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

Regular article

Predictors of addiction treatment providers' beliefs in the disease andchoice 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 beliefsin the disease and choice models of addiction, as assessed by the 18-item Addiction Belief Scale of J. Schaler (1992). Factor analysis of itemscores 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 historyvariables, treatment providers working in the United States more strongly believe addiction is a disease, whereas U.K.-based providers morestrongly believe that addiction is a choice and a way of coping with life. Beliefs that addiction is a disease were stronger among those whoprovide for-profit treatment, have stronger spiritual beliefs, have had a past addiction problem, are older, are members of a group of addictionprofessionals, and have been treating addiction longer. Conversely, those who viewed addiction as a choice were more likely to providepublic/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 thelonger 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 themedical, social science, legal, and spiritual communities intothose 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 betraced back to this dichotomy in causation—drug-addictedindividuals are either “responsible/moral agents who perpe-trate acts of mayhem on themselves…or victims of a disorder

⁎ Corresponding author. School of Psychological Sciences and Health,University of Strathclyde, 40 George Street, Glasgow, G1 1QE Scotland, UK.

E-mail address: christopher.russell@strath.ac.uk (C. Russell).

0740-5472/10/$ – see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.jsat.2010.09.006

which undermines their values and best intentions” (White,2001). Regardless of the scientific credibility of the diseaseand choice (or “free will”) models, research has shown thatclients of addiction services tend to adopt the addictionideology of their treatment service (Koski-Jannes, 2004).Therefore, the extent to which addiction treatment providersbelieve their clients' addictive behaviors are diseased orchosen should be expected to have a strong bearing on howclients will attribute the causes of their problems, seek toresolve these problems, and believe in their capacity toachieve a desired change. Extending research by Schaler(1992), we examined addiction treatment providers' beliefsabout addiction and investigated the factors explainingvariance in beliefs, with a specific interest in the importanceof country in which treatment is provided.

1.1. Dichotomous and trichotomous thinking about addiction

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

151C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

two chosen for scrutiny in this study. Several otherperspectives of addiction—such as an illness, disorder,malady, allergy, ailment, sickness, condition, habit, func-tional attribution, and social construction among others—can be viewed as implicitly ascribing or alluding to therespective disease/choice model assumptions about addic-tion as a compelled versus chosen act, an involuntary versusvoluntary act, and a problem inherent to the drug versus aproblem inherent to the mind of the user. Alternatively, sometheorists refute the suggestion that addiction can be fit to adisease–choice dichotomy, arguing addiction to be acomplex, messy intertwining of the user's biology andsociology that subsumes elements of the disease and choicemodel without contradiction.

Consequently, a disease–intermediate–choice trichotomyhas emerged. White's (2001) “degrees of freedom” perspec-tive, for example, argues addiction as a “process disease”should be discussed not in terms of complete control orcomplete loss of control, but in terms of degrees ofdiminishment and enhancement of volitional control. Theproblem with an intermediate perspective, however, is that itmust logically presume there exists a critical, discrete pointalong the freedom continuum at which drug use becomes nolonger governed by phenomenological wants but byphysiological needs. This “tipping point” has survived as acore hypothesis of 19th-century disease conceptualizationsof inebriety—Joseph Parrish suggested in 1888 that “a linecould be crossed where drunkenness evolves into a diseasethat is no longer under the conscious control of the drinker”(cited by White, 2000)—through to the modern diseaseconcept—“the non-addicted brain is distinctly different fromthe addicted brain…Ametaphorical switch in the brain seemsto be thrown as a result of prolonged drug use. Initially, druguse is voluntary, but when that switch is thrown, theindividual moves into the state of addiction characterized bycompulsive drug seeking and use” (Leshner, 1997, p. 46).1

To create an intermediate perspective would therefore beredundant for the purposes of asking whether drug seekingand use are willed or determined. Thus, although the validityof a trichotomous model of the governing factors inaddiction and the mechanisms of change at the boundaryof each state will continue to be debated, this study wasconcerned only with treatment providers' beliefs in thedisease and choice models.

1.2. The disease and choice models

The disease and choice models of addiction emerged fromdifferent assumptions about the origins of behavior; namely,whether behavior is determined by physical mechanism orwilled by an emergent force that transcends direct physicalmechanism (Davies, 1997). Consequently, they hold diver-gent 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.

become addicted to drugs and alcohol, their capacity forcontrol during consumption, and their prospects for changewithout medical treatment. That the different sets offundamental assumptions driving each model are philosoph-ically irreconcilable also necessitates, we argue, proponentsof one model to be equally passionate critics of the other.

The disease model describes addiction/substance depen-dency as a primary, progressive, chronic relapsing diseasethat is either genetically transmitted or acquired throughexcessive consumption (Leshner, 1997; Ketcham et al.,2000). Here, initial drug use occurs voluntarily. As repeateddrug use changes neural and brain function, however, theuser progressively loses control over their initial voluntarybehavior to the point that further drug seeking and usebecome acts of compulsion, not choice (Ochoa, 1994; Foulds& Ghodse, 1995). Thus, getting drug users who are in theearly or latter stages of an addiction into treatment withmedical experts often represents their best hope for arrestingbut never curing the addiction (Milam & Ketcham, 1983). Inresponse to criticism, however, that a large body of scientificevidence on alcoholism and alcohol problems has contra-dicted the view of addiction as “an incurable, unitary, all-or-nothing disorder caused solely by hereditary physicalabnormalities” (Miller, 1993, p. 133), a more scientificallydefensible disease model has been sought in recent years.Miller proposed that research, treatment, and educationabout alcoholism should be based on a disease model thatdescribes alcohol problems on continua of severity and anetiological model comprising interactions of drug properties,drug user, and drug setting.

The alternative model describes addiction as a motivatedchoice. Here, drug taking is at all times somethingindividuals do voluntarily, usually when life is going badlyor to avoid coping with problems in living (Schaler, 2000).When these problems in living are resolved, individualsnormally find that the addiction resolves with them, whileother individuals mature out of their addiction in time (Peele,Brodsky, & Arnold, 1991) or learn to control theirconsumption (Heather & Robertson, 1989). In this way,addiction is seen as more to do with the environments peoplelive in than with brain pharmacology (Alexander, Hadaway,& Coambs, 1980; Cohen, Liebson, Faillace, & Allen, 1971;Robins, Helzer & Davis, 1975). With regard to the issue ofcontrol, choice proponents argue that not only do drug usersnever lose control over their drug use but that the best way tocurb problem drug use is to make and implement betterdecisions, which does not require them to seek medicaltreatment. Choice proponents tend to allow discussion ofaddiction as a metaphorical disease but refute that it is aliteral brain disease (McMurran, 1994). They note that alarge body of scientific evidence contradicts disease modelclaims regarding heritability, loss of control, and effective-ness of treatment, and they denounce the disease model'sinference of a critical discrete event discriminating addictedand nonaddicted drug users' as myth. They argue that drugusers are always free to choose to stop and that drug users'

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

difficulty in effecting change should not be mistaken for alack of freedom to do so.

1.3. Milestones in the evolution of the disease model

Treatment providers' support for each of the competingmodels may vary depending on whether treatment isprovided in the United States or not. Although the idea ofalcoholism as a disease did not originate in the United States,the modern disease concept of alcoholism has been 200 yearsin the making2, during which time the United States haspresided over the most significant events in changing publicconceptions of drunkenness and drug use from voluntarychoices to involuntary compulsions (Levine, 1978; Peele,1989). Benjamin Rush first medicalized the problem ofdrunkenness in the early 19th century, his definition of a“disease of the will” becoming a central message of theAmerican Temperance Movement (Levine, 1978).

The term inebriety was introduced in the late 19th centuryto explain the seeking and problem use of a variety of drugsas due to a common underlying pathology. Interest turned tothe effects of drugs' effects on the host, and doctors began tohypothesize that the inebriate's apparent loss of control andother symptoms could be traced to rogue hereditary and/orself-impaired biological mechanisms that mark a primarydisease of the nervous system. In particular, the work of theDrs. Parrish (1883) and Crothers (1893)—prominent leadersof the American Association for the Cure of Inebriety—described inebriety as a disease that is curable in the sensethat other diseases are curable and as inherited or acquiredthrough excessive consumption. This disease concept ofinebriety began a movement to treat inebriates at specializedinstitutions in medical and scientific ways similar to otherdiseases (i.e., through the development of vaccines). Duringthis period, Dr. Norman Kerr (1888) was advocating acomparable disease concept in England. Consequently,disease thinking about inebriety soon spread throughoutthe United States and United Kingdom.

