drug use. Seven variables were significant in explaining variance in addiction beliefs. After controlling for the variance accounted for by eight variables, treatment providers‘ strength of beliefs in the disease model of addiction was significantly predicted by the country in which treatment is provided. Those who provide addiction treatment in the US more strongly believe that addiction is a disease than those who provide addiction treatment in the UK, whereas UK-based treatment providers more strongly believe that addiction is a choice than US-based treatment providers. Those more likely to believe that addiction is a disease also tend to provide treatment for-profit, have stronger spiritual beliefs, have had a personal problem with addiction in the past, are members of a group of addiction professionals, have been treating addiction problems for longer, and are older. In contrast, those who believe addiction is a choice tend to provide public/not-forprofit treatment, have weaker spiritual beliefs, be younger, and not be members of a group of addiction professionals. The country in which treatment is provided moderates the effect of treatment profit status on providers‘ beliefs about addiction as a choice and as a way of coping with life, with those providing public/not-for-profit treatment in the US more strongly believing that that addiction is a choice and a way of coping with life than US-based providers of private/for-profit treatment. Finally, treatment providers who have had a personal problem with addiction in the past are more likely to believe addiction is a disease if they have attended a 12-step group for longer and are presently abstinent. Beliefs that addiction is a choice weaken among these treatment providers the longer they remain members of a 12-step-based group. Overall,

25

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION results suggest treatment providers‘ beliefs about what addiction is largely fit a diseasechoice model dichotomy, that agreement with one model predicts disagreement with the other, and that addiction aetiology and course are understood very differently by US and UK treatment communities.

4.2. Conflicting beliefs in the US versus the UK about “what addiction is” The assumed global dominance of the disease model of addiction was not found; rather, the concept of addiction meant very different things to the sampled UK and US treatment communities. The relative strength of the UK‘s choice model endorsement is very surprising given the unequivocal rejection of the idea that addicted individuals are able to control themselves by influential national health bodies such as the National Health Service; ―addiction is not having control over doing, taking, or using something, to the point that it becomes harmful‖ (NHS, 2010). Not having control implies addiction compels action regardless of the will of the individual. Thus, it appears that those working at the front line of UK addiction treatment view and, therefore, likely explain addiction to their clients in ways which contradict the disease-based definitions and media messages of authoritative health bodies. However, we have no evidence that treatment providers treat clients in line with their beliefs when their beliefs conflict with their institution‘s addiction ideology. This is certainly a next step in this research. The US-based sample‘s tendency to favour the disease model, however, was expected. Relative to UK treatment providers, US treatment providers both endorsed the view of addiction as a disease and rejected the view of addiction as a choice and as a way of coping with life. Disease model beliefs appear to have persisted as the dominant view of addiction in the US since Schaler‘s initial use of the Addiction Beliefs Scale (1992), though three methodological issues suggest caution when comparing these studies. First, though

26

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION assumed by Schaler to be very high, Schaler does not report the US-based proportion of his sample; second, Schaler‘s methodology involved mailing and requesting the return of paper copies of his survey, whereas the current sample were recruited and provided data online; and third, the current study did not use a repeated-measures design; it is highly unlikely that any treatment providers provided data for both our study and Schaler‘s study, and tracking down Schaler‘s sample was impossible. Thus, we can only tentatively conclude that the disease model has prevailed as the dominant of the two models of addiction within US treatment services across the past 20 years. That no prior research on UK-based treatment providers‘ disease/choice model beliefs exists, however, prevents any conclusions about whether the addiction beliefs of our UK sample reflect a snapshot in an increasing, stable, or decreasing trend of disease model support. Current findings provide a context for assessing the stability of disease model support over time, perhaps with developments and marked changes to scientific and political perspectives on addiction, and a context for assessing addiction beliefs internationally. One explanation for the discrepancy in belief systems between the US and UK may lay in the sizeable difference between these country‘s public funding of addiction research. In a recent national report, Colin Blakemore, then head of the UK‘s Medical Research Council (MRC) reported that, ―In 2003 to 2004 [the MRC] spent £2 million in total out of a £450 million budget on addiction research. The total budget of the three NIH [US National Institutes of Health] institutes that work in this area is $2.9 billion so even if one takes a conservative estimate of how much of that is actually devoted to addiction research it comes out to about five hundred times higher than in the UK—in other words about a hundred times more per head of the population‖ (The Science and Technology Committee, 2006). In the same report, former Chair of the Advisory Council on the Misuse of Drugs Technical Committee, David Nutt estimated the expenditure differential to be 1000-fold in favour of the

