Predictors of addiction treatment providers' beliefs in the disease and choice models of addiction

Journal of Substance Abuse Treatment 40 (2011) 150 – 164

Regular article

Predictors of addiction treatment providers' beliefs in the disease and choice models of addiction Christopher Russell, (M.Sc.)⁎, John B. Davies, (Ph.D., F.B.Ps.S.), Simon C. Hunter, (Ph.D.) School of Psychological Sciences and Health, University of Strathclyde, Glasgow, G1 1QE Scotland, UK Received 8 January 2010; received in revised form 16 September 2010; accepted 22 September 2010

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 of J. Schaler (1992). Factor analysis of item scores revealed a three-factor structure, labeled “addiction is a disease,” “addiction is a choice,” and “addiction is a way of coping with life,” and factor scores were analyzed in separate hierarchical multiple regression analyses. Controlling for demographic and addiction history variables, treatment providers working in the United States more strongly believe addiction is a disease, whereas U.K.-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 for-profit treatment, have stronger spiritual beliefs, have had a past addiction problem, are older, are members of a group of addiction professionals, and have been treating addiction longer. Conversely, those who viewed addiction as a choice were more likely to provide public/not-for-profit treatment, be younger, not belong to a group of addiction professionals, 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. © 2011 Elsevier Inc. All rights reserved. Keywords: Addiction; Treatment providers; Beliefs; Disease; Choice

1. Introduction The question “what is addiction?” has long polarized the medical, social science, legal, and spiritual communities into those who view addiction as a disease (Benowitz, 2008; Jellinek, 1960; Ketcham, Asbury, Schulstad & Ciaramicoli, 2000; Kalivas & Volkow, 2005; Koob & Nestler, 1997; Leshner, 1997; Lyvers, 1998; Maltzman, 1994; Vaillant, 1990) and those who view addiction as a cognizant choice (Fingarette, 1988a, 1988b; Heyman, 2009; Merry, 1966; Szasz, 1972; Playfair, 1991; Room, 1983; Schaler, 2000). Many professional and lay conceptions of addiction can be traced back to this dichotomy in causation—drug-addicted individuals 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 behaviors 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

⁎ Corresponding author. School of Psychological Sciences and Health, University of Strathclyde, 40 George Street, Glasgow, G1 1QE Scotland, UK. E-mail address: [email protected] (C. Russell). 0740-5472/10/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jsat.2010.09.006

The disease and choice models of addiction are not the only perspectives of addiction in existence; they are only the

C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

two chosen for scrutiny in this study. Several other perspectives of addiction—such as an illness, disorder, malady, allergy, ailment, sickness, 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 that 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” 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 conceptualizations 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 by 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” (Leshner, 1997, p. 46).1 To create an intermediate perspective would therefore be redundant for the purposes of asking whether drug seeking and use are willed or determined. Thus, although the validity of a trichotomous model of the governing factors in addiction and the mechanisms of change at 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 behavior; namely, whether behavior is determined by physical mechanism or willed by an emergent force that transcends direct physical mechanism (Davies, 1997). Consequently, they hold divergent but equally powerful assumptions about how people 1

Allan I. Leshner was the director of National Institute of Drug Abuse (NIDA) at time of publication.

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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 necessitates, we argue, proponents of one model to be equally passionate critics of the other. The disease model describes addiction/substance dependency as a primary, progressive, chronic relapsing disease that is either genetically transmitted or acquired through excessive consumption (Leshner, 1997; Ketcham et al., 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 behavior 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-ornothing disorder caused solely by hereditary physical abnormalities” (Miller, 1993, p. 133), a more scientifically defensible disease model has been sought in recent years. Miller proposed that research, treatment, and education about alcoholism should be based on a disease model that describes alcohol problems on continua of severity and an etiological 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 other 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 (Alexander, Hadaway, & Coambs, 1980; Cohen, Liebson, Faillace, & Allen, 1971; Robins, Helzer & Davis, 1975). 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 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 nonaddicted drug users' as myth. They argue that drug users are always free to choose to stop and that drug users'