Public thinking about the disease of drunkenness took offin 1935 with the inception and rapid growth of AlcoholicsAnonymous (AA), a spiritual self-help fellowship made upof self-described recovering alcohol-dependent individualscommitted to helping one another maintain sobriety (Kurtz,1988). Although AA literature does not refer to alcoholismas a literal disease, Kurtz (2002) states that AA and membersof AA do use medical terms—illness, sickness, malady—and the disease concept to reflect their belief about thesolution to alcoholism—abstinence—and to convey thehopelessness of alcohol-dependent individuals to changethemselves. Ragge (1998), for example, traces sevenfeatures of the modern disease concept of alcoholism (e.g.,beliefs that an intense physical craving is responsible foralcohol-dependent individuals' loss of control and that

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

physiology, not psychology, determines whether one drinkerwill become addicted and another will not) to the Big Bookof AA (Alcoholics Anonymous World Services, 1939), thefellowship's core publication. Alcoholics Anonymous,through its public relations campaigns, has been instrumen-tal in spreading and popularizing the disease concept ofalcoholism while avoiding discourse of alcoholism as aliteral disease.

Addiction as a disease in the United States gainedmomentum in the mid-1990s with significant increases inpublic funding of research into the genetic and neurobio-logical foundations of addiction (Institute of Medicine[IOM], 1996). This research agenda, accompanied by apublic education campaign that used a basic vocabulary toteach a basic level of understanding about brain rewardcircuitry, sought to “move ‘addiction is a disease’ from thestatus of an ideological proclamation by policy activists andan organizing metaphor for individuals seeking to resolvealcohol and other drug problems to a science-groundedconclusion” (White, 2007). In recent years, former andcurrent directors of the National Institute of Drug Abuse,Alan Leshner (1997) and Nora Volkow, respectively, haveused high-profile, highly respected academic outlets tosummarize 20 years of evidence from neurosciences andbehavioral sciences, which they claim prove addiction is abrain disease. Leshner, additionally, called for public policy,education, and addiction treatment to catch up with thesescientific facts. Volkow's keynote speech to the AnnualConference of the American Psychiatric Association in 2007followed on from a special issue of Nature Neuroscience(multiple authors, 2005) in which a group of renownedneuroscientists reported the latest evidence on the neurobi-ology of addiction. Their findings described addiction as afundamentally neurobiological disorder.

Finally, as a vehicle for the dissemination of this newneuroscientific evidence base to the public, the IOM (1996)recommended that education about addiction should explainin basic language that drugs can alter neural or brainfunction, how these changes impair the user's ability to makechoices about using drugs, and that treatment is effective.The “brain hijacking” metaphor—“the concept that thesedrugs can capture control of brain mechanisms that controlmotivations and emotions”—was proposed as an effectivedevice to increase understanding about a common effect ofsome drugs on the brain. This device has since featuredprominently in major media pieces such as a TIMEMagazine(2007) feature article entitled, “HowWe Get Addicted” and a14-part NIDA-funded TV special by HBO DocumentaryFilms (2007) entitled, Addiction: Why Can't They Just Stop?

Today, the American Medical Association (Morse &Flavin, 1992), American Psychiatric Association (2000), andNIDA (2009) continue to define as the essence of addictionuncontrollable, compulsive drug seeking and use. Conse-quently, the use of the word addiction in public discoursehas come to describe the activities that people engage inbecause they are physically unable to avoid doing so

153C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

(Levine, 1978; Mercadante, 1996; Schaler, 2000). Althoughthe disease model now dominates addiction discourseinternationally, the prominent role played by the UnitedStates' psychiatric, medical, research, media, and spiritualcommunities in shaping the modern disease concept ofaddictive behaviors suggests that support for the view ofaddiction as a disease may be stronger within the U.S. versusnon–U.S. treatment communities.

1.4. Previous research

Investigation of these questions was motivated by Schaler(1992), who found that treatment providers tended to believethat addiction is a disease from which only about 25% ofpeople recover without medical or 12-step–based treatment.Treatment providers who reported stronger beliefs thataddiction is a disease were significantly more likely to bewomen, members of the National Association for Alcohol-ism and Drug Abuse Counselors (NAADAC), present or pastmembers of AA, certified addiction counselors/therapists,abstinent at present, and have stronger spiritual beliefs asdefined in AA philosophy. Strength of spiritual beliefs, asmeasured by the Spiritual Belief Scale (SBS; Schaler, 1992)accounted for most variance (41%) in disease beliefs.However, although Schaler's sample comprised treatmentproviders working in the United States, Canada, andAustralia, differences across these locations were notinvestigated. This precludes offering conclusions aboutsupport for the disease model in the United States relativeto out-with the United States and the hypothesizedsignificance of the country of treatment as a predictor ofaddiction beliefs. Data were also not collected on the profitstatus of treatment provided.

Furthermore, there are a number of reasons to suspect thataddiction beliefs may have changed since 1992. Theseinclude high staff turnover rates, new pharmacological andpsychotherapeutic treatment approaches to addiction, policychanges regarding public funding of addiction treatment andinsurance coverage, new laboratory and field evidence ontreatment effectiveness including the much publicizedfindings of Project MATCH (1997) and UK AlcoholTreatment Trial (2005), the aforementioned U.S.-led re-search drive to emphasize the neuronal mechanisms andheritability of addiction, and the transmission of the basicfacts of addiction neuroscience to the public, policy makers,and treatment providers. Thus, we examined whether asimilar factorial structure emerged from ABS scores andwhether factors found by Schaler to explain variance remainpotent 18 years on.

1.5. Current study aims

The purpose of this study was to assess (a) whether beliefin the disease model of addiction is stronger among treatmentproviders who work in the United States versus out-with theUnited States and (b) the variance in disease and choice

beliefs explained by demographic and personal andprofessional 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 ofthe 21 and 94 regional Drug and Alcohol Action Teams(DAATs) in Scotland and England, respectively. As part ofregional National Health Service Health Boards, DAATsare responsible for the top–down and bottom–up commu-nication of substance misuse-related data between addic-tion treatment services and local and central governmentand, therefore, have excellent access to voluntary andstatutory addiction treatment providers within their region.Drug and Alcohol Action Teams were asked to forwardthe survey pack to managers of local addiction treatmentservices. In turn, managers were asked to forward thesurvey to all staff who are directly involved in theprovision of addiction treatment.

Second, survey packs were sent via e-mail to 785 personswho could be identified as chief executive officers/managersof addiction treatment services on the Web sites of severallarge associations and online databases of addictiontreatment professionals. These were NAADAC, the Associ-ation for Addiction Professionals, Federation of Drug andAlcohol Professionals (a U.K. branch of NAADAC),European Federation of Therapeutic Communities, Europe-an Association for the Treatment of Addiction, Associationof Intervention Specialists, Recover Now, Time for NewBeginnings, Sober Recovery, Addiction Treatment CenterDirectory, Substance Abuse and Mental Health ServicesAdministration, Substance Abuse Treatment Facility Locator(U.S. Department of Health and Human Services), andAlcohol Focus Scotland. Treatment providers typicallyprovide contact information for public viewing on theseWeb sites for the benefit of persons seeking help for anaddiction problem, although they are assumed to not opposebeing contacted in this way by other interested parties.Indeed, no treatment providers objected to being contacted inthis way and many were quite happy to know they wereaccessible in this way.

Third, survey packs were circulated to subscribers of thefollowing e-newsletter mailing lists: (1) U.K. lists: AlcoholMisuse, Drug Misuse Research, Drug Day Programmes,Wired In, and Therapeutic Community Open Forum; (2) U.S./Canadian lists: Addict-L, Addiction Medicine, andApolnet; (3) European lists: Therapeutic Communities andEuropean Working Group on Drugs Oriented Research; and(4) international lists: the Kettil Bruun Society and GamblingIssues International. These lists cover approximately 2,500subscribers in total. The e-survey was closed 2 months afterthe final survey pack was sent out.

