By shifting from the view that drug and alcohol use is a disease, social workers have been granted more flexibility in their invention with substance users. Discuss.

Assignment Title:

For purposes of clarification, the term ‘substance users’ throughout this essay will denote problematic drug users whose problems cause physical and mental harm to themselves, or to their families and children, neighbours, communities and the broader society regardless of the legal status of the drug. After all, the principles involved in working with addictive behaviours for social workers remain the same, whatever the substance involved.

There are many who use legal drugs in much the same way that others use illegal substances in the sense that they can cause themselves or others significant harm. Therefore, the concept of ‘drugs’ will be extended to incorporate alcohol, tobacco, solvents, and over-the-counter prescription drugs.

This question suggests that it is beneficial for Social Workers to have greater flexibility in their intervention with substance users in order to provide better service delivery, and that by shifting away from the notion that drug and alcohol use is a disease helps to attain this goal. A theoretical understanding of addiction is of crucial importance in developing effective methods of intervention for social workers to control and prevent addictive behaviours and reduce associated problems. Therefore, this essay will explore the theoretical models in order to assess the implications they have on service intervention with regards to substance use, i.e. the disease model, and the psychosocial model.

A crucial question in substance use, is what factors are involved in mediating the shift from use to abuse, regardless of its legal status. There have been a number of approaches explaining addiction and each area of explanation has been supported with empirical evidence. There are three different areas of explanation. The first involves the neurobiological effects of drugs and explains drug dependence, or ‘addiction’ in biological terms. The second area is psychological, this concentrates on models of behaviour and differences between individuals. The final area of explanation considers the social and environmental factors that influence the likelihood of substance misuse.

The Disease model focuses on a genetic predisposition to substance abuse within the individual. It postulates ‘innate constitutional physical mechanisms in specific individuals that impel or influence them either to experiment with drugs or to abuse them once they are exposed to them’, (Thombs, 1994,p.12). Thombs (1994) also explains how substance misuse is often described as a primary disease, not the result of another condition. This is usually taken to mean that the disease is not actually caused by drug use, heavy drinking, stress, or psychiatric disorders. Rather, it is thought to be the cause of these very conditions. In other words, drug use is a secondary symptom or manifestation of an underlying disease process known as ‘addiction.’

Disease model would suggest that substance users are not responsible for their actions.

That ‘deviance could be located within the pathology of the individual of their families.’ (Downes and Rock, 2007,p.273). This would suggest that some people are more vulnerable than others to developing substance use problems.

Many studies have found a genetic factor related to substance abuse, and research on numerous drugs of dependence and abuse is growing. High risk and twin studies have further underlined the significance of genetic factors in addiction. Kendler, Jacobson, Prescott and Neale (2003) found genetic links with substance users in male twin studies. Very strong evidence for the genetic vulnerability for drug abuse comes from studies with identical twins that were separated from birth. In a study by Grove and colleagues, the heritability for drug abuse was estimated to be 45% (Grove, et al, 1990)

Research suggests that certain mechanisms of neurons known as ‘glutamatergic’ may play an important role in addiction processes, including craving and addiction memory. Goodwin et al (1973) (from Barber 1995), ‘carried out a study in which 55 adoptees whose biological parents had been diagnosed as alcoholic were followed up and found to have four times the rate of alcoholism as adoptees from non-alcoholic biological parents.’ Barber also cited a study conducted by G.E.Vaillant that found that having a relative with a drinking problem significantly increased the risk of developing alcohol abuse, irrespective of whether the individual actually lived with the problem drinker,’ (Barber,1995,p. 18).

Understandably, this does not necessarily suggest that alcoholism is inherited, nor suggest that been addicted to one substance or activity is related to other addictive traits. It merely proposes the notion that certain individuals can have an underlying vulnerability to the development of drinking problems.

The disease model labels substance users as addicts, and terms the activity of substance use as ‘addiction’. However, the term ‘addict’ can carry negative connotation. To label someone as an addict, alcoholic, or a drunk, can stigmatize the individual for life. It can lead to stereotyping and take away their identity, thus encouraging them to perform to the label in order to obtain a service. It can also accuse the individual in advance of being weak and not able to hold up under pressure without resorting to drugs. For these reasons it can also lead to genetic discrimination with regards to health and life insurance, employment, and adoption.