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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. Although the idea of alcoholism as a disease did not originate in the United States, the modern disease concept of alcoholism has been 200 years in the making2, during which time the United States 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 medicalized 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 hypothesize that the inebriate's apparent loss of control and other symptoms could be traced to rogue hereditary and/or self-impaired biological mechanisms that 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 that 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 specialized 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 United States and United Kingdom. Public thinking about the disease of drunkenness took off in 1935 with the inception and rapid growth of Alcoholics Anonymous (AA), a spiritual self-help fellowship made up of self-described recovering alcohol-dependent individuals committed to helping one another maintain sobriety (Kurtz, 1988). Although AA literature does not refer to alcoholism as a literal disease, Kurtz (2002) states that AA and members of AA do use medical terms—illness, sickness, malady— and the disease concept to reflect their belief about the solution to alcoholism—abstinence—and to convey the hopelessness of alcohol-dependent individuals 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 alcohol-dependent individuals' loss of control and that 2

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

physiology, not psychology, determines whether one drinker will become addicted and another will not) to the Big Book of AA (Alcoholics Anonymous World Services, 1939), the fellowship's core publication. Alcoholics Anonymous, through its public relations campaigns, has been instrumental in spreading and popularizing the disease concept of alcoholism while avoiding discourse of alcoholism as a literal disease. Addiction as a disease in the United States 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 [IOM], 1996). This research agenda, accompanied by a public education campaign that 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, respectively, have used high-profile, highly respected academic outlets to summarize 20 years of evidence from neurosciences and behavioral 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 to the Annual Conference of the American Psychiatric Association in 2007 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. 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 NIDA-funded TV special by HBO Documentary Films (2007) entitled, Addiction: Why Can't They Just Stop? Today, the American Medical Association (Morse & Flavin, 1992), American Psychiatric Association (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 that people engage in because they are physically unable to avoid doing so

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(Levine, 1978; Mercadante, 1996; Schaler, 2000). Although the disease model now dominates addiction discourse internationally, the prominent role played by the United States' psychiatric, medical, research, media, and spiritual communities in shaping the modern disease concept of addictive behaviors suggests that support for the view of addiction as a disease may be stronger within the U.S. versus non–U.S. treatment communities. 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 women, members of the National Association for Alcoholism and Drug Abuse Counselors (NAADAC), present or past members of AA, certified addiction counselors/therapists, abstinent at present, and have stronger spiritual beliefs as defined in AA philosophy. Strength of spiritual beliefs, as measured by the Spiritual Belief Scale (SBS; Schaler, 1992) accounted for most variance (41%) in disease beliefs. However, although 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 United States relative to out-with the United States and the hypothesized 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 publicized findings of Project MATCH (1997) and UK Alcohol Treatment Trial (2005), the aforementioned U.S.-led research drive to emphasize 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 United States versus out-with the United States and (b) the variance in disease and choice

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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 National Health Service Health Boards, DAATs are responsible for the top–down and bottom–up communication of substance misuse-related 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. Drug and Alcohol Action Teams 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 e-mail to 785 persons who could be identified as chief executive officers/managers of addiction treatment services on the Web sites 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 (U.S. Department of Health and Human Services), and Alcohol Focus Scotland. Treatment providers typically provide contact information for public viewing on these Web sites for the benefit of persons seeking help for an addiction problem, although 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) U. S./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 2 months after the final survey pack was sent out.

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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 United States with those in several countries was not possible and creating a “U.S.-versus-not-U.S.” variable was considered misleading, given that 79% of the “not U.S.” respondents came from the United Kingdom. Purely due to the geographical distribution of our sample, it was decided to exclude the 99 non-U.K. and non-U.S. respondents so as to compare the strength of disease beliefs of treatment providers working in the United States versus the United Kingdom. This left a final sample of 591. Due to the opportunistic sampling method, it was impossible to calculate a survey return rate. Professional characteristics of the sample by country are summarized in Table 1. 2.3. Materials Treatment providers were invited by e-mail to complete an e-survey of their addiction beliefs. This e-mail 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 ABS, the SBS, and questions about their personal and professional addiction history. Other information collected included age (in years) and sex. 2.3.1. The Addiction Belief Scale The 18 items of this scale comprise statements about addiction as described in the disease (nine items) and choice (nine items) models regarding etiology, the need for treatment, and addicted individuals' capacity for self-control, insofar as these assumptions can be dichotomized. An example of a statement that 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 five-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 (minimum = 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