27

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION US. Future research should ask whether there exists a significant association between this research expenditure differential, a differential in breadths of evidence bases regarding addiction aetiology and treatment effectiveness, and the differential in disease beliefs about addiction reported by the current US and UK samples of treatment providers.

4.3. Methodological limitations The e-survey methodology was inexpensive and allowed faster and wider access to and response from our sample than could have been achieved by mailing paper versions of a survey or conducting face-to-face/telephone interviews. The manual demands of generating a sample of 591 treatment providers in such ways would have been impractical for this study, though we acknowledge that e-surveys may induce a sampling bias, and so caution is suggested in generalising results to the wider US and UK treatment communities. For example, results may not accurately describe the beliefs of treatment providers who declined to participate, had difficulty in navigating the online format and so did not complete the survey (and so, were excluded from analyses), and those for whom electronic contact details were unavailable/unknown and so could not be invited to participate. Researchers who wish to make comparisons involving current findings should appreciate that the dynamics of completing e-surveys versus paper-and-pencil surveys may be different. The larger sample of UK-based versus US-based providers may be partially attributed to the researchers‘ greater knowledge of and access to UK treatment services. Though the UK sample was boosted by enlisting the help of UK DAATs to distribute survey packs, we made every effort to offset this imbalance through an exhaustive recruitment of US-based treatment providers through voluntary, statutory, and private association websites and online databases. Additionally, approximately 1750 (70%) of the 2500 subscribers of targeted e-newsletters are

28

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION believed to be US-based. Nonetheless, recruitment would have benefited from collaboration with researchers experienced in accessing US treatment services.

4.3. Implications of treatment providers‟ ambivalent and strong beliefs about addiction Irrespective of either model‘s validity, these findings indicate a potential for a diversity of addiction beliefs to exist within treatment services, which has implications for how effectively treatment providers work with each other and with clients. People often enter addiction treatment because they seek definitive answers as to why they find self-control of drug use so elusive, to know what is ‗wrong‘ with them. Ambivalence on the aetiology of addiction reported by some groups of treatment providers and the stronger committal of the US and UK treatment communities to the disease and choice models respectively may, therefore, facilitate and obstruct clients‘ change process in different ways. On one side, treatment providers with strong beliefs in either model are more likely to send a clear and unambiguous message to clients about what addiction is and what it is not. Defining the problem and giving clients clear direction as to what they should do and expect in the short and long-term should enhance clients‘ perceived self-efficacy and optimism for change. In contrast, providers who reserve judgment or show ambivalence as to what causes addiction (which could implies endorsement of an eclectic treatment approach) may send mixed messages to clients about the nature of their problems and how best to deal with them. Thus, it may be argued from a pragmatic standpoint that is it better for treatment providers to convey a definitive perspective of addiction to their clients, whichever that perspective may be. On the other side, treatment providers who are strongly committed to either model may be less flexible to change when their beliefs are challenged by scientific evidence or the anecdotes of other therapists and clients. In this way, non-committed providers should be