Addiction is seen as a treatable disease. The disease model does offer a hopeful alternative to those who feel they cannot stop using and cannot face life without the help of drugs or alcohol. The treatment offered is to encourage abstinence so that substance users can lead fulfilling lives. Moderate drinking is not viewed as an option and abstinence is viewed as the only acceptable treatment goal. There are many treatment programs based on this model such as Alcoholics Anonymous, Narcotics Anonymous, and 12 step program. These programs aim to generate ‘hope in the individuals that they are able to gain confidence in themselves and believe that they can overcome substance abuse, reducing feelings of guilt as a result of the mutual support of Alcoholics Anonymous’. (Boss, 2004, p.27). The goals of treatment and strategies for change are prescribed for the client by the therapist.

However, this sends out the message that the client is incapable of making sound decisions, and they place emphasis on acceptance of the self as having the problem, and reduces personal choice, judgement and control. Also, setting goals of total abstinence may be too difficult and unattainable for some individuals, and may lead to feelings of being overwhelmed and frustrated. Also, often when the word disease is mentioned most think of something like cancer, aids, heart attacks, etc. Something that can be isolated in part and extracted from the body and visibly observed by the eye under a microscope or other apparatus. However, this is not the case with the disease of substance use or alcoholism. But to consume illicit substances one has to engage in willful misconduct. Therefore, associating the term ‘disease’ with substance users only supports the individual to excuse themselves from the consequences of their actions.

Yet the advantage with the disease model is that it is uncomplicated and relatively simple to understand. It removes the stigma that is traditionally associated with substance dependence and has perhaps encouraged individuals to attend meetings or agree to treatment programs whom previously may have avoided treatment for fear of being labelled weak or depraved.

Also, as Cape, Hulse and White (2002, p. 243) argues that ‘the assumption here is that there is no cure, and that one will be an addict or alcoholic for the rest of his or her life,’ as reflected in many of the Alcoholics Anonymous proverbs ‘once an alcoholic, always an alcoholic’. However, evidence suggests that there is a high rate of recovery among alcoholics and addicts, both treated and untreated. According to Treatment of Drug Abuse and Addiction (author unknown, 1995),

‘One recent study found that 80% of all alcoholics who recover for a year or more do ...

This is a preview of the whole essay

‘One recent study found that 80% of all alcoholics who recover for a year or more do so on their own, some after being unsuccessfully treated…

When a group of these self-treated alcoholics was interviewed, 57% said they simply decided that alcohol was bad for them. 29% said health problems, frightening experiences, accidents, or blackouts persuaded them to quit. Others used such phrases as "Things were building up" or "I was sick and tired of it." Support from a husband or wife was important in sustaining the resolution.’

(Treatment of Drug Abuse and Addiction, 1995)

Also, Sobell and Sobell conducted a trial of controlled drinking treatment for alcoholics in 1976. Subjects were assigned one of two treatment goals subjects, split into two groups between either drinking treatment or standard abstinence based treatment. Follow-up data suggested that the controlled drinking group had functioned significantly better than the abstinence group. The investigators concluded that controlled drinking can be considered as an alternative treatment goal to abstinence for some alcoholics. An independent follow-up in which interviewers were kept blind as to the treatment group confirmed the results of the earlier study. (Caddy, Addington, & Perkins, 1978).

Also, a study by Marlatt and Gordon (Barber, 1995,p. 94) found from various treatments that only 6% of relapses were caused due to craving for the substance.

The disease model has been so highly profitable and politically successful that it has spread to include problems of ‘eating, child abuse, gambling, shopping, premenstrual tension, compulsive love affairs, and almost every other form of self-destructive behavior.’ (Peale, 1989, p. 96). Herbert Fingarette stated that the alcohol industry itself contributes to forming a public perception of alcoholism as a disease, as a marketing ploy: ‘By acknowledging that a small minority of the drinking population is susceptible to the disease of alcoholism, the industry can implicitly assure consumers that the vast majority of people who drink are not at risk.’ (Fingarette, 1988, p.46)

This compromise was more preferable than the old commitment to prohibition, which criminalized the entire liquor industry. Governments are able to monopolise the sale of alcohol because the alcohol making procedure (like tobacco) is an industrial process that can be monitored, controlled, and taxed. Therefore, prohibiting alcohol would constitute in substantial losses of revenue for the government.