Table 1 Demographic and professional characteristics of addiction treatment providers by country: count (percentage within country) Variable

United States

N 219 Age, M (SD) ⁎⁎ 47.61 (10.60) Sex Male 95 (43.4) Female 124 (56.6) Profit status Private/for-profit 70 (32.0) Public/not-for-profit 149 (68.0) Years as treatment provider 0–1 13 (5.9) 2–5 53 (24.2) 6–10 50 (22.8) 11–15 36 (16.4) 16–20 23 (10.5) 21+ 44 (20.1) Certified ⁎⁎⁎ Yes 115 (52.8) No 103 (47.2) Professional group member ⁎⁎⁎ Yes 99 (45.4) No 119 (54.6) Problems treated Alcohol 191 (87.2) Illicit drugs 185 (84.5) Prescription drugs 172 (78.5) Nicotine/tobacco ⁎⁎⁎ 84 (39.2) Gambling ⁎⁎⁎ 82 (37.4) Video gaming ⁎⁎ 27 (12.3) Sex/Pornography ⁎⁎⁎ 39 (17.8) Food ⁎⁎ 34 (15.5) Shopping ⁎⁎ 28 (12.8) Internet use ⁎⁎⁎ 30 (13.7) Treatment methods used Psychotherapeutic a 190 (88.0) Pharmacotheraputic b 135 (62.5) 12-Step ⁎, c 99 (45.8)

United Kingdom

Total

372 44.03 (10.68)

591 45.35 (10.78)

145 (39.0) 227 (61.0)

240 (40.6) 351 (59.4)

118 (31.7) 254 (68.3)

188 (31.8) 403 (68.2)

28 (7.6) 99 (26.8) 104 (28.1) 59 (15.9) 41 (11.2) 39 (10.5)

41 (7.0) 152 (25.8) 154 (26.1) 95 (16.1) 64 (10.9) 83 (14.1)

111 (30.2) 256 (69.8)

226 (38.6) 359 (61.4)

74 (20.3) 290 (79.7)

153 (31.4) 332 (68.6)

320 (86.0) 327 (87.9) 271 (72.8) 64 (17.2) 63 (16.9) 18 (4.8) 26 (7.0) 29 (7.8) 19 (5.1) 19 (5.1)

511 (86.5) 512 (86.6) 443 (75.0) 148 (25.0) 145 (24.5) 45 (7.6) 65 (11.0) 63 (10.7) 47 (8.0) 49 (8.3)

326 (91.6) 210 (59.0) 125 (35.1)

516 (90.2) 335 (60.3) 224 (39.2)

Note: Country × Variable differences were tested using the χ2 statistic for categorical variables and an independent groups t test on the one continuous variable (age). a Psychotherapeutic methods included reported use of at least one of cognitive–behavioral therapy, individual and group counseling, person– center 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. b Pharmacotherapeutic methods included reported use of substitute prescribing to support maintenance, detoxification, reduction, or abstinence (at least one of methadone, buprenorphine [Subutex], lofexidine, naltrexone, chlordiazepoxide, disulfiram, acamprosate, baclofen, thiamine, benzodiazepine, disulfiram [Antabuse], acamprosate [Campral], diazepam, and vitamin B). c 12-Step methods included reported use of 12-Step Model, 12-Step Facilitation, Minnesota Model, and AA/NA model. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

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model of addiction, respectively. Schaler (1995) reported strong internal consistency for the ABS (α = .91, 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, that is, 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 the work of 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 loaded 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 multifactorial structure. Results of this analysis are reported in Section 3.2.

professional group of addiction treatment providers, whether they are a certified counselor 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 AA, Narcotics Anonymous (NA), or any other 12-step–based program; number of years in total they have been a member of a 12step–based program; and whether they are abstinent at present. Respondents who indicated “no” to the past addiction problem question did not answer these five follow-up questions. Finally, an empty text box at the end of the survey allowed respondents to comment on the survey.

