ABSTRACT 
Title of Dissertation: ADDICTION BELIEFS OF TREATMENT 
PROVIDERS: FACTORS EXPLAINING 
VARIANC.E 
Jeffrey Alfred Sc:haler, Doctor of Philosophy, 1993 
Dissertation directed by: Robert W. Huebner, Ph.D., Associate Professor, 
Department of Human Development 
/Institute for Child Study 
This study investigated factors accounting for variance in beliefs 
among addiction-treatment providers regarding the etiology of addiction 
(N=295). A survey was mailed to members of three national treatment-
provider organizations. The 18-item Addiction Belief Scale (ABS) assessed 
strength of belief in the disease versus free-will model of addiction (a==.91). 
Seo.res on an eight-item Spiritual Belief Scale assessing spiritual thinking 
based on Alcoholics Anonymous (AA) philosophy (a=.92), the 
Multidimensional Health Locus of Control scales, and demographic 
questions were used to predict scores on the ABS. 
These variables together accounted for 62 percent of the variance in 
addiction beliefs, (p<.001). Spiritual thinking explained 42 percent of the 
variance, (p<.001). 
The findings support the idea that spiritual thinking, health locus-
of-control orientation, prof~~-s.ion_:!:!~~~ul:.a -;~fJ};1ation._~[der, and the 
n f?i 1!:"\  . ,. I ? ?"? I i< I , ' > ii ? I ii t ~~1 ' ~ :,. t" ? 1? . .?' J ? t?;:  J ~ ~ ~ ? ~ { ' :!. ~ i , l l ~ :1,\j r.,. ,, ~ ?. . :i '.,1  \ ? ?j 1_. ? "l, ?:..?.v \,::_i,i D14il Ii. I \_; ~:'1.:\/ _.I .....,. ..... ..1 
number of alcoholic drinks and/ or mood-altering drugs consumed, are 
each significant in their ability to explain variance in addiction beliefs. 
Treatment providers who believed in a metaphysical power that can 
influence personal experience, and those who attributed responsibility for 
their experience of health and illness to powerful others, believed in the 
disease model of addiction, as did females. Treatment providers not 
inclined to be spiritual thinkers, and not inclined to attribute responsibility 
for health and illness to powerful others, believed in the free-will model of 
addiction, as did males. The more drinks and/or drugs consumed per 
week, the more likely the treatment provider believed in the free-will 
model of addiction. The less drinks/ drugs consumed, the stronger the 
belief in the disease model. 
Addiction beliefs also varied significantly by religious affiliation. 
Catholics were more likely to believe in the disease model of addiction, 
followed by Protestants and then Jews. Atheists believed more strongly in 
the free-will model, followed by agnostics. 
Factor analysis of the ABS showed that beliefs regarding personal 
power, dichotomous-thinking, and beliefs regarding addiction as a way of 
coping with life are core issues in what has come to be known as "the 
disease-model controversy." 
Implications for clinical and public policy are discussed. 
ADDICTION BELIEFS OF TREATMENT PROVIDERS: 
FACTORS EXPLAINING VARIANC E 
by 
Jeffrey Alfred Schaler 
Dissertation submitted to the Faculty of the Graduate School 
of The University of Maryland in partial fulfillment 
of the requirements for the degree of 
Doctor of Philosophy 
1993 
C. I 
tvl!) 
DG ' l /j;; ,~ v11'.t 1, 
Advisory Committee: 
Associate Professor Robert W. Huebner, Chairman/ Advisor 
Professor Robert H. L. Feldman 
Associate Professor Charles H. Flatter . I\J\t<1J. 
Ass.istant Professor Harry B. Green 
Associate Professor Emeritus Bonnie B. Tyler Sbla.,\i,A" 
:s i ~\ ? / 
? Copyright by 
Jeffrey Alfred Schaler 
1993 
ii 
PREFACE 
It is related of a peasant who came [barefooted] to the Capital, 
and had made so much money that he could buy himself a pair of 
shoes and stockings and still had enough left over to get drunk on-
it is related that as he was trying in his drunken state to find his way 
home he lay down in the middle of the highway and fell asleep. 