As previously mentioned, the disease model tends to focus on the object of addiction rather than the behaviour of the individual. Therefore, if the addiction involves drugs, then an assumption is often made that drugs have the power to force people to consume them. This seems to be the position our society has taken toward drugs, as echoed in sentiments such as ‘war on drugs’, rather than focusing the concerns on the behaviour of the substance user. Evidence of this is the banning and criminalization of certain drugs in our society. To focus on the legality, availability, and chemical properties of drugs avoids addressing the importance of behaviour and the reasons why people choose to use drugs.

This has perhaps due to the Home Office, the police and other law-enforcement agencies taking the lead role in administering drug policies in the UK. This will inevitably influence the perception that issues surrounding drugs and substance use are seen as a crime-prevention and criminal justice problem. The principal objective is to advocate total prohibition of illegal substances with emphasis on a punitive approach, also by disrupting the drugs supply chain from halting the importation of illegal drugs into the country and the production of them within the UK. However, drugs are often just as accessible within the confines of prison as they are in the community, and therefore continue their drug use. Also, ‘many drug users receive poor support in prison, with many going on to re-use or overdose on their release’, (unknown author, Politics.co.uk, 2008). The latest Drugs Strategy report has also outlined problems with this approach, stating that ‘at the moment large amounts of money are wasted in attempting to achieve the impossible’ (Drugs – facing facts report of the RSA Commission on Illegal Drugs, 2007. p,11). It is also argued that:-

‘targeting distributors and wholesalers does remove drugs before they hit the streets in small quantities but such operations are resource-intensive. Equally, targeting street dealers helps reduce the social problems they cause but dealers are quickly replaced and only tiny quantities of drugs are removed from circulation.’ (Travis, 2005)

Both the disease model and the criminalization approach bear similarities in the sense that they both advocate prohibition and abstinence as the only option in tackling a highly complex social problem. Yet, research suggests that any approach that has total prohibition as its principal objective has been less than wholly successful due to it’s over simplistic approach of attempting to achieve a drugs-free society.

Substance use is more likely to be prevalent among those experiencing disadvantaged circumstances of social exclusion. Often, social disadvantage and exclusion are major issues prior to the onset of a drug habit. Also, ‘the experience of marginalization for substance users [caused by society’s punitive approaches] only leads them internalise their problems and blame themselves’ (Buchanan 2004, p.392). This can have detrimental effects on encouraging drug users to seek help for fear of reprimand and face the possibility of further exclusion. This is because the implementation of policy comes from the criminal-justice system which neglects other approaches, such as those centred around individual health, public health, families, education, housing, social care and so forth.

The disease model clearly provides only a limited perspective on treatment methods because it does not take the circumstances of substance users into account. But the research covered also suggests that substance use is also a more complex social issue that neither orientation of the disease model or criminogenic approach seems to acknowledge. An insight into other approaches and perspectives may give us a greater understanding of what treatment and intervention methods can be adopted for cases of substance users.

The family and twin studies have not only shown that genetic factors are of great importance in the chances of developing addiction, but also that non-genetic factors play an important role. This is because studies in identical twins have consistently shown rates well below 100% (Kendler & Prescott, 1998, p.349), a clear indication that non-genetic factors are also important in determining drug addiction and substance use. Marlatt & Gordon (1980) found in a study that ‘74% of alcohol relapses preceded either by negative emotional states, like depression (38%), inter-personal conflict (18%), or social pressure (18%), [and that] heroin users were most troubled by social pressures, negative emotional states, negative physical states, and interpersonal conflict.’ (from Barber, 1995 p, 95)

Family seems to play a big role in the tendencies of siblings to abuse drugs. These tendencies increase with parents’ drug use and attitudes towards drugs’, (Hawkins, Catalano & Miller 1992, pg 112). ‘The nature of the family relationships also has an affect on the likelihood of adolescents abusing drugs’ (Hawkins et al, pg 70).