2.3.2. The Spiritual Belief Scale The eight items of this scale measure spiritual thinking as defined in the philosophy of AA as belief in a metaphysical power that can influence personal experience. Items were adapted from how spirituality is discussed in the Big Book of AA to form statements about God and “spiritual health.” Items reflect the four spiritual characteristics of AA— release, gratitude, humility, and tolerance—identified by Kurtz (1988). Respondents rate on a five-point Likert scale the extent to which they agree with each statement (1 = strongly disagree to 5 = strongly agree). Higher scores indicate stronger spiritual beliefs. The highest possible score is 40 (minimum = 8). Schaler (1996) reported strong internal consistency for the SBS (α = .92, standardized item, α = .91, n = 280) and a two-factor structure described as “release– gratitude–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 the work of Schaler (1996).

3.2. Factor analysis of the ABS

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

3. Results 3.1. Power analysis 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 10 predictors, power = 1.00. Thus, it was concluded that the present analysis was sufficiently powered.

Separate factor analyses were conducted to compare the ABS factor structures for the U.K.- (n = 372) and U.S.-based (n = 219) samples. Despite the ABS's apparent bipolar content on a single dimension of addiction beliefs, extremely similar four-factor solutions were found for each country. Within the U.K. 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], 18 [.62]) loaded on factor 4. The only differences in the composition of the four factors extracted from U.S.-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 analyzed using varimax rotation with Kaiser normalization. Three factors were extracted, which we labeled “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

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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 of addiction3 (items 1 [.67; 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 alcohol-dependent individual 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 to very good internal consistency and correlated strongly with each other, as shown in Table 2. 3.3. Hierarchical multiple regression models To investigate the variables that explain variance in addiction treatment providers' beliefs about 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

3

Correlation values in brackets.

Table 2 Correlation matrix and internal consistency values (α) for ABS subscales and ABS total score

Factor 1 Factor 2 Factor 3 ABS

Factor 1 a

Factor 2 b

Factor 3 c

ABS total d

–

−.43 ⁎⁎⁎ – .

−.21 ⁎⁎⁎ .36 ⁎⁎⁎ –

.76 ⁎⁎⁎ .22 ⁎⁎⁎ .24 ⁎⁎⁎ –

Cronbach's α = .79, 10 items, N = 591 (“addiction is a disease”). Cronbach's α = .71, 6 items, N = 591 (“addiction is a choice”). c Cronbach's α = .54, 2 items, N = 591 (“addiction is a way of coping with life”). d Cronbach's α = .67, 18 items, N = 591. ⁎⁎⁎ p b .001. a

b

= 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 = United Kingdom, 1 = United States) 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. 3.4. Variables explaining variance in treatment providers' beliefs that “addiction is a disease” 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 b .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 b .001, and β = .15, p b .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 b .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 b .01) with factor 1 score. Professional group members more strongly believe (M = 29.61, SD = 6.09) that addiction is a disease than nonmembers (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 b .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,

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Table 3 Mean scores and standard deviations for the three factors of the ABS Variable Sex Male Female Country United Kingdom United States Profit status Private/for-profit Public/not-for-profit United States × Profit Status Private/for-profit Public/not-for-profit United Kingdom × Profit Status Private/for-profit Public/not-for-profit Years treating addiction problems 0–1 2–5 6–10 11–15 16–20 21+ Member of professional group Yes No Past addiction problem Yes No Attended treatment in the past a Yes No Attended 12-step group in the past a Yes No Attend 12-step group at present a Yes No Years as member of 12-step group a 0 0–1 2–5 6–10 11–15 16–20 21–25 25+ Abstinent at present a Yes No

n

Disease

Choice

Way of coping with life

269 322

27.63 (6.72) 26.86 (6.07)

16.83 (3.63) 17.05 (3.45)

6.76 (1.47) ⁎⁎ 7.17 (1.49)

372 219

24.97 (5.77) 31.02 (5.53)

17.96 (3.22) 15.24 (3.39)

7.40 (1.35) 6.28 (1.48)

188 403

28.97 (6.53) ⁎⁎ 26.39 (6.15)