Then along came a wagon, and the driver shouted to him to move 
or he would run over his legs. Then the drunken peasant awoke, 
looked at his legs, and since by reason of the shoes and stockings he 
didn't recognize them, he said to the driver, 'Drive on, they are not 
my legs.' 
- Soren Kierkegaard 
in The sickness unto death 1 
Doublethink means the power of holding two contradictory 
beliefs in one's mind simultaneously, and accepting both of 
them .... These contradictions are not accidental, nor do they result 
from ordinary hypocrisy: they are deliberate exercises in 
doublethink. For it is only by reconciling contradictions that power 
can be retained indefinitely ... .lf human equality is to be forever 
averted- if the High, as we have called them, are to keep their 
places permanently-then the prevailing mental condition must be 
controlled insanity. 
-George Orwell 
in 19842 
iii 
DEDICATION 
To 
my daughter 
Magda Elise Schaler, 
my parents 
Sarah Elizabeth Schiltz and Otto-Gerhard Julius Schaler, 
and 
the memory of Joel M. Cantor 
iv 
ACKNOWLEDGMENTS 
Or. Robert W. Huebner patiently guided me through my dissertation 
and r,enewed my faith in the doctoral process. 
Drs. Bonnie B. Tyler, Robert H. L. Feldman, Harry B. Green, and 
Charles H. Flatter, my dissertation committee members, have ea,ch been 
very supportive during this project, as wen as throughout my graduate 
school experience in general. Their confid(ence in my work is appreciated. 
Or. iErnest Kurtz, at 1the University of Michigan, and Dr. Paul Antze, 
at York University in Toronto, gave generously of their ,time and expertise 
regarding Alcoholics Anonymous. The Spiritual Belief Scale would have 
been very difficult to create without their advice, criticism and invaluable 
suggestions. 
Dr. Stanton Peele helped m e a great deal wiith the Addiction Belief 
Sca[e. Always available by phone, his ,expertise :and sugg,estions were 
importanit in this cur.rent project, and others [ hav1e underta~en ,over the 
years. 
Dr. Kaye Middieton Fillmore, at the University of California-San 
Francisco, gave me important feedback on the Addiction Belief Scale. 
Dr. G. Alan Marlatt, at the University of Washington-Seattle, gave 
me suggestions regarding the populaition sample. 
Dr. Bruce K. Alexander, at Simon Fraser University, blazed an 
int,ellectua[ trail for me. His friendship and support has been important to 
me in my work generally. 
The following individl!lals and their respective organizations 
generously donated the mailing lists of their members: Dr. Daniel 
Kivlahan, Secretary-Treasurer of the Society for Psychologists in Addictive 
Behaviors; Jack and Lois Trimpey, founders and directors of Rational 
V 
Recovery Systems, Inc.; and Linda Kaplan, Executive Director, and Natalie. 
Fern, both of the. National Association of Alcoholism and Drug Abuse 
Counselors. 
I am grateful to the directors and staff of several addiction-treatment 
clinics in the Washington, D.C. metropolitan area for taking time out of 
their busy schedules to assist me with the pilot study for this project. Their 
criticism and suggestions were incorporated in the design of the final 
survey used. They include George Kolodner, M.D. and the staff of Kolmac 
Clinic, and Dr. Rosalind Goldfarb and the staff of Circle Treatment Clinic. 
I would also like to thank the 327 addiction-treatment providers 
who participated in this study. I especially appreciate the many comments 
they gave regarding the instrument and the issues raised by this study 
generally. 
Three mentors are especially important to me: Mr. Amos M. 
Gunsberg, a remarkable psychologist and "performance coach" in private 
practice in Manhattan - New York City; Dr. Herbert Fingarette, philosophy 
professor emeritus, University of California - Santa Barbara; and Thomas 
S. Szasz, M.D., psychiatry professor emeritus, S.U.N.Y. - Syracuse. I am 
fortunate to know these courageous individuals. 