Psychology has its own share of trying to explain substance use. For instance, the psychodynamic model purports that addictive behaviour, like drug use, is the result of an interaction between external events and repressed or unconscious mental processes of which the subject remains unaware unless revealed and interpreted by psychoanalysis. The psychodynamic model proved to be very successful in shedding light onto the importance of early childhood development and parental influences as possible origins of addictive behaviour. However, the psychodynamic belief that individuals are predisposed to addiction by negative affective states are not supported by existing research findings. According to Cox (1985, p.112), ‘there is little evidence that psychological distress leads to addiction. It appears that negative affective states are usually the consequences of years of substance use, not the precursors, as claimed by the psychodynamic model.’

Unlike the psychodynamic model, behavioural models of addiction are based upon the assumption that the continued use of all drugs that stimulates euphoria is caused by their ‘extremely potent reinforcing effects’, (McAuliffe & Gordon, 1980, p. 137), and the more they use, the more intense the sensation and the greater motivation to continue use. Also, the intake of a dose to alleviate withdrawal distress is also explained in terms of reinforcing contingencies, whereby, the drug addict takes a dose to experience relief from pain, (negative reinforcement). This is clearly a factor in a certain segment of narcotic addicts, but it does not describe the use of all addicts, as McAuliffe and Gordon (1974) point out. Positive reinforcement applies to all drug use, insofar as taking drugs generates euphoria. However, this does not explain why some individuals who experience euphoria continue taking a certain drug, while others, who also experience euphoria, discontinue its use.

Other factors that will also affect the likelihood of a person developing drug abuse are: socio-cultural background, those who have performed worse in education and those form higher rates of crime’, (Institute of Medicine, 1996, p. 184). It would appear that susceptibility to social influences generally, and some influences promoting substance use in particular, are ‘related to low self-esteem, low self-satisfaction, low self-confidence, greater need for social approval, low level of assertiveness and impatience to assume adult roles or to appear grown up.’ (Botvin, 1990,p. 466)

Social Learning theory can help explain how these emotional predicaments are influenced through a combination of environmental (social) and psychological factors. This model indicates that the proponents of an individual’s behaviour could be a property of the social situation rather than the individual unlike the ‘disease model’.

Social learning theory explains ‘human behavior in terms of continuous reciprocal interaction between cognitive, behavioral, an environmental influences.’ (Bandura, 1977.p, 76). The central hypothesis of this theory is that through direct observation and through communications, we learn about substance use from personal experience, parents, peers, the media and other sources. Individuals learn to engage in substance use, primarily through their association with others. They are reinforced for this activity and learn beliefs that are favourable to substance use. As a consequence, they come to view substance use as something that is desirable or at least justifiable in certain situations. So it can be applied extensively to understanding how drug taking behaviours are acquired and maintained via the learning process through modelling or imitation of significant others. For example, Smythe, Barry and Keenan (2005) found that the socialised nature of heroin injecting in Dublin contributed to the Hepatitis C epidemic in the city. Users of the drug see their peers sharing needles and see no immediate negative effect, therefore copying and conforming to that behaviour to fit their social group. Alcohol use in western societies fulfils a social function in that people congregate and relax in pubs and clubs. Similarly, heroin users meet and share the experience, often using their own language and social codes. Taking the drug Ecstasy is the central activity at many nightclubs and ‘rave’ parties. It may be likely that within this subculture, the addict finds a socially validated role and that this is the motivation for continued substance use. Labelling theory would suggest that these users may then avoid stigmatisation by either maintaining conventional lifestyles and concealing their drug-taking behaviour or by affiliating more and more with an underground subculture. Otherwise, once their behaviour has been brought to the attention of significant others, the user is labelled deviant.

However, these reasons go more way to explain the beginnings of drug use rather than the causes of addiction. Psychological, social and environmental factors could be considered more as the catalysts of drug use, and that causes of addiction are due more to genetic factors.