15.85 (3.46) ⁎⁎ 17.47 (3.45)

6.55 (1.75) ⁎⁎⁎ 7.19 (1.31)

70 149

33.96 (4.54) 29.64 (5.43)

13.13 (2.55) 16.23 (3.28)

5.41 (1.35) 6.68 (1.36)

118 254

26.02 (5.68) 24.49 (5.75)

17.46 (2.88) 18.19 (3.35)

7.22 (1.62) 7.48 (1.20)

41 152 154 95 64 83

27.15 (6.35) ⁎⁎ 27.32 (6.35) 27.19 (6.34) 27.20 (5.83) 27.42 (6.25) 27.60 (7.39)

16.83 (3.60) 17.17 (3.76) 17.64 (3.11) 16.29 (3.09) 16.39 (3.44) 16.47 (4.14)

7.17 (1.58) 7.21 (1.56) 7.12 (1.34) 6.81 (1.45) 6.53 (1.74) 6.76 (1.32)

173 409

29.61 (6.09) ⁎⁎ 26.27 (6.17)

15.70 (3.23) ⁎ 17.46 (3.50)

6.59 (1.49) 7.16 (1.47)

199 392

29.15 (6.39) 26.27 (6.17)

16.06 (3.79) 17.40 (3.31)

6.76 (1.63) 7.09 (1.41)

135 64

29.69 (6.45) 28.02 (6.17)

15.70 (3.71) 16.81 (3.87)

6.70 (1.65) 6.91 (1.59)

145 54

30.17 (6.29) 26.41 (5.89)

15.37 (3.69) 17.93 (3.45)

6.61 (1.68) 7.17 (1.44)

94 105

31.60 (5.57) 26.96 (6.31)

14.40 (3.44) 17.54 (3.48)

6.46 (1.75) 7.04 (1.47)

10 63 10 17 20 23 13 42

24.40 (4.86) 25.70 (5.91) 24.40 (6.93) 30.88 (5.94) 30.70 (5.55) 32.13 (4.70) 32.00 (5.40) 32.83 (5.07)

17.30 (3.13) 18.40 (3.31) 18.00 (3.89) 14.88 (4.23) 16.35 (3.94) 14.39 (2.39) 14.77 (2.20) 13.38 (2.96)

7.50 (1.08) 7.21 (1.45) 6.90 (2.18) 7.12 (1.76) 6.95 (1.54) 6.48 (1.28) 6.15 (1.68) 6.00 (1.75)

145 53

29.90 (6.32) 23.78 (3.74)

15.61 (3.69) 19.39 (2.81)

6.69 (1.64) 7.35 (1.50)

Note: The highest possible scores for factor 1 = 50, factor 2 = 30, and factor 3 = 10. Higher scores on each factor reflect stronger addiction beliefs. a Question answered only by the 199 respondents who indicated they have had a personal addiction problem in the past. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

p b .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). 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 b .001. After partialing out variance explained by variables in step 1, providing addiction treatment in the United States was positively associated (β = .32, p b .001) with factor 1 score. Providers of addiction treatment in the United States more strongly believe (M = 31.02, SD = 5.53) in the disease model of addiction than

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Table 4 Separate hierarchical multiple linear regression analyses using scores on three factors extracted from the ABS as criterion variables Disease Step

Predictor

Step 1 β

Choice Step 2 β

Step 3 β

Sex −.03 .02 .01 Age .15 ⁎⁎ .14 ⁎⁎ .13 ⁎⁎ Years treating addiction problems a −.13 ⁎⁎ −.13 ⁎⁎ .14 ⁎⁎ Certified .00 −.02 −.03 Professional group membership .11 ⁎⁎ .06 .05 Past addiction problem .09 ⁎ .08 .07 Profit status .10 ⁎⁎ .13 ⁎⁎⁎ .08 ⁎ SBS .40 ⁎⁎⁎ .28 ⁎⁎⁎ 027 ⁎⁎⁎ Disease: F(8, 565) = 26.47, p b .001, R2 = .273 Choice: F(8, 565) = 12.89, p b .001, R2 = .154 Way of coping with life: F(8, 565) = 9.45, p b .001, R2 = .118 2 Country – .32 ⁎⁎⁎ .28 ⁎⁎⁎ Disease: Fchange(1, 564) = 68.55, p b .001, R2change = .080 Choice: Fchange(1, 564) = 48.71, p b .001, R2change = .067 Way of coping with life: Fchange(1, 564) = 57.80, p b .001, R2change = .082 3 Country × Profit Status – – .10 Disease: Fchange(1, 563) = 3.84, p = .051, R2change = .004 Choice: Fchange(1, 563) = 10.80, p b .001, R2change = .015 Way of coping with life: Fchange(1, 563) = 14.40, p b .001, R2change = .020 1