29

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION more open to weighing up contrasting empirical and anecdotal evidence and adapting treatment to reflect current thinking on addiction. The strongly disease and choice modelcommitted US and UK treatment communities, however, may be less willing to revise their treatment philosophy in the face of evidence which suggests a revision should be considered. Among the strongest disease beliefs in the current sample were reported by treatment providers who have had a personal addiction problem in the past but are abstinent at present; these groups of treatment provider may be most likely to stick with the treatment methods which have worked for clients and themselves in the past, regardless of client differences in symptomatology, environments, and reasons for drug use. Finally, a common criticism of the disease-choice debate is that absolute truths about addiction are irrelevant so long as people do ‗recover‘. The success of treatment may therefore depend on the degree of congruence between treatment providers‘ and clients‘ beliefs about addiction (Keane & Raynor, 1993). Assuming that disease-based messages will be less effective if clients ultimately believe that they are not diseased (and likewise for choice-based messages), the ABS may be used to match therapists and clients on belief compatibility at intake. If the success of addiction treatments is shown to depend on therapists fostering clients‘ clear and uncompromised addiction beliefs of whatever kind, then we may be justified in re-directing research efforts from searching for absolute truths about addiction to the importance of subjective experiences and lay conceptualisations of addiction.

Acknowledgements The authors are grateful to all participants who gave up their valuable time to help with this research, and to Rowdy Yates, Douglas Cameron, Moira Plant, Stanton Peele, and two anonymous reviewers for their suggestions at various stages.

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION

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TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Table 1. Demographic and professional characteristics of addiction treatment providers by country: Count (% within country). Variable

US

UK

Total

N

219

372

591

47.61ª (10.60b)

44.03ª (10.68b)

45.35ª (10.78b)

Male

95 (43.4)

145 (39.0)

240 (40.6)

Female

124 (56.6)

227 (61.0)

351 (59.4)

Private/for-profit

70 (32.0)

118 (31.7)

188 (31.8)

Public/not-for-profit

149 (68.0)

254 (68.3)

403 (68.2)

0–1

13 (5.9)

28 (7.6)

41 (7.0)

2–5

53 (24.2)

99 (26.8)

152 (25.8)

6 – 10

50 (22.8)

104 (28.1)

154 (26.1)

11 – 15

36 (16.4)

59 (15.9)

95 (16.1)

16 – 20

23 (10.5)

41 (11.2)

64 (10.9)

21+

44 (20.1)

39 (10.5)

83 (14.1)

Yes

115 (52.8)

111 (30.2)

226 (38.6)

No

103 (47.2)

256 (69.8)

359 (61.4)

Yes

99 (45.4)

74 (20.3)

153 (31.4)

No

119 (54.6)

290 (79.7)

332 (68.6)

Alcohol

191 (87.2)

320 (86.0)

511 (86.5)

Illicit drugs

185 (84.5)

327 (87.9)

512 (86.6)

Prescription drugs

172 (78.5)

271 (72.8)

443 (75.0)

Nicotine/tobacco***

84 (39.2)

64 (17.2)

148 (25.0)

Gambling***

82 (37.4)

63 (16.9)

145 (24.5)

Video gaming**

27 (12.3)

18 (4.8)

45 (7.6)

Sex/Pornography***

39 (17.8)

26 (7.0)

65 (11.0)

Food**

34 (15.5)

29 (7.8)

63 (10.7)

Age** Sex

Profit Status

Years As Treatment Provider

Certified***

Professional Group Member***

Problems Treated

37

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Shopping**

28 (12.8)

19 (5.1)

47 (8.0)

Internet use***

30 (13.7)

19 (5.1)

49 (8.3)

190 (88.0)

326 (91.6)

516 (90.2)

135 (62.5)

210 (59.0)

335 (60.3)

99 (45.8)

125 (35.1)

224 (39.2)