The research collected appears to suggest that working with substance users from a disease model seems to treat someone’s ‘illness’ independently from their life events, relationships and place in the community. As a result, the disease model is deficient for social work practice because of its limited perspective on the human condition and does not account for the enormous complexity of the problem. This is because the hallmark of the social work profession is to focus on the person and the environment in which they inhabit, and dedicated to the understanding and modification of the social factors prevalent in client problems. A move away from the disease model would shift the focus primarily onto what goes on between people and the environment and the exchange between them. Therefore, it is paramount for social work intervention strategies to shift from the perspective of the disease model, to a more holistic perspective. This approach would assist the social worker in addressing both the causes and implications of the clients’ issues by assessing their interrelations between the individual, home, the workplace, social networks, community etc. In other words, it is about looking at the social contexts of addictive behaviours in order to embrace the complexity in its work with clients. This would then take into account the individual differences of clients. After all, no single treatment is appropriate for all individuals.

It is this view that lies at the core of social work. It is the commitment to these core values and ethics that make Social Work distinctive profession. This view embraces the notion that people are not thought of as isolated individuals but as elements of a social system. General systems theory helps to explain this perspective. ‘The general systems view of society is a way of thinking about the world which draws a parallel between the way society operates and the way biological systems operate’ (Barber, 1995, p. 26). Partners and families of substance users are also hugely affected, their partners’ emotional needs and protection of children must be considered. Social work seeks to enhance the social functioning of the individual. They focus on the clients relationships between themselves and the environment. By establishing what problems the client is having in relation to drug use. Substance use is ‘often in the context of a more pressing social problem such as domestic violence, homelessness or poverty’ (Barber, 1995,p. 73). Service users may be suffering from mental health problems, possibly due to previous traumatic experiences in which drugs are used to self medicate. Therefore, social workers are likely to confront substance users in a wide variety of settings, many of which are outside specialist drug treatment agencies. They may also be involved with other criminal activities to feed their habit such as prostitution, theft, burglary etc, and be exposing themselves to the infection of transmitted diseases such as HIV, AIDS and Hepatitis C.

For social workers, the importance of the problem surrounding the issue with ‘addiction’ lies in its implications for treatment and intervention. One of the major concerns of the social worker is to foster better adjustment for the substance user and his/her family. This would involve assisting them with coping strategies, carrying out socially desired goals, maintaining a positive self-concept and maintaining a positive outlook on the situation. ‘Treatment’ would therefore encompass the need to address the full range of drug users’ needs, not only their physical and mental-health needs.

Social learning theory emphasises the importance of self-efficacy and self-regulation processes. Self-efficacy can be described as the system that enables the individual to exercise a measure of control over their thoughts, feelings, motivations and actions. This theory also sees personality and behaviour as changeable. Therefore, ‘if one can change the way the individual thinks, or change the environment they are responding to, their behaviour will change’ (McMurran, 1994, p. 122). Applications derived from social learning theory include teaching individuals to recognise the risk factors that lead to substance use, improving alternative coping skills, and enhancing the individual’s self-efficacy beliefs so that these alternative skills can be used effectively. This approach places the responsibility onto the client, thus promoting self-directedness for the substance user. It also encourages internal attributions of the client, rather than telling the client what to do and seeing the client as helpless or without control. From this approach, the objectives for treatment would be to help the client assume responsibility for change and to provide an opportunity for learning survival skills that can be applied to any problems that may arise in the future.

There is an emphasis placed on the person’s choices such as the decision to continue to take substances or not, unlike the disease approach. However, the shift away from the disease model is not to suggest that abstinence should not be an option. It should always be recommended to clients with alcohol related organic damage, or pregnancy, irrespective of level of dependence. Therefore, the process of working with a substance user from a psychosocial approach can vary between working towards the goal of total abstinence to one of harm reduction and minimisation.