I am also very grateful to Dr. William Groman, psychology professor 
emeritus, Virginia Commonwealth University, my first and greatest 
teacher of gestalt therapy, who got me on the path so many years ago, a 
path that eventually led to this doctoral degree. 
I would like to thank Dr. Sidney Fine in Milwaukee for the suppoFt, 
friendship and encouragement he has given me over the years. 
Dr. Isaiah Zimmerman gave me important support and intellectual 
challenge through many years of meaningful conversations. 
vi 
I would also like to thank many psychotherapy clients of mine from 
the past 20 years, my students at American University, and now those at 
Johns Hopkins University. I have presented many of my ideas to them. 
They have challenged me on more than one occasion. Our conversations 
and their excitement have influenced my thinking about psychology, 
human development, addiction and social policy. 
I am fortunate to have so many good friends, friends who listen to 
me, witness my adventures, and tell me the truth: Mr. Ernest H. Bradley, 
Dr. Paul Moore, III, Dr. James I. Kepner, Ellen Luff, Esq., Dr. Ron Aarons, 
Dr. John 0. Becker, and Mr. Sherman Basinger. 
A special thanks to Dr. Huntington Harris in Leesburg, Va., for the 
many years of friendship, encouragement to complete this project, and 
conversations on "the existential front." 
Finally, I thank my wife and colleague, Dr. Renee Royak-Schaler-a 
brilliant scholar and academician who has always encouraged me to 
complete this project- for comforting me when I get too disturbing, and 
disturbing me when I get too comfortable. 
Thank you all. 
Vll 
TABLE OF CONTENTS 
Section Page 
LIST OF TABLES ......................................................................................................... xiii 
CHAPTER I - INTRODUCTION .............................................................................. 1 
Purpose ................... ,. ........................................................................................ -11 ?????????? 4 
The Importance of Studying Beliefs of Addiction-Treatment 
Providers ........................................................................................................... 5 
Rationale for Independent Variables .......................................................... 9 
Spiritual-Thinking Variable ............................................................. 10 
Rationale ................................................................................... 10 
Characteristics of Spiritual Thinking in AA ..................... 11 
Evidence of Spiritual Thinking in AA ............................... 12 
Examples of the Four Characteristics of Spiritual 
Thinking in.  .AA. .............................................................................. 14 
Gratitude ....................................................................... 14 
Tolerance. ...................................................................... 15 
Humility. ....................................................................... 15 
Release ........................................................................... 15 
Implications of Spiritual Thinking for 
Explaining Beliefs About Addiction ................................... 16 
The Multidimensional Health Locus of Control Scales 
Variable ................................................................................................. 17 
Rationale ................................................................................... 17 
Relationship of the MHLC to the Concept of Self-
Efficacy .................................................................... ................... 19 
Implications. ............................................................................. 24 
Demographic Variables. ..................................................................... 25 
Vlll 
Rationale .......................................................................... ......... 25 
Age. ................................................................................. 25 
Gend,er ........................................................................... 26 
Race/Ethnicity. ............................................................. 26 
Marita l and Educatfonal Status ................................ 27 
Religim.11s Affiliation. ................., . ................................ 28 
Certificatilon, AA Statu s, Recovery Status,, 
AA, Experience .................................................. .......... . 29 
Abs.tinence Status and Number of 
Drinks/Drugs Ingested/Week .................................. 29 
Professional-Group AffiUa1tion ................................ 30 
Re?covery Beliefs .................................................................................. 31 
I~a tio:nale for Population ............................................................................... 31 
Conceptual Definitions ........... ,. .......................................... ,,. ........................ 33 
The Disease M'odeJ of Addiction ...................................................... 34 
The Free-WiH Model of Addiction ................................................. 34 
Spiritual Thinking ..................................................................... ......... 34 
Self-Efficacy ........................................................., . ................................. 34 
Addiction .............................................................................................. 35 
Drug Addict .......................................................................................... 35 
Recovery. ............................................................................................... 35 