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

Variable United States United Kingdom Total

N 219 372 591Age, M (SD) ⁎⁎ 47.61 (10.60) 44.03 (10.68) 45.35 (10.78)SexMale 95 (43.4) 145 (39.0) 240 (40.6)Female 124 (56.6) 227 (61.0) 351 (59.4)Profit statusPrivate/for-profit 70 (32.0) 118 (31.7) 188 (31.8)Public/not-for-profit 149 (68.0) 254 (68.3) 403 (68.2)Years as treatment provider0–1 13 (5.9) 28 (7.6) 41 (7.0)2–5 53 (24.2) 99 (26.8) 152 (25.8)6–10 50 (22.8) 104 (28.1) 154 (26.1)11–15 36 (16.4) 59 (15.9) 95 (16.1)16–20 23 (10.5) 41 (11.2) 64 (10.9)21+ 44 (20.1) 39 (10.5) 83 (14.1)Certified ⁎⁎⁎

Yes 115 (52.8) 111 (30.2) 226 (38.6)No 103 (47.2) 256 (69.8) 359 (61.4)Professional group member ⁎⁎⁎

Yes 99 (45.4) 74 (20.3) 153 (31.4)No 119 (54.6) 290 (79.7) 332 (68.6)Problems treatedAlcohol 191 (87.2) 320 (86.0) 511 (86.5)Illicit drugs 185 (84.5) 327 (87.9) 512 (86.6)Prescription drugs 172 (78.5) 271 (72.8) 443 (75.0)Nicotine/tobacco ⁎⁎⁎ 84 (39.2) 64 (17.2) 148 (25.0)Gambling ⁎⁎⁎ 82 (37.4) 63 (16.9) 145 (24.5)Video gaming ⁎⁎ 27 (12.3) 18 (4.8) 45 (7.6)Sex/Pornography ⁎⁎⁎ 39 (17.8) 26 (7.0) 65 (11.0)Food ⁎⁎ 34 (15.5) 29 (7.8) 63 (10.7)Shopping ⁎⁎ 28 (12.8) 19 (5.1) 47 (8.0)Internet use ⁎⁎⁎ 30 (13.7) 19 (5.1) 49 (8.3)Treatment methods usedPsychotherapeutic a 190 (88.0) 326 (91.6) 516 (90.2)Pharmacotheraputic b 135 (62.5) 210 (59.0) 335 (60.3)12-Step ⁎, c 99 (45.8) 125 (35.1) 224 (39.2)

Note: Country × Variable differences were tested using the χ2 statistic forcategorical variables and an independent groups t test on the onecontinuous variable (age).

a Psychotherapeutic methods included reported use of at least one ofcognitive–behavioral therapy, individual and group counseling, person–center therapy, motivational interviewing, biopsychoscoial models, stressmanagement, art therapy, equine therapy, family systems approach, couplestherapy, occupational therapy, rational emotive therapy, emotion-focusedtherapy, mindfulness, meditation, psychodynamic therapy, Jungian therapy,Rogerian therapy, narrative therapy, systems theory, motivational enhance-ment 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 substituteprescribing 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-StepFacilitation, Minnesota Model, and AA/NA model.

⁎ p b .05.⁎⁎ p b .01.⁎⁎⁎ p b .001.

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

2.2. Sample characteristics

The survey received 854 responses. Of these, 164 wereexcluded because the Addiction Belief Scale (ABS) wasincomplete (n = 160) or because respondents were notproviders of addiction treatment/were no longer activelytreating clients (n = 14). We had initially planned to comparethe strength of disease beliefs in the United States versusseveral countries. However, the majority of survey responsescame from treatment providers working in the UnitedKingdom (n = 372) and the United States (n = 219), withthe remaining 99 respondents representing 21 othercountries. Thus, comparing disease beliefs in the UnitedStates with those in several countries was not possible andcreating a “U.S.-versus-not-U.S.” variable was consideredmisleading, given that 79% of the “not U.S.” respondentscame from the United Kingdom. Purely due to thegeographical distribution of our sample, it was decided toexclude the 99 non-U.K. and non-U.S. respondents so as tocompare the strength of disease beliefs of treatmentproviders working in the United States versus the UnitedKingdom. This left a final sample of 591. Due to theopportunistic sampling method, it was impossible tocalculate a survey return rate. Professional characteristicsof the sample by country are summarized in Table 1.

2.3. Materials

Treatment providers were invited by e-mail to completean e-survey of their addiction beliefs. This e-mail gave abrief explanation of the study, confirmed that local ethicalapproval had been granted, assured respondents of confi-dentiality, and gave contact information for the primary andsecondary authors. The survey comprised three parts: theABS, the SBS, and questions about their personal andprofessional addiction history. Other information collectedincluded age (in years) and sex.

2.3.1. The Addiction Belief ScaleThe 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 fortreatment, and addicted individuals' capacity for self-control,insofar as these assumptions can be dichotomized. Anexample of a statement that reflects the disease model is“Physiology, not psychology, determines whether onedrinker will become addicted to alcohol and another willnot” (item 11). An example of an item reflecting the choicemodel is “People can stop relying on drugs or alcohol as theydevelop new ways to deal with life” (item 6). Respondentsrate on a five-point Likert scale the extent to which theyagree with each statement (1 = strongly disagree to 5 =strongly agree) and the nine choice model items are reversescored. The highest possible score is 90 (minimum = 18),with a conceptual median of 54. A score higher or lower than54 on the ABS indicates a belief in the disease or choice

155C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

model of addiction, respectively. Schaler (1995) reportedstrong internal consistency for the ABS (α = .91,standardized item, α = .91, n = 266) and a three-factorstructure described as “power” (α = .91, n = 274),“dichotomous thinking” (α = .83, n = 285), and “addictionas a way of coping with life” (α = .47, n = 286). Highconstruct validity was evidenced by a strong negativecorrelation (r = −.67, p = .01) between respondents' ABSscores and their beliefs about the percentage of individualsable to recover from an addiction without any form ofmedical or 12-step–type treatment, that is, the stronger theirbelief in addiction as a disease (higher ABS score), the lowerthe percentage of individuals they believed are able torecover without treatment. The full ABS and factorialanalysis can be found in the work of Schaler (1995).

Despite reporting a three-factor structure, Schaler initiallyscored ABS items in accordance with a single factor, bipolarin nature, with endorsement of the disease model at one endand endorsement of the choice model at the other end. Assuch, the nine items designed to represent beliefs in thechoice model were reverse scored. To determine whether thisscoring system was appropriate for current data, a factoranalysis of current ABS data was conducted to checkwhether addiction beliefs loaded on a single “disease–choice” factor (and so choice items can be reverse scored andABS total scores used as a dependent measure of belief in thedisease model) or whether addiction beliefs conform to amultifactorial structure. Results of this analysis are reportedin Section 3.2.

2.3.2. The Spiritual Belief ScaleThe eight items of this scale measure spiritual thinking as

defined in the philosophy of AA as belief in a metaphysicalpower that can influence personal experience. Items wereadapted from how spirituality is discussed in the Big Book ofAA to form statements about God and “spiritual health.”Items reflect the four spiritual characteristics of AA—release, gratitude, humility, and tolerance—identified byKurtz (1988). Respondents rate on a five-point Likert scalethe extent to which they agree with each statement (1 =strongly disagree to 5 = strongly agree). Higher scoresindicate stronger spiritual beliefs. The highest possible scoreis 40 (minimum = 8). Schaler (1996) reported strong internalconsistency 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 andfactorial analysis can be found in the work of Schaler (1996).

2.3.3. Addiction history questionsQuestions regarding respondents' professional addiction

history were whether they are an addiction treatmentprovider, job title, the country and state/county in whichthey provide treatment; the profit status of their treatmentfacility, number of years experience as an addictiontreatment provider, whether they are a member of any

professional group of addiction treatment providers, whetherthey are a certified counselor or therapist for treating anaddiction, and which types of addiction problems they treat.