Way of coping with life

Step 1 β

Step 2 β

Step 3 β

Step 1 β

Step 2 β

Step 3 β

.00 −.10 ⁎ .02 −.01 −.11 ⁎ −.06 −.14 ⁎⁎ −.24 ⁎⁎⁎

−.04 −.08 .01 .01 −.06 −.06 −.17 ⁎⁎⁎ −.13 ⁎⁎

−.03 −.08 .02 .02 −.05 −.06 −.08 −.12 ⁎⁎

.12 ⁎⁎ −.12 ⁎ −.02 −.04 −.05 .03 −.16 ⁎⁎⁎ −.14 ⁎⁎⁎

.07 −.10 ⁎ −.02 −.01 .00 .02 −.19 ⁎⁎⁎ −.03

.08 ⁎ −.10 ⁎ −.02 .00 .02 .03 −.09 −.01

–

−.30 ⁎⁎⁎

−.22 ⁎⁎⁎

–

−.33 ⁎⁎⁎

−.24 ⁎⁎⁎

–

–

−.18 ⁎⁎⁎

–

–

−.21 ⁎⁎⁎

a Ordinal scale variable. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

those who provide addiction treatment in the United Kingdom (M = 24.97, SD = 5.77). Step 3 in the model yielded a nonsignificant increase of 0.4% explained variance, Fchange(1, 563) = 3.84, p N .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 b .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 b .001, and β = −.10, p b .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 b .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 b .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 b .001. After partialing out variance explained by variables in step 1, providing addiction treatment in the United States was negatively associated (β = −.30, p b .001) with factor 2 score. Providers of addiction treatment in the United Kingdom more strongly believe (M = 17.96, SD = 3.22) that addiction is a choice than those who provide addiction treatment in the United States (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 b .001. To interrogate this interaction, simple effects analyses were conducted (i.e., repeating the analysis with neither the Country × Profit Status interaction term nor main effects of country), first for U.S.-based treatment providers (n = 219) and then for U.K.-based treatment providers (n = 372). This revealed a significant negative association between profit status and factor 2 score among U.S.-based treatment providers (β = −.40, p b .001) after controlling for seven variables entered at step 1, Fchange(1, 207) = 31.42, p b .001, R2 change = .117. No significant association was found between profit status and factor 2 score among U.K.-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,

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Table 5 Decomposition of Country × Profit Status interaction effects found for factors 2 and 3: Results from U.S.-based (and U.K.-based) treatment providers Choice Step

Predictor

Step 1 β

Sex −.02 (−.08) Age −.19 ⁎ (−.05) Years treating addiction problems a .13 (.08) Certified .06 (−.03) Professional group membership .00 (−.14 ⁎) Past addiction problem −.09 (−.08) SBS −.15 ⁎ (−.16 ⁎⁎) Choice, U.S.-based: F(7, 208) = 3.74, p b .001, R2 = .082 Choice, U.K.-based: F(7, 350) = 4.07, p b .001, R2 = .075 Way of coping with life, U.S.-based: F(7, 208) = 2.84, p b .01, R2 = .088 Way of coping with life, U.K.-based: F(7, 350) = 2.32, p b .05, R2 = .044 2 Profit status – Choice, U.S.-based: Fchange(1, 207) = 31.42, p b .001, R2change = .117 Choice, U.K.-based: Fchange(1, 349) = 1.74, p N .05, R2change = .005 Way of coping with life, U.S.-based: F(1, 207) = 32.56, p b .001, R2 = .124 Way of coping with life, U.K.-based: F(1, 349) = 2.92, p N .05, R2 = .008 1