Treatment Methods Used Psychotherapeutic c Pharmacotheraputic 12-Step* e

d

Note. Country X Variable differences were tested using the chi-square statistic for categorical variables and an independent-groups t-test on the one continuous variable (age). *p < .05; **p < .01; ***p < .001 ªMean; bStandard deviation c Psychotherapeutic methods included reported use of at least one of: Cognitive-Behavioural Therapy; Individual and Group Counselling; Person-centre Therapy; Motivational Interviewing; Biopsychoscoial models; Stress Management; Art Therapy; Equine Therapy; Family Systems Approach; Couples Therapy; Occupational Therapy; Rational Emotive Therapy; Emotion-Focused Therapy; Mindfulness; Meditation; Psychodynamic Therapy; Jungian Therapy; Rogerian Therapy; Narrative Therapy; Systems Theory; Motivational Enhancement Therapy; Anger Management Therapy; Nations Healing; Trauma Therapy; Grief and Loss Therapy; Acupuncture; Gestalt therapy; Humanistic Therapy; Stages of Change Approach; Bowinian Approach; Shiatsu; and Yoga. d Pharmacotherapeutic methods included reported use of substitute prescribing to support maintenance; detox; reduction; or abstinence (at least one of Methadone; Subutex; Lofexidine; Buprenorphine; Naltrexone; Chlordiazepoxide; Disulfiram; Acamprosate; Baclofen; Thiamine; Benzodiazepine; ; Libram; Antabuse; Campral; Diazepam; and Vitamin B) e 12-Step Methods included reported use of 12-Step Model; 12-Step Facilitation; Minnesota Model; A.A./N.A. Model.

38

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Table 2. Correlation matrix and internal consistency values (α) for ABS sub-scales and ABS total score. Factor 1a

Factor 2b

Factor 3c

ABS Totald

-

-.43***

-.21***

.76***

Factor 2

-

.36***

.22***

Factor 3

.

-

.24***

Factor 1

ABS

-

a

Cronbach‘s α = .79, ten items, N = 591; ‗Addiction is a disease‘) Cronbach‘s α = .71, six items, N = 591; ‗Addiction is a choice‘) c Cronbach‘s α = .54, two items, N = 591; ‗Addiction is a way of coping with life‘) d Cronbach‘s α = .67, eighteen items, N = 591) ***p < .001 b

39

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION

Table 3. Mean scores and standard deviations for the three factors of the Addiction Belief Scale (ABS). Variable

n

Disease

Choice

WOCWL

Male

269

27.63 (6.72)

16.83 (3.63)

6.76 (1.47)**

Female

322

26.86 (6.07)

17.05 (3.45)

7.17 (1.49)

UK

372

24.97 (5.77)

17.96 (3.22)

7.40 (1.35)

US

219

31.02 (5.53)

15.24 (3.39)

6.28 (1.48)

Private/for-profit

188

28.97 (6.53)**

Public/not-for-profit

403

26.39 (6.15)

17.47 (3.45)

7.19 (1.31)

Private/for-profit

70

33.96 (4.54)

13.13 (2.55)

5.41 (1.35)

Public/not-for-profit

149

29.64 (5.43)

16.23 (3.28)

6.68 (1.36)

Private/for-profit

118

26.02 (5.68)

17.46 (2.88)

7.22 (1.62)

Public/not-for-profit

254

24.49 (5.75)

18.19 (3.35)

7.48 (1.20)

0–1

41

27.15 (6.35)**

16.83 (3.60)

7.17 (1.58)

2–5

152

27.32 (6.35)

17.17 (3.76)

7.21 (1.56)

6 – 10

154

27.19 (6.34)

17.64 (3.11)

7.12 (1.34)

11 – 15

95

27.20 (5.83)

16.29 (3.09)

6.81 (1.45)

16 – 20

64

27.42 (6.25)

16.39 (3.44)

6.53 (1.74)

21+

83

27.60 (7.39)

16.47 (4.14)

6.76 (1.32)

Yes

173

29.61 (6.09)**

15.70 (3.23)*

6.59 (1.49)

No

409

26.27 (6.17)

17.46 (3.50)

7.16 (1.47)

Yes

199

29.15 (6.39)