Regarding personal addiction history, respondents wereasked if they have personally had a problem with anaddiction in the past. If “yes” was indicated, they were thenasked several follow-up questions: whether they have everattended a treatment agency in the past; whether they haveattended in the past or presently do attend AA, NarcoticsAnonymous (NA), or any other 12-step–based program;number of years in total they have been a member of a 12-step–based program; and whether they are abstinent atpresent. Respondents who indicated “no” to the pastaddiction problem question did not answer these fivefollow-up questions. Finally, an empty text box at the endof the survey allowed respondents to comment on the survey.

3. Results

3.1. Power analysis

Power analyses were performed to determine whether theplanned multiple regression analysis would be sufficientlypowered to detect meaningful effects (f2 for multipleregression, see Cohen, 1988) given a sample of 591. Theanalysis showed that when N = 591 and α = .05 and with 10predictors, power = 1.00. Thus, it was concluded that thepresent analysis was sufficiently powered.

3.2. Factor analysis of the ABS

Separate factor analyses were conducted to compare theABS factor structures for the U.K.- (n = 372) and U.S.-based(n = 219) samples. Despite the ABS's apparent bipolarcontent on a single dimension of addiction beliefs, extremelysimilar 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 diseaseitems (9 [.53], 11 [.57], 14 [.68], and 17 [.49]) and one choiceitem (12 [−.66]) loaded on factor 1; six choice items (4 [.66],7 [.60], 8 [.50], 13 [.54], 15 [.61], and 16 [.48]) loaded onfactor 3; and two choice items (6 [.70], 18 [.62]) loaded onfactor 4. The only differences in the composition of the fourfactors extracted from U.S.-based scores were that item 12switched from being negatively correlated with disease itemsin factor 2 to strongly positively correlated with the choiceitems 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 inseparate analyses, all ABS scores (N = 591) were factoranalyzed using varimax rotation with Kaiser normalization.Three factors were extracted, which we labeled “addiction isa disease,” “addiction is a choice,” and “addiction is a way ofcoping with life,” respectively. These factors togetherexplained 50.13% of common variance. Factor 1 had an

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

Factor 1 a Factor 2 b Factor 3 c ABS total d

Factor 1 – −.43 ⁎⁎⁎ −.21 ⁎⁎⁎ .76 ⁎⁎⁎

Factor 2 – .36 ⁎⁎⁎ .22 ⁎⁎⁎

Factor 3 . – .24 ⁎⁎⁎

ABS –a Cronbach's α = .79, 10 items, N = 591 (“addiction is a disease”).b 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.

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

eigenvalue of 6.08 and explained 33.80% of variance. Tenitems loaded on this factor, nine of which were designed torepresent 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 ofaddiction (12: “Alcoholics can learn to moderate theirdrinking or cut down on their drug use”), which was stronglynegatively correlated (−.55). Disagreement with item 12implied the belief that alcohol-dependent individual areunable to learn to moderate drinking/drug use, which isconsistent with the disease perspective. The item with thestrongest correlation value reads, “Addicts cannot controlthemselves 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 thechoice model loaded on this factor (items 4 [.58], 7 [.72],8 [.50], 13 [.54], 15 [.62], and 16 [.54]). The item with thestrongest correlation value reads, “Addiction has more to dowith the environments people live in than the drugs they areaddicted 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 thestrongest correlation reads, “Drug addiction is a way of lifepeople rely on to cope with the world.” However, theoverall pattern mirrored that revealed by the factor analysisof the entire sample: Items designed to represent the diseaseand choice models correlated positively with their own kindand correlated negatively with items representing thealternative model.

Therefore, scores were summed for each of the threefactors extracted by the main factor analysis (“addiction is adisease,” “addiction is a choice,” and “addiction is a way ofcoping with life”) and used as criterion variables insubsequent regression analyses. These factors had maximumscores of 50, 30, and 10, respectively, with higher scoresreflecting stronger beliefs in each factor. Each factor hadgood to very good internal consistency and correlatedstrongly with each other, as shown in Table 2.

3.3. Hierarchical multiple regression models

To investigate the variables that explain variance inaddiction treatment providers' beliefs about addiction, threeseparate hierarchical multiple linear regression analyses wereconducted, 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 theABS used, respectively, as the criterion variables. To controlfor their effects, eight variables were entered at step one ofeach 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.

= yes), member of a group of addiction treatment profes-sionals (0 = no, 1 = yes), had a personal addiction problem inthe past (0 = no, 1 = yes), the profit status of treatmentprovision (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 statuson ABS score by country, an interaction term for profit statusand country was regressed on ABS score at step 3. Datasatisfied assumptions of linearity, multicollinearity, andhomoscedasticity of residuals. Mean scores and standarddeviations 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% ofvariance in treatment providers' beliefs in the disease modelof addiction (see Table 4). Step 1 produced a significantmodel, F(8, 565) = 26.47, p b .001, and accounted for 27.3%of variance in factor 1 scores. Six of the eight variables madesignificant contributions.

Score on the SBS and age were both positively associated(β = .40, p b .001, and β = .15, p b .001, respectively) withABS score. These indicate that belief in the disease modelstrengthens with level of spiritual thinking and with age.Providing private/for-profit treatment was positively associ-ated (β = .10, p b .01) with factor 1 score. Those whoprovide addiction treatment for-profit more strongly believe(M = 28.96, SD = 6.53) that addiction is a disease than thosewho provide public/not-for-profit treatment (M = 26.39, SD= 6.15). Being a member of a professional group of addictiontreatment providers was positively associated (β = .11, p b.01) with factor 1 score. Professional group members morestrongly believe (M = 29.61, SD = 6.09) that addiction is adisease than nonmembers (M = 26.27, SD = 6.17). Numberof years of experience as a treatment provider was positivelyassociated with factor 1 score (β = .13, p b .01), with diseasebeliefs strongest (M = 27.60, SD = 7.39) among those whohave provided addiction treatment for the longest (21+years). Finally, having had a personal problem withaddiction in the past was positively associated (β = .10,

Table 3Mean scores and standard deviations for the three factors of the ABS

Variable n Disease Choice Way of coping with life

SexMale 269 27.63 (6.72) 16.83 (3.63) 6.76 (1.47) ⁎⁎

Female 322 26.86 (6.07) 17.05 (3.45) 7.17 (1.49)CountryUnited Kingdom 372 24.97 (5.77) 17.96 (3.22) 7.40 (1.35)United States 219 31.02 (5.53) 15.24 (3.39) 6.28 (1.48)Profit statusPrivate/for-profit 188 28.97 (6.53) ⁎⁎ 15.85 (3.46) ⁎⁎ 6.55 (1.75) ⁎⁎⁎

Public/not-for-profit 403 26.39 (6.15) 17.47 (3.45) 7.19 (1.31)United States × Profit StatusPrivate/for-profit 70 33.96 (4.54) 13.13 (2.55) 5.41 (1.35)Public/not-for-profit 149 29.64 (5.43) 16.23 (3.28) 6.68 (1.36)United Kingdom × Profit StatusPrivate/for-profit 118 26.02 (5.68) 17.46 (2.88) 7.22 (1.62)Public/not-for-profit 254 24.49 (5.75) 18.19 (3.35) 7.48 (1.20)Years treating addiction problems0–1 41 27.15 (6.35) ⁎⁎ 16.83 (3.60) 7.17 (1.58)2–5 152 27.32 (6.35) 17.17 (3.76) 7.21 (1.56)6–10 154 27.19 (6.34) 17.64 (3.11) 7.12 (1.34)11–15 95 27.20 (5.83) 16.29 (3.09) 6.81 (1.45)16–20 64 27.42 (6.25) 16.39 (3.44) 6.53 (1.74)21+ 83 27.60 (7.39) 16.47 (4.14) 6.76 (1.32)Member of professional groupYes 173 29.61 (6.09) ⁎⁎ 15.70 (3.23) ⁎ 6.59 (1.49)No 409 26.27 (6.17) 17.46 (3.50) 7.16 (1.47)Past addiction problemYes 199 29.15 (6.39) 16.06 (3.79) 6.76 (1.63)No 392 26.27 (6.17) 17.40 (3.31) 7.09 (1.41)Attended treatment in the past a

Yes 135 29.69 (6.45) 15.70 (3.71) 6.70 (1.65)No 64 28.02 (6.17) 16.81 (3.87) 6.91 (1.59)Attended 12-step group in the past a