D,isea.se and, Behavior ......................................................................... 36 
Hea]th, Locus of Control.. ................................................................... 37 
Attribution. ................................................... ........................................ 37 
Recapit.ulation of Research, Interest ........................................................... . 38 
CHAPTER H - REVIEW OF THE LITERATURE ........... .................................... ..... 40 
Three: Mode]s of Addiction Beliefs. ...................................................... .. ..... 40 
ix 
The Maturationist Paradigm ............................................................ 42 
The- Behaviorist Paradigm ................................................................ 46 
The Interactionist Paradigm ............................................................. 48 
Summary ...................................................................................................................... 51 
A Historical Trace of Beliefs Regarding the Etiology of 
Addiction .. ~ ...................................... ,. . ,., .................................................................................................................. 52 
Overview ................................................................. ,, ..................................................................... 53 
Colonial Period. ....................................................................... 54 
Benjamin Rush and. the Medicalization of 
Socially-Deviant Behavior .................................................... 55 
The Temperance Movement. ............................................... 58 
Prohibition, Repeal, and the Birth of Alcoholics 
Anonymous ............................................................................. 61 
Loss-of-Control Theory and the Disease Conce,pt 
of Alcoholism .......................................................................... 64 
Genetic Studies ........................................................................ 67 
Current Beliefs and Controversy ......................................... 73 
Evidence Against the Loss-of-Control Theory. ................. 75 
Leaming Theory Perspectives on Addiction. .................... 82 
Summary ................................................................................................................................. 104 
CHAPTER III - METHOD ........................................................................................... 107 
Procedure .......................................................................................................... 107 
Description of Scales Used in the Survey .................................................. 109 
The Addiction Belief Scale (ABS) .................................................... 110 
The Spiritual Belief Scale (SBS) ....................................................... 112 
The Multi-Dimensional Health Locus of Control Scales 
(MHLC) .................................................................................................. 116 
X 
Demographic Questions .................................................................... 119 
Addiction Recovery Without Treatment Beliefs. ........................ 122 
Comments ............................................................................................ 122 
Treatment-Provider Groups. ............................................................ 122 
Sample Characteristics ................................................................................... 123 
Statistical Procedwes ...................................................................................... 123 
CHAP'TER IV - RESULTS .......................................................................................... 126 
Results for the ABS. ............................................................................ 127 
Results for the SBS. ............................................................................. 127 
Results for the MHLC Scales ............................................................. 127 
Results for the IHLC Scale ..................................................... 127 
Results for the PHLC Scale .................................................... 127 
Results for the CHLC Scale .................................................... 127 
Recovery Beliefs Without Treatment.. .......................................... 128 
Findings Related to the Research Questions. ................................ 129 
Some Additional Fm.dings ............................................................................ 135 
Correlation Coefficients for Spiritual Beliefs (SBS) ..................... 135 
CHAPTER V - CONCLUSIONS, DISCUSSION, AND 
IMPLICATIONS ........................................................................................................... 137 
Recapitulation of the Research Interest.. ................................................... 137 
Summary of Method. ...................................................................................... 138 
Conclusions. ..................................................................................................... 139 
Spiritual Thinking and Addiction Beliefs ..................................... 139 
Health Locus of Control Orientation and Addiction 
Beliefs. ..................................? ? ................................................................ 140 
Demographic Characteristics and Addiction Beliefs ................... 140 
XI 
Professional-Group Affiliation and Addiction 
Beliefs. .............................................................................................. 142 