16.06 (3.79)

6.76 (1.63)

No

392

26.27 (6.17)

17.40 (3.31)

7.09 (1.41)

Sex

Country

Profit Status 15.85 (3.46)** 6.55 (1.75)***

US X Profit Status

UK X Profit Status

Years Treating Addiction Problems

Member of Professional Group

Past Addiction Problem

Attended Treatment in Pastª

40

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Yes

135

29.69 (6.45)

15.70 (3.71)

6.70 (1.65)

No

64

28.02 (6.17)

16.81 (3.87)

6.91 (1.59)

Yes

145

30.17 (6.29)

15.37 (3.69)

6.61 (1.68)

No

54

26.41 (5.89)

17.93 (3.45)

7.17 (1.44)

Yes

94

31.60 (5.57)

14.40 (3.44)

6.46 (1.75)

No

105

26.96 (6.31)

17.54 (3.48)

7.04 (1.47)

0

10

24.40 (4.86)

17.30 (3.13)

7.50 (1.08)

0–1

63

25.70 (5.91)

18.40 (3.31)

7.21 (1.45)

2–5

10

24.40 (6.93)

18.00 (3.89)

6.90 (2.18)

6 – 10

17

30.88 (5.94)

14.88 (4.23)

7.12 (1.76)

11 – 15

20

30.70 (5.55)

16.35 (3.94)

6.95 (1.54)

16 – 20

23

32.13 (4.70)

14.39 (2.39)

6.48 (1.28)

21 – 25

13

32.00 (5.40)

14.77 (2.20)

6.15 (1.68)

25+

42

32.83 (5.07)

13.38 (2.96)

6.00 (1.75)

Yes

145

23.78 (3.74)

19.39 (2.81)

7.35 (1.50)

No

53

29.90 (6.32)

15.61 (3.69)

6.69 (1.64)

Attended 12-step group in Pastª

Attend 12-step group at Presentª

Years as Member of 12-step Groupª

Abstinent at Presentª

N.B. The highest possible scores for factor 1 = 50; factor 2 = 30; and factor 3 = 10. Higher scores on each factor reflect stronger addiction beliefs. ªQuestion answered only by the 199 respondents who indicated they have had a personal addiction problem in the past. *p < .05; **p < .01; ***p < .001

41

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Table 4. Separate hierarchical multiple linear regression analyses using scores on three factors extracted from the Addiction Belief Scale (ABS) as criterion variables. Disease Step 1 β

Step 2 β

Choice Step 3 β

Step 1 β

Step 2 β

WOCWL Step 3 β

Step 1 β

Step 2 β

Step 3 β

Step

Predictor

1

Sex

-.03

.02

.01

.00

-.04

-.03

.12**

.07

.08*

Age

.15**

.14**

.13**

-.10*

-.08

-.08

-.12*

-.10*

-.10*

Years Treating Addiction Problemsa

-.13**

-.13**

.14**

.02

.01

.02

-.02

-.02

-.02

.00

-.02

-.03

-.01

.01

.02

-.04

-.01

Professional Group Membership

.11**

.06

.05

-.11*

.-.06

-.05

-.05

.00

.02

Past Addiction Problem

.09*

.08

.07

-.06

-.06

-.06

.03

.02

.03

Profit Status

.10**

.13***

.08*

-.14**

-.17***

-.08

-.16***

-.19***

-.09

SBS

.40***

.28***

027***

-.24***

-.13**

-.12**

-.14***

-.03

-.01

-

.32***

.28***

-

-.30***

-.22***

-

-.33***

-.24***

Certified

.00

Disease: F(8, 565) = 26.47, p < .001, R²= .273 Choice: F(8, 565) = 12.89, p < .001, R²= .154 WOCWL: F(8, 565) = 9.45, p < .001, R²= .118 2