Yes 145 30.17 (6.29) 15.37 (3.69) 6.61 (1.68)No 54 26.41 (5.89) 17.93 (3.45) 7.17 (1.44)Attend 12-step group at present a

Yes 94 31.60 (5.57) 14.40 (3.44) 6.46 (1.75)No 105 26.96 (6.31) 17.54 (3.48) 7.04 (1.47)Years as member of 12-step group a

0 10 24.40 (4.86) 17.30 (3.13) 7.50 (1.08)0–1 63 25.70 (5.91) 18.40 (3.31) 7.21 (1.45)2–5 10 24.40 (6.93) 18.00 (3.89) 6.90 (2.18)6–10 17 30.88 (5.94) 14.88 (4.23) 7.12 (1.76)11–15 20 30.70 (5.55) 16.35 (3.94) 6.95 (1.54)16–20 23 32.13 (4.70) 14.39 (2.39) 6.48 (1.28)21–25 13 32.00 (5.40) 14.77 (2.20) 6.15 (1.68)25+ 42 32.83 (5.07) 13.38 (2.96) 6.00 (1.75)Abstinent at present a

Yes 145 29.90 (6.32) 15.61 (3.69) 6.69 (1.64)No 53 23.78 (3.74) 19.39 (2.81) 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.

157C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

p b .05) with factor 1 score. Those who have had a personaladdiction problem more strongly believe (M = 29.15, SD =6.39) that addiction is a disease than those who have not hadan addiction problem (M = 26.23, SD = 6.16).

Step 2 in the model accounted for a significant increaseof 8.0% explained variance in factor 1 scores, Fchange(1,

564) = 68.55, p b .001. After partialing out varianceexplained by variables in step 1, providing addictiontreatment in the United States was positively associated (β= .32, p b .001) with factor 1 score. Providers of addictiontreatment in the United States more strongly believe (M =31.02, SD = 5.53) in the disease model of addiction than

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

Step Predictor

Disease Choice Way of coping with life

Step 1 β Step 2 β Step 3 β Step 1 β Step 2 β Step 3 β Step 1 β Step 2 β Step 3 β

1 Sex −.03 .02 .01 .00 −.04 −.03 .12 ⁎⁎ .07 .08 ⁎

Age .15 ⁎⁎ .14 ⁎⁎ .13 ⁎⁎ −.10 ⁎ −.08 −.08 −.12 ⁎ −.10 ⁎ −.10 ⁎Years treating addiction problems a −.13 ⁎⁎ −.13 ⁎⁎ .14 ⁎⁎ .02 .01 .02 −.02 −.02 −.02Certified .00 −.02 −.03 −.01 .01 .02 −.04 −.01 .00Professional group membership .11 ⁎⁎ .06 .05 −.11 ⁎ −.06 −.05 −.05 .00 .02Past addiction problem .09 ⁎ .08 .07 −.06 −.06 −.06 .03 .02 .03Profit status .10 ⁎⁎ .13 ⁎⁎⁎ .08 ⁎ −.14 ⁎⁎ −.17 ⁎⁎⁎ −.08 −.16 ⁎⁎⁎ −.19 ⁎⁎⁎ −.09SBS .40 ⁎⁎⁎ .28 ⁎⁎⁎ 027 ⁎⁎⁎ −.24 ⁎⁎⁎ −.13 ⁎⁎ −.12 ⁎⁎ −.14 ⁎⁎⁎ −.03 −.01

Disease: F(8, 565) = 26.47, p b .001, R2 = .273Choice: F(8, 565) = 12.89, p b .001, R2 = .154Way of coping with life: F(8, 565) = 9.45, p b .001, R2 = .118

2 Country – .32 ⁎⁎⁎ .28 ⁎⁎⁎ – −.30 ⁎⁎⁎ −.22 ⁎⁎⁎ – −.33 ⁎⁎⁎ −.24 ⁎⁎⁎Disease: Fchange(1, 564) = 68.55, p b .001, R2change = .080Choice: Fchange(1, 564) = 48.71, p b .001, R2change = .067Way of coping with life: Fchange(1, 564) = 57.80, p b .001, R2change = .082

3 Country × Profit Status – – .10 – – −.18 ⁎⁎⁎ – – −.21 ⁎⁎⁎Disease: Fchange(1, 563) = 3.84, p = .051, R2change = .004Choice: Fchange(1, 563) = 10.80, p b .001, R2change = .015Way of coping with life: Fchange(1, 563) = 14.40, p b .001, R2change = .020a Ordinal scale variable.⁎ p b .05.⁎⁎ p b .01.⁎⁎⁎ p b .001.

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

those who provide addiction treatment in the UnitedKingdom (M = 24.97, SD = 5.77).

Step 3 in the model yielded a nonsignificant increase of0.4% explained variance, Fchange(1, 563) = 3.84, p N .05.Therefore, the country of treatment did not moderate theeffect of profit status on treatment providers' beliefs thataddiction 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% ofvariance in treatment providers' beliefs that addiction is amotivated choice. Step 1 produced a significant model, F(8,565) = 12.89, p b .001, and accounted for 15.4% ofvariance in factor 2 score. Four of the eight variables madesignificant contributions.

In complete contrast to factor 1 scores, score on the SBSand 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 weakenas strength of spiritual thinking increases and with age.Providing private/for-profit treatment was negatively asso-ciated (β = −.14, p b .01) with factor 2 score. Those whoprovide public/not-for-profit addiction treatment morestrongly believe (M = 17.47, SD = 3.45) that addiction is achoice than those who provide private/for-profit treatment(M = 15.70, SD = 3.46). Being a member of a professionalgroup of addiction treatment providers was negativelyassociated (β = −.11, p b .01) with factor 2 score. Treatment

providers whom are not members of a group of addictionprofessionals 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 increaseof 6.7% explained variance in factor 2 score, Fchange(1, 564)= 48.71, p b .001. After partialing out variance explainedby variables in step 1, providing addiction treatment in theUnited States was negatively associated (β = −.30, p b.001) with factor 2 score. Providers of addiction treatmentin the United Kingdom more strongly believe (M = 17.96,SD = 3.22) that addiction is a choice than those whoprovide 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 effectsanalyses were conducted (i.e., repeating the analysis withneither the Country × Profit Status interaction term nor maineffects 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 betweenprofit status and factor 2 score among U.S.-based treatmentproviders (β = −.40, p b .001) after controlling for sevenvariables entered at step 1, Fchange(1, 207) = 31.42, p b .001,R2

change = .117. No significant association was foundbetween profit status and factor 2 score among U.K.-basedproviders (see Table 5). This indicates that country oftreatment moderates the relationship between profit statusand treatment providers' beliefs that addiction is a choice,

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

Step Predictor

Choice Way of coping with life

Step 1 β Step 2 β Step 1 β Step 2 β

1 Sex −.02 (−.08) .04 (−.08) .05 (.06) .11 (.07)Age −.19 ⁎ (−.05) −.10 (−.05) −.10 (−.18 ⁎⁎) −.01 (−.18 ⁎⁎)Years treating addiction problems a .13 (.08) −.12 (.08) −.10 (.03) −.10 (.03)Certified .06 (−.03) .09 (−.03) .10 (−.06) .13 (−.06)Professional group membership .00 (−.14 ⁎) .07 (−.13 ⁎) −.08 (.00) −.01 (.01)Past addiction problem −.09 (−.08) −.07 (−.07) .03 (.01) .05 (.02)SBS −.15 ⁎ (−.16 ⁎⁎) −.05 (.16 ⁎⁎) −.23 ⁎⁎⁎ (.07) −.12 (.07)

Choice, U.S.-based: F(7, 208) = 3.74, p b .001, R2 = .082Choice, U.K.-based: F(7, 350) = 4.07, p b .001, R2 = .075Way of coping with life, U.S.-based: F(7, 208) = 2.84, p b .01, R2 = .088Way of coping with life, U.K.-based: F(7, 350) = 2.32, p b .05, R2 = .044

2 Profit status – −.40 ⁎⁎⁎ (−.07) −.41 ⁎⁎⁎ (−.09)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 = .005Way of coping with life, U.S.-based: F(1, 207) = 32.56, p b .001, R2 = .124Way of coping with life, U.K.-based: F(1, 349) = 2.92, p N .05, R2 = .008

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

159C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

with only U.S.-based providers of public/not-for-profittreatment 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% ofvariance in treatment providers' beliefs that addiction is away of coping with life. Step 1 produced a significant model,F(8, 565) = 9.45, p b .001, and accounted for 11.8% ofvariance in factor 3 score. Four of the eight variables madesignificant contributions.