Further evidence to support the behavioural and social models for treatment intervention is from research conducted by Orford & Edwards (1977). They discovered ‘that drinkers from relatively cohesive domestic relationships were more than twice as likely to maintain treatment gains as drinkers from non-cohesive relationships’. (from Barber, 1995, p. 133). In other words, building and encouraging social support will aid positive reinforcement. This could involve working with the client’s partner by assisting them with positive coping mechanisms. For example, McCrady (1988) suggested that ‘nagging and repeatedly telling the drinker to cut down, issuing warnings about the dreadful things that will happen if drinking does not stop, or bringing up past hurts or problems in an aggressive or accusatory manner.’ (from Barber, 1995, p. 64) this procedure was found to have a considerable success amongst alcoholics.

This approach can also reduce substance dependence through reinforcement training programmes, where positive reinforcement is encouraged within their immediate environment, i.e. home, family, social network etc. For example, scheduling activities that the substance user will enjoy but would be difficult to engage in under the influence of drugs. Go-Karting, sports activities for younger users. Or taking their children on a picnic. All positive reinforcers then need to be removed if the substance user relapses.

Identifying and avoiding the negative reinforcements are of equal significance because they are often counter productive

As previously mentioned, abstinence is viewed as the only acceptable treatment goal with treatment programs originating from the disease model. However, research suggests that relapse is a common factor in the road to recovery. According to Linton (2008, p.18), there are five stages that people go through when changing behaviour. Stage 1; the individual is unaware they have a problem or aware of the problem with no desire to change it. Stage 2; the individual begins to think that a problem exists, and may consider making a change but have no yet made any attempts. Stage 3; by this stage, the individual has now acknowledged the fact that they may have a problem and are forming plans in changing their behaviour. Stage 4; by this stage the individual is now putting their plans into motion and making active attempts in changing their behaviour. Stage 5; this is the final stage where the individual works to maintain the changes they have made. They commit to leading a new lifestyle. A final piece of the changing process is lapses or relapses. Research suggests that this will occur on average two or three times throughout the stages of change (smokers three to seven times). A shift away from the disease model would be more accepting of relapses as part of the process. After a lapse, the social worker can work with the individual to modify and re-evaluate their plan, make alterations to it, and put a new plan into action. For example, a coping response can be developed to deal with situations i.e. prevention plans to assist the individual in recovery to identify and deal with high-risk situations, this would be to ensure the individual would be less likely to find him or herself in situations that lead to relapse.

In conclusion, the disease model seems to offer only one perspective on providing methods of treatment. Although much evidence supports the notion that genetic and biological factors play a considerable part in addiction, the methods for treatment underpinned by the disease model appear to be insufficient. The research covered suggests that there is no one single approach to treatment for all individuals. But by shifting away from the disease model towards a more psychosocial perspective, matching individuals to treatment options will increase, as will the effectiveness and efficiency of treatment given. This is because this approach allows social workers to see substance users in the context of their life experiences and therefore gain a better understanding as to why they are in their present situation.

As mentioned earlier, negative reinforcement such as punitiveness as a motivational device does not seem to work, as the research covered shows that drug abusers are just as likely to change their behaviour for positive as for negative reasons.

Substance use should therefore be viewed as a social issue, not as a disease that isolates the problem within the individual. Legislation should reflect this by being less heavily influenced by the demands of the criminal justice system. Laws should acknowledge that, whether we like it or not, drugs are and will remain a fact of life. Promoting abstinence from drugs is too simplistic given the complexity of the problem, especially considering that there is every reason to think that people will always consume drugs regardless of its legal status, and despite the negative messages of drugs portrayed through education and the media. Policies need to be less heavily influenced by the demands of the criminal justice system. Policies could be designed to incorporate services that would enable people to overcome dependency: housing, education, employment, child care and family support. The advantages would be threefold; treatment for substance use would then be viewed as a health and social problem; less money spent on failing punitive methods; and would encourage substance users to seek help without fear of reprimand.

Imprisonment should still have its place, but many punitive measures only exacerbate the social issues surrounding many substance users. Many drug users remain socially excluded, unable to find employment because of a history of drug use and/or the activities surrounding drug use. This would allow access to treatment easier for drug users regardless of whether or not they have committed an offence. Understandably, the social worker is unable to exert much influence on such variables, but it can be helpful at least to anticipate the pressures that exist within society.

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