Way of coping with life Step 2 β

Step 1 β

Step 2 β

.04 (−.08) −.10 (−.05) −.12 (.08) .09 (−.03) .07 (−.13 ⁎) −.07 (−.07) −.05 (.16 ⁎⁎)

.05 (.06) −.10 (−.18 ⁎⁎) −.10 (.03) .10 (−.06) −.08 (.00) .03 (.01) −.23 ⁎⁎⁎ (.07)

.11 −.01 −.10 .13 −.01 .05 −.12

−.40 ⁎⁎⁎ (−.07)

(.07) (−.18 ⁎⁎) (.03) (−.06) (.01) (.02) (.07)

−.41 ⁎⁎⁎ (−.09)

a Ordinal scale variable. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

with only U.S.-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. 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 b .001, and accounted for 11.8% of variance in factor 3 score. Four of the eight variables made significant contributions. Score on the SBS and age were again both negatively associated (β = −.14, p b .001, and β = −.12, p b .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 b .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 b .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 b .001. After partialing out variance explained by variables in step 1, providing addiction treatment in the

United States was negatively associated (β = −.33, p b .001) with factor 3 score. Providers of addiction treatment in the United Kingdom more strongly believe (M = 7.40, SD = 1.35) that addiction is a choice than those who provide addiction treatment in the United States (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 b .001. To interrogate this interaction, simple effects analyses were again conducted, first for U.S.-based sample (n = 219) and then the U.K.-based sample (n = 372). This revealed a significant positive association between profit status and factor 3 score in the United States (β = .47, p b .001) after controlling for seven variables entered at step 1, Fchange(1, 207) = 32.56, p b .001, R2change = .124. Again, no significant association was found between profit status and factor 3 score in the U.K. sample. This indicates that country of treatment moderates the relationship between profit status and treatment providers' beliefs in the disease model, with only U.S.-based treatment providers reporting significantly stronger 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,

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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 the past (0 = no, 1 = yes), attended 12-step– based group in the 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 b .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 b .001) 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 b .05) with factor 1 score. Treatment

providers who have had a personal addiction problem and are presently abstinent more strongly believe (M = 29.90, SD = 6.32) that addiction is a disease than those who are not presently abstinent (M = 23.78, SD = 3.74). 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 b .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 b .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 nonsignificant increase of 1.8% explained variance in factor 3 scores, Fchange(5, 179) = 0.64, p N .05. Thus, treatment providers who have had a personal addiction problem in the past did not significantly vary in their beliefs about addiction as a way of coping with life across the step 2 variables.

Table 6 Separate hierarchical multiple linear regression analysis using scores on three factors extracted from the 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 Step

Predictor

1

Step 1 β

Sex .00 Age .12 −.07 Years treating addiction problems a Certified −.07 Professional group membership .09 Country .19⁎⁎ Profit status .08 SBS .48 ⁎⁎⁎ Disease: F(8, 184) = 15.54, p b .001, R2 = .403 Choice: F(8, 184) = 7.57, p b .001, R2 = .248 Way of coping with life: F(8, 184) = 5.29, p b .001, R2 = .187 2 Attended treatment in the past – Attended 12-step–based group in the past – Attend 12-step–based group at present – Years membership of 12-step–based group – Present abstinence status – Disease: Fchange(5, 179) = 7.48, p b .001, R2change = .122 Choice: Fchange(5, 179) = 6.13, p b .001, R2change = .110 Way of coping with life: Fchange(5, 179) = 0.64, p N .05, R2change = .018 a Ordinal scale variable. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