Score on the SBS and age were again both negativelyassociated (β = −.14, p b .001, and β = −.12, p b .05,respectively) with factor 3 score. These indicate that beliefsthat addiction is a way of coping with life weaken as strengthof spiritual thinking increases and with age. Providingprivate/for-profit treatment was negatively associated (β =−.16, p b .001) with factor 3 score. Those who providepublic/not-for-profit addiction treatment more stronglybelieve (M = 7.19, SD = 1.49) that addiction is a way ofcoping with life than those who provide private/for-profittreatment (M = 6.55, SD = 1.75). Being female was positivelyassociated (β = .12, p b .01) with factor 3 score. Femaletreatment providers more strongly believe (M = 7.17, SD =1.49) that addiction is a way of coping with life than maletreatment providers (M = 6.76, SD = 1.47).

Step 2 in the model accounted for a significant increase of8.2% explained variance in factor 2 scores, Fchange(1, 564) =57.80, p b .001. After partialing out variance explained byvariables 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 theUnited Kingdommore strongly believe (M = 7.40, SD = 1.35)that addiction is a choice than those who provide addictiontreatment 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 effectsanalyses were again conducted, first for U.S.-based sample(n = 219) and then the U.K.-based sample (n = 372). Thisrevealed a significant positive association between profitstatus 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, R2

change = .124. Again, nosignificant association was found between profit status andfactor 3 score in the U.K. sample. This indicates that countryof treatment moderates the relationship between profit statusand treatment providers' beliefs in the disease model, withonly U.S.-based treatment providers reporting significantlystronger beliefs (M = 6.68, SD = 1.36) than private/for-profitproviders (M = 5.41, SD = 1.35) that addiction is a way ofcoping with life.

3.7. Hierarchical multiple regression models applied todata provided only by treatment providers who havehad a past addiction problem

Three separate hierarchical multiple linear regressionanalyses were then conducted to investigate the variance inaddiction beliefs of treatment providers who have had a pastaddiction problem (n = 199) explained by five personaladdiction history variables. Three ABS factor scores wereagain used as criterion variables. To control for their effects,

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

sex, age, number of years as an addiction treatment provider,certification status as an addiction treatment provider,membership status of a group of addiction treatmentprofessionals, country of treatment, profit status of treatment,and SBS score were all entered at step 1. A further fivevariables were entered at step 2 of the equation: attendedtreatment 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 in12-step–based group, and abstinence status at present (0 =not abstinent, 1 = abstinent). Power analysis confirmed thatwith a sample of 199, α = .05, and with 13 predictorvariables, power = .89, meaning this regression model wassufficiently powered to detect meaningful factor effects.

3.8. Variables explaining variance in “addiction is a disease”beliefs of treatment providers who have had a pastaddiction problem

Controlling for the effects of the eight variables enteredat step 1, step 2 in the model accounted for a significantincrease of 12.2% explained variance in factor 1 scores,Fchange(5, 179) = 7.48, p b .001 (see Table 6). Two of thefive variables made significant contributions. Number ofyears as a member of a 12-step group was positivelyassociated (β = .24, p b .001) with factor 1 score. Thelonger treatment providers are members of a 12-step–basedgroup, the more strongly they come to believe addiction is adisease. Being abstinent at present was also positivelyassociated (β = .16, p b .05) with factor 1 score. Treatment

Table 6Separate hierarchical multiple linear regression analysis using scores on three factorby treatment providers who reported having had a personal problem with addictio

Step Predictor

Disease

Step 1 β S

1 Sex .00Age .12Years treating addiction problems a −.07 −Certified −.07 −Professional group membership .09Country .19⁎⁎Profit status .08SBS .48 ⁎⁎⁎ 3

Disease: F(8, 184) = 15.54, p b .001, R2 = .403Choice: F(8, 184) = 7.57, p b .001, R2 = .248Way 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 = .122Choice: Fchange(5, 179) = 6.13, p b .001, R2change = .110Way 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.

providers who have had a personal addiction problem andare presently abstinent more strongly believe (M = 29.90,SD = 6.32) that addiction is a disease than those who arenot 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 pastaddiction problem

Controlling for the effects of the eight variables entered atstep 1, step 2 in the model accounted for a significant increaseof 5.3% explained variance in factor 1 scores, Fchange(5, 179)= 6.13, p b .001. Only one variable made a significantcontribution. Number of years as a member of a 12-stepgroup was negatively associated (β = .26, p b .001) withfactor 2 score. The longer treatment providers are membersof a 12-step–based group, the less they come to viewaddiction as a choice.

3.10. Variables explaining variance in “addiction is a wayof coping with life” beliefs of treatment providers who havehad a past addiction problem

Controlling for the effects of the eight variables enteredat step 1, step 2 in the model accounted for a nonsignificantincrease of 1.8% explained variance in factor 3 scores,Fchange(5, 179) = 0.64, p N .05. Thus, treatment providerswho have had a personal addiction problem in the past didnot significantly vary in their beliefs about addiction as away of coping with life across the step 2 variables.

s extracted from the ABS as criterion variables: Conducted on data providedn in the past (n = 199)

Choice Way of coping with life

tep 2 β Step 1 β Step 2 β Step 1 β Step 2 β

.00 −.07 −.08 .09 .08

.10 −.11 −.07 −.08 −.07

.10 .07 .09 .02 .04

.07 .06 .07 .01 .01

.06 −.12 −.07 −.06 −.05

.14 −.24⁎⁎ −.17 ⁎ −.34 ⁎⁎⁎ −.31 ⁎⁎⁎

.06 −.08 −.06 −.19 ⁎⁎ −.18 ⁎⁎9 ⁎⁎⁎ −.26 ⁎⁎ −.12 .02 .06

.00 – −.03 – −.03

.12 – .06 – .06

.08 – −.14 – .00

.24 ⁎⁎ – −.26 ⁎ – −.14

.16 ⁎ – −.12 – −.04

161C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

4. Discussion

4.1. Key findings

Addiction treatment providers in the United States andUnited Kingdom were surveyed on their beliefs about theetiology of addiction, the need to receive treatment, and theaddicted individuals' capacity for self-control during druguse. Seven variables were significant in explaining variancein addiction beliefs. After controlling for the varianceaccounted for by eight variables, treatment providers'strength of beliefs in the disease model of addiction wassignificantly predicted by the country in which treatment isprovided. Those who provide addiction treatment in theUnited States more strongly believe that addiction is adisease than those who provide addiction treatment in theUnited Kingdom, whereas U.K.-based treatment providersmore strongly believe that addiction is a choice than U.S.-based treatment providers. Those more likely to believe thataddiction is a disease also tend to provide for-profittreatment, have stronger spiritual beliefs, have had a personalproblem with addiction in the past, are members of a groupof addiction professionals, have been treating addictionproblems for longer, and are older. In contrast, those whobelieve addiction is a choice tend to provide public/not-for-profit 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 theeffect of treatment profit status on providers' beliefs aboutaddiction as a choice and as a way of coping with life, withthose providing public/not-for-profit treatment in the UnitedStates more strongly believing that that addiction is a choiceand a way of coping with life than U.S.-based providers ofprivate/for-profit treatment.

Finally, treatment providers who have had a personalproblem with addiction in the past are more likely to believeaddiction is a disease if they have attended a 12-step groupfor longer and are presently abstinent. Beliefs that addictionis a choice weaken among these treatment providers thelonger they remain members of a 12-step–based group.Overall, results suggest treatment providers' beliefs aboutwhat addiction is largely fit a disease–choice modeldichotomy, that agreement with one model predictsdisagreement with the other, and that addiction etiologyand course are understood very differently by U.S. and U.K.treatment communities.