Gender and Addiction Beliefs .............................................. 142 
Frequency of Alcoholic Drinks and Mood-
Altering Drug Use/Week and Addiction Beliefs ............. 143 
Discussion ......... ,. ............................................... "" ........... ,. ................................. 143 
Discussion of the Findings in Light of the Research 
Questions .............................................................................................. 143 
Implications. ......................................................................................... 150 
Implications for Theory ......................................................... 150 
Implications for Practice ........................................................ 152 
Implications for Further Research ...................................... 154 
APPENDIX A - ABS Survey Instrument ............................................................... 156 
APPENDIX B - Letter Accompanying Survey Instrument. ................................ 163 
APPENDIX C - Reminder Postcard .......................................................................... 164 
APPENDIX D - Mean Scores for the Addiction Belief Scale .............................. 165 
APPENDIX E - Mean Scores for the Spiritual Belief Scale ................................. 167 
APPENDIX F - Mean Scores for the MHLC Scales .......................... - .................. 168 
APPENDIX G - Comments by Subjects (sic) ........................................................... 169 
Comments From Non-Addiction Treatment Providers ........................ 190 
APPENDIX H ? Correlation Coefficient Matrix ..................................................... 195 
APPENDIX I - Intercorrelation of Addiction Belief Scale Item (A) by 
Spiritual Belief Scale Item (S) Coefficients ............................................................ 197 
APPENDIX J ? Significant Group Compositions: Chi-Square 
Analysis of Expected vs Observed Frequencies. .................................................... 198 
APPENDIX K - Factor Analyses of the SBS and the ABS ................................... 199 
Results for the Factor Analyses of the SBS and the ABS. ....................... 199 
Xll 
Results for the Factor Analysis of the SBS ..................................... 199 
Results for the Factor Analysis of the ABS .............?.?.................... 199 
Discussion of the Factor Analyses of the SBS and the ABS ................... 204 
Discussion of Factor Analysis of the SBS ....................................... 204 
Discussion of Factor Analysis of the ABS ................................ ...... 206 
REF'ERENCES. .............................................................................................................. 216 
FC>OI'NOTES ................................................................................................................ 255 
XIIL 
LIST OF TABLES 
Number 
1. Addiction Models, Beliefs, and Attributions of Treatment 
Providers ......................................................................................................................................................................................... 19 
2. The Relationship Between Self-Efficacy Expectation, Locus of 
Control Orientation, and Outcome-Expectancy Attribution ............................. 23 
3. Distribution of the Addiction Belief Study Survey by Professional 
Groups., .............................................................................................................., . ............. ~ ................. 108 
4. The Addiction Belief Scale (ABS) ....................................................................... 111 
5. Reliabilities and Means for the ABS, SBS, and MHLC Scales ...................... 113 
6. The Spiritual Belief Scale (SBS) .......................................................................... 114 
7. The Multidimensional Health Locus of Control Scales (MHLC) ................ 118 
8. Demographic Characteristics of the Sample. .................................................... 120 
9. Sample Characteristics by Treatment-Provider Groups ................................ 124 
10. Factors Explaining Variation in Addiction Beliefs ....................................... 129 
11. Correlation Coefficients for Spiritual Beliefs (SBS) ...................................... 136 
12. Factor Analysis of Scores on the Spiritual Belief Scale: Varimax 
Rotation.. ..................................................................................................................................... t. ............... 200 
13. Factor Analysis of Scores on the Addiction Belief Scale: Varimax 
Rotation ......................................................... ............................. .. .... ....................................................................................... ,., 201 
1 
CHAPTER I 
INTRODUCTION 
I never saw a man so distressed as you were by my will; unless it 
were. .. at. .. my scientific heresies .... It can make no change. You do not 
understand my position. .. .! am painfully situated. ... [M)y position is a 
very strange-a very strange one. It is one of those affairs that 
cannot be mended by talking. ... [I]ndeed it isn't what you fancy; it is 
not as bad as that; and just to put your good heart at rest, I will tell 
you one thing: the moment I choose, I can be rid of Mr. Hyde. I give 
you my hand upon that; and I thank you again and again .... 3 
Thus wrote Robert Louis Stevenson in his classic novel Dr. Jekyll 
find Mr. Hyde. It is the story of a doctor, a scientist, transformed in 
character by a drug that he drank- a drug that created a metamorphosis, 
changing him from one person into another. 
