More than 30 years ago, Dr. Howard Shaffer, then Director of the Division on Addiction, warned about “conceptual crises” in the field of addiction. In that paper, he noted that the field was characterized by many “mini-theories,” a “lack of integration between research, theory, and practice,” and a general lack of agreement on the key components of addiction. Though the field has made immense progress in the past three decades, it still struggles with the absence of a single integrated theory of addiction and the presence of multiple definitions and models.
But why does it matter? Why do we need to pay attention to the theories that guide our field? Can’t we just look at the data and draw conclusions based on what we see? Whether we know it or not, our theories influence the data we collect, the questions we ask, and the way we interpret what we find. Theories of addiction have treated addiction as a moral failing, a rational choice, a motivational disorder, and a disease, to name a few. Each of those theories has guided the questions we ask about addiction and the interventions we support. For example, punitive responses to addiction likely derive from a rational choice or moral failing theory, whereas rehabilitative responses are often tied to a disease model of addiction. Fortunately, through the scientific method, theories can be tested. And evidence can move us toward reframing, reconsidering, modifying, or jettisoning our theories. A theory, and the models and frameworks that inform that theory, can move us toward deeper understanding of the mechanisms and processes through which phenomena occur. Theories are necessary for understanding and explanation. And theories, when rigorously and transparently tested, can protect us from mistaking noise for signal. The key to that statement is “rigorously and transparently.” It is tempting to manipulate the data to fit our theory, and sometimes, it is easier to see what we expect to see than accept the unexpected and revise our theories accordingly. However, as our last special series addressed at length, we must be open to change, and applying the open science practices discussed in that series will allow for better and more accurate theories in the long-run.
In 2004, Dr. Shaffer and colleagues introduced the Syndrome Model of Addiction. While not a theory per se (see Dr. Shaffer’s editorial later this month about models vs. theories), that model rests on the theory that addiction depends not solely on the object of addiction, but a complex interaction between individual, environment and object, and that addiction is an underlying syndrome that can have multiple expressions linked to both ingested chemicals and activities. The model lays out specific risk factors, pathways, and sequelae that can be tested. During the 15 years since then, the field has further explored those complex interactions, the fundamental intertwined roles of individual experience and environmental influence, and the possibility that addiction might be conceptualized as one expression of an even broader syndrome.
This February, The BASIS focuses on these theories of addiction, highlighting several recent and integrative theories that have been proposed and tested. This week, The DRAM focuses on the application of social practice theory (i.e., the study of shared and routinized behavioral practices within groups) to our understanding of alcohol use patterns at a public health level. Next week, ASHES revisits the controversial gateway theory of substance use (i.e., the theory that the use of one more accessible and acceptable substance can lead, causally, to the use of other substances) as applied to e-cigarettes. Later, STASH discusses how accessibility to drugs, supervision, and school environment relate to substance use in adolescent students through the lens of routine activity theory. Finally, The WAGER closes the series by reviewing research that has evaluated and refined the Pathways Model of problem gambling (i.e., a model that describes three separate progressions to problem gambling) since it was originally proposed in 2002.
In addition to these articles, we feature three op-eds from experts at the forefront of developing and applying theories and models of addiction. Next week, Dr. Elda Chan, Director of St. John’s Cathedral Counseling Service and Fieldwork Supervisor at the University of Hong Kong, shares how the Integrated Centre on Addiction Prevention and Treatment integrated the syndrome model of addiction into all of their clinical practice. Later, Tanya Freedland, Clinical Trainer and Research Associate at University of Michigan’s Center for Practice Transformation, and Dr. Robert Krueger, the Hathaway Distinguished Professor of Clinical Psychology at the University of Michigan, discuss the application of an integrated empirical model of psychopathology to addiction. Finally, in the last week we feature an editorial by Drs. Howard Shaffer, Morris E. Chafetz Associate Professor of Psychiatry in the Field of Behavioral Sciences at Harvard Medical School; Robert Ladouceur, Professor Emeritus at Universite Laval; and Alex Blaszczynski, Professorial Research Fellow and Co-Director of the Gambling Treatment and Research Clinic at the University of Sydney that explores the differences between models and theories in their application to responsible gambling.
As always, we hope you enjoy and learn from these reviews and op-eds. We invite you to post your comments below.
— Sarah E. Nelson, Ph.D.
The Division on Addiction currently receives funding from The Foundation for Advancing Alcohol Responsibility (FAAR), The Healing Lodge of the Seven Nations via the Indian Health Service with funds approved by the National Institute of General Medical Sciences, National Institutes of Health; The Integrated Centre on Addiction Prevention and Treatment of the Tung Wah Group of Hospitals; the Gavin Foundation via the Substance Abuse and Mental Health Services Administration (SAMHSA); University of Nevada, Las Vegas via MGM Resorts International; and GVC Holdings, PLC.
During the past 5 years, I have served as a paid grant reviewer for the National Center for Responsible, Gaming (NCRG), GambleAware, Manitoba Responsible Gaming, Alberta Gambling Research Institute, and the National Institutes of Health (NIH). I have received speaker honoraria and travel support from the Responsible Gaming Association of New Mexico and I have received honoraria funds for preparation of a book chapter from Universite Laval.