4.2. Conflicting beliefs in the United States versus theUnited Kingdom about “what addiction is”

The assumed global dominance of the disease model ofaddiction was not found; rather, the concept of addictionmeant very different things to the sampled U.K. and U.S.treatment communities. The relative strength of the UnitedKingdom's choice model endorsement is very surprisinggiven the unequivocal rejection of the idea that addicted

individuals are able to control themselves by influentialnational 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 actionregardless of the will of the individual. Thus, it appearsthat those working at the frontline of U.K. addictiontreatment view and, therefore, likely explain addiction totheir clients in ways that contradict the disease-baseddefinitions and media messages of authoritative healthbodies. However, we have no evidence that treatmentproviders treat clients in line with their beliefs when theirbeliefs 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 diseasemodel, however, was expected. Relative to U.K. treatmentproviders, U.S. treatment providers both endorsed the viewof addiction as a disease and rejected the view of addiction asa choice and as a way of coping with life. Disease modelbeliefs appear to have persisted as the dominant view ofaddiction in the United States since Schaler's (1992) initialuse of the ABS, although three methodological issuessuggest caution when comparing these studies. First,although assumed by Schaler to be very high, Schaler doesnot report the U.S.-based proportion of his sample; second,Schaler's methodology involved mailing and requesting thereturn of paper copies of his survey, whereas the currentsample were recruited and provided data online; third, thecurrent study did not use a repeated-measures design; it ishighly unlikely that any treatment providers provided datafor both our study and Schaler's study, and tracking downSchaler's sample was impossible. Thus, we can onlytentatively conclude that the disease model has prevailedas 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 anyconclusions about whether the addiction beliefs of our U.K.sample reflect a snapshot in an increasing, stable, ordecreasing trend of disease model support. Current findingsprovide a context for assessing the stability of disease modelsupport over time, perhaps with developments and markedchanges to scientific and political perspectives on addictionand a context for assessing addiction beliefs internationally.

One explanation for the discrepancy in belief systemsbetween the United States and United Kingdom may lay inthe sizeable difference between these country's publicfunding of addiction research. In a recent national report,Colin Blakemore, then head of the United Kingdom'sMedical Research Council (MRC) reported that, “In 2003 to2004 [the MRC] spent £2 million in total out of a £450million budget on addiction research. The total budget of thethree NIH [U.S. National Institutes of Health] institutes thatwork in this area is $2.9 billion so even if one takes aconservative estimate of how much of that is actuallydevoted to addiction research it comes out to about five

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

hundred times higher than in the UK—in other words abouta hundred times more per head of the population” (TheScience and Technology Committee, 2006). In the samereport, former chair of the Advisory Council on the Misuseof Drugs Technical Committee, Professor David Nutt,estimated the expenditure differential to be 1,000-fold infavor of the United States. Future research should askwhether there exists a significant association between thisresearch expenditure differential, a differential in breadths ofevidence bases regarding addiction etiology and treatmenteffectiveness, and the differential in disease beliefs aboutaddiction reported by the current U.S. and U.K. samples oftreatment providers.

4.3. Methodological limitations

The e-survey methodology was inexpensive and allowedfaster and wider access to and response from our sample thancould have been achieved by mailing paper versions of asurvey or conducting face-to-face/telephone interviews. Themanual demands of generating a sample of 591 treatmentproviders in such ways would have been impractical for thisstudy, although we do acknowledge that e-surveys mayinduce a sampling bias, and so caution is suggested ingeneralizing results to the wider U.S. and U.K. treatmentcommunities. For example, results may not accuratelydescribe the beliefs of treatment providers who declined toparticipate, had difficulty in navigating the online format andso did not complete the survey (and so, were excluded fromanalyses), and those for whom electronic contact details wereunavailable/unknown and so could not be invited toparticipate. Researchers who wish to make comparisonsinvolving current findings should also appreciate that thedynamics of completing e-surveys versus paper-and-pencilsurveys may be different.

The larger sample of U.K.-versus-U.S.-based providersmay be partially attributed to the researchers' greaterknowledge of and access to U.K. treatment services.Although the U.K. sample was boosted by enlisting thehelp of U.K. DAATs to distribute survey packs, we madeevery effort to offset this imbalance through an exhaustiverecruitment of U.S.-based treatment providers throughvoluntary, statutory, and private association Web sites andonline databases. Additionally, approximately 1,750 (70%)of the 2,500 subscribers of targeted e-newsletters arebelieved to be based in the United States. Nonetheless,recruitment would have benefited from collaboration withresearchers experienced in accessing U.S. treatment services.

4.4. Implications of treatment providers' ambivalent andstrong beliefs about addiction

Irrespective of either model's validity, current findingsindicate a potential for a diversity of addiction beliefs to existwithin treatment services, which has implications for howeffectively treatment providers work with each other andwith

clients. People often enter addiction treatment because theyseek definitive answers as to why they find self-control ofdrug use so elusive and to know what is “wrong” with them.Ambivalence on the etiology of addiction reported by somegroups of treatment providers and the stronger committal ofthe U.S. and U.K. treatment communities to the disease andchoice models, respectively, may, therefore, facilitate andobstruct clients' change process in different ways.

On one side, treatment providers with strong beliefs ineither model are more likely to send a clear and unambiguousmessage to clients about what addiction is and what it is not.Defining the problem and giving clients clear direction as towhat they should do and expect in the short and long termshould enhance clients' perceived self-efficacy and optimismfor change. In contrast, providers who reserve judgment orshow ambivalence as to what causes addiction (whichimplies endorsement of an eclectic treatment approach) maysend mixed messages to clients about the nature of theirproblems and how best to deal with them. Thus, it may beargued from a pragmatic standpoint that is it better fortreatment providers to convey a definitive perspective ofaddiction to their clients, whichever that perspective may be.

On the other side, treatment providers who are stronglycommitted to either model may be less flexible to changewhen their beliefs are challenged by scientific evidence orthe anecdotes of other therapists and clients. In this way,noncommitted providers should be more open to weighingup contrasting empirical and anecdotal evidence andadapting treatment to reflect current thinking on addiction.The strongly disease- and choice model-committed U.S. andU.K. treatment communities, however, may be less willingto revise their treatment philosophy in the face of evidencewhich suggests a revision should be considered. Among thestrongest disease beliefs in the current sample were reportedby treatment providers who have had a personal addictionproblem in the past but are abstinent at present; these groupsof treatment provider may be most likely to stick with thetreatment methods that have worked for clients andthemselves in the past, regardless of client differences insymptomatology, environments, and reasons for drug use.

Finally, a common criticism of the disease–choice debateis that absolute truths about addiction are irrelevant so longas people do “recover.” The success of treatment maytherefore depend on the degree of congruence betweentreatment providers' and clients' beliefs about addiction(Keene & Raynor, 1993). Assuming that disease-basedmessages will be less effective if clients ultimately believethat they are not diseased (and likewise for choice-basedmessages), the ABS may be used to match therapists andclients on belief compatibility at intake. If the success ofaddiction treatments is shown to depend on therapistsfostering clients' clear and uncompromised addiction beliefsof whatever kind, then we may be justified in abandoning thesearch for absolute truths about addiction and insteadfocusing on the importance of subjective experiences andlay conceptualizations of addiction to the change process.

163C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150–164

Acknowledgments

The authors are grateful to all participants who gave uptheir valuable time to help with this research and to RowdyYates, Douglas Cameron, Moira Plant, Martin Plant, StantonPeele, Ted Russell, Gemma McGill and three anonymousreviewers for their suggestions at various stages. Dedicatedto Martin Plant.

References

Alcoholics Anonymous World Services. (1939). Alcoholics Anonymous.New York: Author.

Alexander, B. K., Hadaway, P. F., & Coambs, R. B. (1980). Rat Parkchronicle. British Columbia Medical Journal, 22, 54−56.

American Psychiatric Association. (2000). Diagnostic and statisticalmanual of mental disorders, (4th ed.). Washington, DC: Author.

Benowitz, N. L. (2008). Clinical pharmacology of nicotine: Implications forunderstanding, preventing, and treating tobacco addiction. ClinicalPharmacology and Therapeutics, 83, 531−541.

Cohen, J. (1988). Statistical power analysis for the behavioural sciences.Hillsdale, NJ: Lawrence Erlbaum Associates.

Cohen, M., Liebson, I. A., Faillace, L. A., & Allen, R. P. (1971). Moderatedrinking by alcoholics: A schedule-dependent phenomenon. Journal ofNervous and Mental Disease, 153, 434−444.