Country

Disease: Fchange(1, 564) = 68.55, p < .001, R²change= .080 Choice: Fchange(1, 564) = 48.71, p < .001, R²change= .067 WOCWL: Fchange(1, 564) = 57.80, p < .001, R²change= .082

42

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION 3

Country X Profit Status

-

-

.10

Disease: Fchange(1, 563) = 3.84, p = .051, R²change= .004 Choice: Fchange(1, 563) = 10.80, p < .001, R²change= .015 WOCWL: Fchange(1, 563) = 14.40, p < .001, R²change= .020 *p < .05; **p < .01; ***p < .001 a

Ordinal scale variable

43

-

-

-.18***

-

-

-.21***

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Table 5. Decomposition of Country X Profit Status interaction effects found for factor 2 and factor 3: Results from US-based (and UK-based) treatment providers. Choice

WOCWL

Step 1 β

Step 2 β

Step 1 β

Step 2 β

-.02 (-.08)

.04 (-.08)

.05 (.06)

.11 (.07)

-.19* (-.05)

-.10 (-.05)

-.10 (-.18**)

-.01 (-.18**)

.13 (.08)

-.12 (.08)

-.10 (.03)

-.10 (.03)

Certified

.06 (-.03)

.09 (-.03)

.10 (-.06)

.13 (-.06)

Professional Group Membership

.00 (-.14*)

.07 (-.13*)

-.08 (.00)

-.01 (.01)

Past Addiction Problem

-.09 (-.08)

-.07 (-.07)

.03 (.01)

.05 (.02)

-.15* (-.16**)

-.05 (.16**)

-.23*** (.07)

-.12 (.07)

Step

Predictor

1

Sex Age Years Treating Addiction Problems

SBS

a

Choice, US-based: F(7, 208) = 3.74, p < .001, R² = .082 Choice, UK-based: F(7, 350) = 4.07, p .05, R² = .008

44

-.41*** (-.09)

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION *p < .05; **p < .01; ***p < .001 a

Ordinal scale variable

45

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Table 6. Separate hierarchical multiple linear regression analysis using scores on three factors extracted from the Addiction Belief Scale (ABS) as criterion variables: Conducted on data provided by treatment providers who reported having had a personal problem with addiction in the past (n = 199). Disease

WOCWL

Step 1 β

Step 2 β

Step 1 β

Step 2 β

Step 1 β

Step 2 β

.00

.00

-.07

-.08

.09

.08

.12

.10

-.11

-.07

-.08

-.07

-.07

-.10

.07

.09

.02

.04

Certified

-.07

-.07

.06

.07

.01

.01

Professional Group Membership

.09

.06

-.12

-.07

-.06

-.05

.19**

.14

-.24**

-.17*

-.34***

-.31***

.08

.06

-.08

-.06

-.19**

-.18**

.48***

39***

-.26**

-.12

.02

.06

-

.00

-

-.03

-

-.03

Attended 12-step-based Group in Past

-

-.12

-

.06

-

.06

Attend 12-step-based Group at Present

-

.08

-

-.14

-

.00

Years membership of 12-step-based Group

-

.24**

-

-.26*

-

-.14

Predictor 1

Choice

Sex Age Years Treating Addiction Problems

a

Country Profit Status SBS Disease: F(8, 184) = 15.54, p < .001, R²= .403 Choice: F(8, 184) = 7.57, p < .001, R²= .248 WOCWL: F(8, 184) = 5.29, p < .001, R²= .187 2 Attended Treatment in Past

46

TREATMENT PROVIDERS‘ BELIEFS ABOUT ADDICTION Present Abstinence Status

-

.16*

Disease: Fchange(5, 179) = 7.48, p < .001, R²change= .122 Choice: Fchange(5, 179) = 6.13, p < .001, R²change= .110 WOCWL: Fchange(5, 179) = 0.64, p > .05, R²change= .018 *p < .05; **p < .01; ***p < .001 a

Ordinal scale variable

47

-

-.12

-

-.04