Choice

Way of coping with life

Step 2 β

Step 1 β

Step 2 β

Step 1 β

Step 2 β

.00 .10 −.10 −.07 .06 .14 .06 39 ⁎⁎⁎

−.07 −.11 .07 .06 −.12 −.24⁎⁎ −.08 −.26 ⁎⁎

−.08 −.07 .09 .07 −.07 −.17 ⁎ −.06 −.12

.09 −.08 .02 .01 −.06 −.34 ⁎⁎⁎ −.19 ⁎⁎ .02

.08 −.07 .04 .01 −.05 −.31 ⁎⁎⁎ −.18 ⁎⁎ .06

.00 −.12 .08 .24 ⁎⁎ .16 ⁎

– – – – –

−.03 .06 −.14 −.26 ⁎ −.12

– – – – –

−.03 .06 .00 −.14 −.04

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4. Discussion 4.1. Key findings Addiction treatment providers in the United States and United Kingdom were surveyed on their beliefs about the etiology of addiction, the need to receive treatment, and the addicted individuals' 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 United States more strongly believe that addiction is a disease than those who provide addiction treatment in the United Kingdom, whereas U.K.-based treatment providers more strongly believe that addiction is a choice than U.S.based treatment providers. Those more likely to believe that addiction is a disease also tend to provide for-profit treatment, 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 United States more strongly believing that that addiction is a choice and a way of coping with life than U.S.-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, results suggest treatment providers' beliefs about what addiction is largely fit a disease–choice model dichotomy, that agreement with one model predicts disagreement with the other, and that addiction etiology and course are understood very differently by U.S. and U.K. treatment communities. 4.2. Conflicting beliefs in the United States versus the United Kingdom 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 U.K. and U.S. treatment communities. The relative strength of the United Kingdom's choice model endorsement is very surprising given the unequivocal rejection of the idea that addicted

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individuals are able to control themselves by influential national health bodies such as the National Health Service (2010): “addiction is not having control over doing, taking, or using something, to the point that it becomes harmful.” Not having control implies addiction compels action regardless of the will of the individual. Thus, it appears that those working at the frontline of U.K. addiction treatment view and, therefore, likely explain addiction to their clients in ways that 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 U.S.-based sample's tendency to favor the disease model, however, was expected. Relative to U.K. treatment providers, U.S. 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 United States since Schaler's (1992) initial use of the ABS, although three methodological issues suggest caution when comparing these studies. First, although assumed by Schaler to be very high, Schaler does not report the U.S.-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; 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 U.S. treatment services across the past 20 years. That no prior research on U.K.-based treatment providers' disease/choice model beliefs exists, however, prevents any conclusions about whether the addiction beliefs of our U.K. 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 United States and United Kingdom 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 United Kingdom'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 [U.S. 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

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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, Professor David Nutt, estimated the expenditure differential to be 1,000-fold in favor of the United States. Future research should ask whether there exists a significant association between this research expenditure differential, a differential in breadths of evidence bases regarding addiction etiology and treatment effectiveness, and the differential in disease beliefs about addiction reported by the current U.S. and U.K. 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, although we do acknowledge that e-surveys may induce a sampling bias, and so caution is suggested in generalizing results to the wider U.S. and U.K. 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 also appreciate that the dynamics of completing e-surveys versus paper-and-pencil surveys may be different. The larger sample of U.K.-versus-U.S.-based providers may be partially attributed to the researchers' greater knowledge of and access to U.K. treatment services. Although the U.K. sample was boosted by enlisting the help of U.K. DAATs to distribute survey packs, we made every effort to offset this imbalance through an exhaustive recruitment of U.S.-based treatment providers through voluntary, statutory, and private association Web sites and online databases. Additionally, approximately 1,750 (70%) of the 2,500 subscribers of targeted e-newsletters are believed to be based in the United States. Nonetheless, recruitment would have benefited from collaboration with researchers experienced in accessing U.S. treatment services. 4.4. Implications of treatment providers' ambivalent and strong beliefs about addiction Irrespective of either model's validity, current 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 and to know what is “wrong” with them. Ambivalence on the etiology of addiction reported by some groups of treatment providers and the stronger committal of the U.S. and U.K. 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 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, noncommitted providers should be more open to weighing up contrasting empirical and anecdotal evidence and adapting treatment to reflect current thinking on addiction. The strongly disease- and choice model-committed U.S. and U.K. 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 that 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 (Keene & 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 abandoning the search for absolute truths about addiction and instead focusing on the importance of subjective experiences and lay conceptualizations of addiction to the change process.

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