Of course, Jekyll and Hyde were literally one person. Stevenson's 
story is a metaphor. Jekyll used the drug to create the illusion of two 
people, not only to himself, but also to those who knew him. The illusion 
was a belief. The drug was used to create a belief about self. Moreover, the 
self created a belief about the drug too. Jekyll believed the drug could 
transform him into another person-Hyde, a crass and violent persona. 
The Stevenson excerpt above appears to show that Jekyll knew he 
and Hyde were the same person. Jekyll chose to "become" Hyde. In so 
doing, he exercised his will to become Hyde. 
Stevenson's story is rich in symbolism. Perhaps few have attempted 
to interpret it as having anything to do with taking a drug to transform the 
2 
experience of self, (R. Roizen, personal communication, 1992). Surely 
Jekyll is not weak-willed regarding his addiction. Quite to the contra?ry, he 
seems "iron-willed" in the sense that he ingests his drug of choice to 
transform himself at any cost, or so it appears, (A. Gunsberg, personal 
communication, 1993). 
There are at least two points worth noting regarding this 
interpretation of Stevenson's novel: (a) Jekyll is describing a sense of 
control he believes he has. He chooses to transform himself into Hyde, 
through the use of a drug, as irrational as this may seem. (b) This is 
precisely the nature of a contemporary controversy regarding scientific and 
lay views on the role of willful control in addictive behavior today: Is drug 
use a choice or a disease? Stevenson's metaphor applies to conflicting 
perspectives on drug addiction and self-deception. The resemblance is 
uncanny. 
For example, while the physical-health risks of mood-altering drug 
use, i.e., what these drugs do to the physical body, are relatively well 
known, heated controversy currently exists within the alcohol/ drug 
research field concerning the relationship between cognitive, behavioral, 
and physiological processes and what motivates or governs addiction, (e.g., 
Szasz, 1989; Cooper et al., 1985; Fingarette, 1989, 1985a, 1985b; Glaser, 1985; 
Pomeroy, 1985; Room, 1985; Takamine, 1985; Keller, 1976; Vatz & 
Weinberg, 1989; Madsen, 1989, 1988, 1985; Madsen et al., 1990; Maltzman, 
1991; Peele, 1988a, 1992; Wallace, 1989a; Alexander, 1990a; Schaler, 1990a, 
1990b, 1989a, 1989c, 1988; Goodwin et al., 1988; etc.). Is drug addiction 
strictly a function of physiology, free will, a combination of the two, or 
simply "moral turpitude?" 
3 
The debate is commonly known as "the disease-model controversy." 
Those who subscribe to the idea that addiction is a disease independent of 
primarily volitional components are known as disease modelists. Those 
who subscribe to the opposite perspective, i.e, drug addiction is a choice, 
not a disease, are known as free-will modelists. 
Researchers from biomedical and psychosocial disciplines define two 
sides of this controversy, expressing concern that scientists tend to 
report their findings as a single body of explanation. One result of 
these ethnoscientific reports is that the competition for explanatory 
ascendancy. ..h as become so fierce between the two broad disciplinary 
approaches that it has often precluded genuine attempts to develop 
and test truly competing hypotheses by those representing either 
broad disciplinary approach or interdisciplinary development and 
testing of interactive hypotheses (e.g. interactions between biological 
factors and environmental factors). (Fillmore & Sigvardsson, 1988, 
p. 609) 
The disparity in scientific opinion regarding addiction, with its focus 
on beliefs regarding personal control, forms the basis for this inquiry into 
beliefs of addiction-treatment providers and factors that may explain 
variation in their beliefs regarding the etiology of drug addiction. 
This inquiry into the beliefs of addiction-treatment providers 
proceeds in the following way: The purpose of the study is presented, 
followed by a statement of the importance of studying beliefs of treatment 
providers. An explanation of the rationale for the independent variables 
and population selected follows, along with conceptual definitions of key 
terms used in the study. After a recapitulation of the research interest, a 
methods section explains how the study was conducted, including 
4 
operational definitions of the variables, and a discussion of statistical 
methods used for data analysis. Results and a discussion of findings 
follows. The appendix contains a sample of the instrument used to assess 
beliefs, additional descriptions of the sample studied, along with a 
compilation of comments made by the subjects regarding the study in 
general, and specific beliefs regarding addiction. 