Crothers, T. D. (1893). The disease of inebriety from alcohol, opium andother narcotic drugs. New York: E. B. Treat.

Davies, J. B. (1997). Pharmacology versus social process. Competing orcomplimentary views on the nature of addiction. Pharmacology &Therapeutics, 80, 265−275.

Fingarette, H. (1988a). Alcoholism—The mythical disease. Public Interest,91, 3−22.

Fingarette, H. (1988b). Heavy drinking: The myth of alcoholism as adisease. Berkeley: University of California Press.

Foulds, J., & Ghodse, A. H. (1995). The role of nicotine in tobacco smoking:Implications for tobacco control policy. Journal of the Royal Society ofHealth, 115, 225−230.

HBO Documentary Films. (2007). Addiction: Why can't they just stop?Retrieved April 1, 2010, from http://www.hbo.com/addiction/thefilm/.

Heather, N., & Robertson, I. (1989). Controlled drinking. London: Methuen.Heyman, G. (2009). Addiction: A disorder of choice. Cambridge, MA:

Harvard University Press.Institute of Medicine. (1996). Dispelling the myths about addiction:

Strategies to increase understanding and strengthen research. Commit-tee to Identify Strategies to Raise the Profile of Substance Abuse andAlcoholism research. Division of Neuroscience and Behavioral Healthand Division of Health Promotion and Disease Prevention, Institute ofMedicine. Washington, DC: National Academy Press.

Jellinek, E. M. (1960). The disease concept of alcoholism. New Brunswick,NJ: Hillhouse.

Kalivas, P. W., & Volkow, N. D. (2005). The neural basis of Addiction: Apathology of motivation and choice. American Journal of Psychiatry,162, 1403−1413.

Keene, J., & Raynor, P. (1993). Addiction as ‘soul sickness’: The influence ofclient and therapist beliefs. Addiction Research and Theory, 1, 77−87.

Kerr, N. (1888). Inebriety. London: H. K. Lewis.Ketcham, K., Asbury, W., Schulstad, M., & Ciaramicoli, A. (2000). Beyond

the influence: Understanding and defeating alcoholism. New York:Bantam Books.

Koob, G. F., & Nestler, E. J. (1997). The neurobiology of drug addiction.Journal of Neuropsychiatry and Clinical Neuroscience, 9, 482−497.

Koski-Jannes, A. (2004). In search of a comprehensive model of addiction.In P. Rosenqvist, J. Blomqvist, A. Koski-Jannes, & L. Ojesjo (Eds.),Addiction and life course (pp. 49−70). Helsinki: NAD.

Kurtz, E. (1988). AA: The story (a revised edition of Not-God: A History ofAlcoholics Anonymous). New York: Harper & Row.

Kurtz, E. (2002). Alcoholics Anonymous and the disease concept ofalcoholism. Alcoholism Treatment Quarterly, 20, 5−39.

Leshner, A. I. (1997). Addiction is a brain disease, and it matters. Science,278, 45−47.

Levine, H. (1978). The discovery of addiction: Changing conceptions ofhabitual drunkenness in America. Journal of Studies on Alcohol, 39,143−174.

Lyvers, M. (1998). Drug addiction as a physical disease: The role of physicaldependence and other chronic drug-induced neurophysiological changesin compulsive drug self-administration. Experimental and ClinicalPsychopharmacology, 6, 107−125.

Maltzman, I. (1994). Why alcoholism is a disease. Journal of PsychoactiveDrugs, 26, 13−31.

McMurran, M. (1994). The psychology of addiction. London: Taylor &Francis.

Mercadante, L. (1996). Victims and sinners: Spiritual roots of addiction andrecovery. Louisville, KY: Westminster John Knox Press.

Merry, J. (1966). The ‘loss of control’ myth. Lancet, 1, 1257−1258.Milam, J., & Ketcham, K. (1983). Under the influence: A guide to the myths

and realities of alcoholism. New York: Bantam Books.Miller, W. R. (1993). Alcoholism: Toward a better disease model.

Psychology of Addictive Behaviors, 7, 129−136.Morse, R. M., & Flavin, D. K. (1992). The definition of alcoholism. Journal

of the American Medical Association, 268, 1012−1014.National Health Service. (2010). NHS choices, your choices, your life.

Addictions. Retrieved January 3, 2010, from http://www.nhs.uk/conditions/Addictions/Pages/Introduction.aspx.

National Institute on Drug Abuse. (2009). NIDA InfoFacts: Understandingdrug abuse and addiction. Retrieved October 10, 2009, from http://www.nida.nih.gov/PDF/InfoFacts/Understanding08.pdf.

Nature Neuroscience (multiple authors). (2005). Focus on neurobiology ofaddiction. [Special issue] Nature Neuroscience, 8, 1105−1489.Retrieved April 1, 2010, from http://www.nature.com/neuro/focus/addiction/index.html.

Ochoa, E. L. M. (1994). Nicotine-related brain disorders: The neurobiolog-ical basis of nicotine dependence.Cellular andMolecular Neurobiology,14, 195−225.

Parrish, J. (1883). Alcoholic inebriety: From a medical standpoint.Philadelphia: P. Blakiston.

Peele, S. (1989). The diseasing of America. Lexington, MA: LexingtonBooks.

Peele, S., Brodsky, A., & Arnold, M. (1991). The truth about addiction andrecovery: The life process program for outgrowing destructive habits.New York: Simon & Schuster.

Playfair, W. (1991). The useful lie. Wheaton, IL: Crossway Books.Project MATCH Research Group. (1997). Matching alcoholism treatment to

client heterogeneity: Project MATCH post-treatment drinking outcomes.Journal of Studies on Alcohol, 58, 7−29.

Ragge, K. (1998). The real A.A.: Behind the myth of 12-step recovery.Tucson, AZ: Sharp Press.

Robins, L. N., Helzer, J. E., & Davis, D. H. (1975). Narcotic use in SoutheastAsia and afterward: An interview study of 898 Vietnam returnees.Archives of General Psychiatry, 32, 955−961.

Room, R. (1983). Sociological aspects of the disease concept ofalcoholism. In R. G. Smart, et al (Ed.), Research advances in alcohol,Vol. 7. (pp. 47−91) New York: Plenum Press.

Schaler J. (1992). Addiction beliefs of treatment providers: Factorsexplaining variance. Ann Arbor, MI: University of Michigan Disserta-tion Services, Order 9327490.

Schaler, J. (1995). The addiction belief scale. International Journal of theAddictions, 30, 117−134.

Schaler, J. (1996). Spiritual thinking in addiction treatment providers. TheSpiritual Belief Scale. Alcoholism Treatment Quarterly, 14, 7−33.

Schaler, J. A. (2000). Addiction is a choice. Chicago, IL: Open Court.

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

Szasz, T. (1972). Bad habits are not diseases: A refutation of the claim thatalcoholism is a disease. Lancet, 2, 83−84.

TIME Magazine. (2007). How we get addicted. Retrieved March 27, 2010,from http://www.time.com/time/magazine/article/0,9171,1640436,00.html.

The Science and Technology Committee. (2006). Select committee on scienceand technology fifth report. Retrieved April 1, 2010, from http://www.publications.parliament.uk/pa/cm200506/cmselect/cmsctech/1031/103102.htm.

UKATT. (2005). Cost effectiveness of treatment for alcohol problems:Findings of the randomized UK Alcohol Treatment Trial (UKATT).British Medical Journal, 331, 544−548.

Vaillant, G. (1990). We should retain the disease concept of alcoholism.Harvard Medical School Mental Health Newsletter, 6, 4−6.

White, W. L. (2000). Addiction as a disease: The birth of a concept.Retrieved March 26, 2010, from http://www.bhrm.org/papers/Counselor1.pdf.

White, W. L. (2001). A disease concept for the 21st century. RetrievedJanuary 3, 2010, from http://www.bhrm.org/papers/Counselor4.pdf.

White, W. L. (2007). In search of the neurobiology of addiction recovery:A brief commentary on science and stigma. Retrieved March 25,2010, from http://www.facesandvoicesofrecovery.org/pdf/White/White_neurobiology_2007.pdf.