Purpose 
The purpose of this study was to investigate factors that may account 
for variance in beliefs regarding the etiology of drug addiction among 
addiction-treatment providers, i.e., the extent to which they believe 
addiction is a disease, devoid of volitional components and dependent 
primarily on physiological factors; or strictly a behavioral phenomenon 
correlated with expectancy and other psychological and self environmental 
factors, in essence, a function of free will. 
The research question this inquiry sought to answer was this: What 
are some of the factors that explain beliefs among addiction treatment 
providers about the etiology of drug addiction? 
Most addiction treatment providers have had experience in 
Alcoholics Anonymous (AA) and related "12-step" programs, (Schaler, 
1991a). AA stresses the importance of a religious or spiritual-conversion 
experience as a way of controlling alcohol intake, in addition to advocating 
strong beliefs regarding locus-of-control orientation, (Alcoholics 
Anonymous World Services, 1976). Three sub-questions follow the main 
research question to further specify these factors: (a) Do spiritual beliefs of 
treatment providers explain variance in beliefs regarding the etiology of 
addiction among treatment providers? And, (b) does the health locus-of-
control orientation of treatment providers explain variation in beliefs 
5 
regarding the etiology of addiction? Additionally, the research interest 
includes (c) whether the following demographic characteristics of addiction 
treatment providers are able to account for variance in beliefs regarding 
addiction: Do their age, gender, race/ ethnicity, educational status, marital 
status, religious affiliation, certification-as-treatment-provider status, alco-
holic/ addict in recovery status, past and present experience in 12-step 
and/ or other treatment programs, plus length of time in these programs, 
as well as their current drinking or drug-taking status, i.e., whether they 
are abstinent or not, and their professional-group affiliation explain 
variation in beliefs regarding the etiology of addiction? 
The Importance of Studying Beliefs of Addiction-Treatment Providers 
In 1979, in response to being asked "what he would most like to 
know," Don Cahalan, an international leader in alcoholism research, 
wrote an opinion piece entitled "Why Does the Alcoholism Field Act Like 
a Ship of Fools?" In it he stated the following: 
Strange behaviors and contradictions of purpose abound .. .in the 
field of alcohol problems. In part this stems from the differences in 
conceptions of alcoholism, held by different people at the same time 
and by the same people at different times, whereby some consider it 
primarily a genetic or functionally-based disease, some consider it a 
bad habit of the individual, and some consider it the fault of the 
environment. These alternative definitions are invoked depending 
upon the type of alcoholic behaviour involved and the function of 
the belief. .. .! contend that unless we understand a great deal more 
about what makes organizations tick, we will have continuous strife 
and gross inefficiency in the getting and spending of public funds on 
the prevention and treatment of alcohol problems. (pps. 235-236) 
6 
By studying the beliefs of addiction-treatment providers perhaps we 
may gain some insight into how the organization "ticks,'' i.e., their beliefs. 
Perhaps this information will assist in decreasing the "strife and gross 
inefficiency" described by Cahalan. 
Reviewing a psychoanalytic critique of substance-abuse treatment 
approaches and the cultural beliefs that sustain them, (Berger, 1991), a 
reviewer for The New England Journal of Medicine seemed to agree that 
addiction-treatment providers who did not engage in 
the kind of personal self-examination through psychotherapy or 
psychoanalysis that is mandatory in psychoanalytic training and is 
undertaken by other serious therapists on their own initiative,. .. 
poorly trained 'drug counselors' ... are therefore in a self-interested 
position to maintain a belief in a psychologically unsophisticated 
model of disease. (Dodes, 1992, p. 1369) 
Thus, an examination, (or lack thereof), of the personal beliefs of 
addiction-treatment providers, is hereby postulated as related to a specific 
model of addiction, and treatment efficacy. 
An editorial in the British Journal of Addiction addressed the ethical 
ramifications of studying beliefs about the etiology of addiction among 
addiction-treatment providers, (Bergmakr & Oscarsson, 1991): 
If we as researchers can make plausible that the therapeutically 
active features of a treatment program are not the ones the 
practitioners themselves believe in, and if this weakens the 
therapeutic effect of these features, should we still do this in the 
name of science and progress?. .. An example of such a 'hidden' 
therapeutic feature could be the belief [emphasis in original] among 
personnel and clients that alcoholism is a disease involving 'loss of' 
7 
or 'impaired control' over the intake of alcohol (and this irrespective 
of the actual existence of such a phenomenon). (p. 141) 
The therapeutically active features of addiction-treatment programs 
may not be the ones the practitioners themselves believe in, and their 
personal beliefs may weaken the therapeutic effect of these features. An 
examination of the relationship between personal beliefs, and beliefs about 
the etiology of addiction, is necessary to understand and investigate these 
possible effects. 
The AA and medically-oriented approach to treating the claimed 
disease of alcoholism/ addiction may, in the long run, lower self-efficacy for 
managing drinking and addiction among those in treatment, and in turn, 
reinforce, i.e., perpetuate, drug addiction as a result. For example, the 
disease of addiction is said, according to those who believe in it's existence, 
to reside within the physiology of the individual, beyond volitional 
control, triggered by alcohol and/ or an addictive drug. This is a 
maturationist and pre-determinist perspective of addiction. Addiction is 
here considered an intrinsic disability, fixed and unchangeable. Regardless 
of how much or sincerely an alcoholic or drug addict may attempt to 
control drug ingestion, they are labeled by addiction-treatment providers as 
incapable of overcoming or managing drinking or addiction on their own. 
They are instructed to rely on an external force outside of self, an external 
locus-of-control orientation is encouraged, if not demanded. They are 
encouraged to "admit" that the task of managing their life is too difficult. 
They are told that in order to get better they must turn their life over to 
"God" or a "Higher Power." Since the recognition of their disease state is 
said to be an integral part of recovery, clients in treatment for drug and 
8 
alcohol addiction must change their concept of self from a healthy person 
to that of being a sick person in order to be ~'treated" successfully. 
There is an obvious contradiction in this approach, (Fingarette, 1988, 
1985a). Alcoholics and addicts must effort to achieve abstinence, a 
volitional act. They must do this, according to adherents of the disease-
model perspective, even though they are also told to believe that they will 
never be cured of their addiction, i.e., they will remain in a state of chronic 
"recovery." 
It is important to study the beliefs of addiction treatment providers 
because their beliefs could have some effect on their clients, stem from 
their own experience of recovery, detract from the empirical validity of 
addiction theory, and avoid the importance of building behavioral self-
efficacy in clients treated for addiction problems. 
This final point may be addressed by learning more about the health 
locus-of-control orientation of addiction-treatment providers. Health 
locus-of-control orientation may assist in predicting behavior capability for 
both provider and client regarding addiction management. It seems 
reasonable to expect that the more internal the health locus-of-control 
orientation, the more likely both are to believe they are in control of their 
own behavior, the more likely both are to believe their behavior can 
influence their experience of health and illness, the higher the probability 
of addiction management. In other words, the more people believe they 
can engage in health-promoting behaviors, the more it is likely they will. 
The less they believe they can engage in health-promoting behaviors, the 
less it is likely they will. 
Understanding these issues may prove useful in the enhancement 
of treatment efficacy, (Clifford, 1983). By investigating the beliefs of 
9 
treatment providers the usefulness of specific addiction theories may be 
increased. New areas of research may be stimulated as a result, e.g., the 
effect of a treatment provider's recovery status on the recovery status of 
patients. Moreover, conflicting theories regarding the etiology of addiction 
may become more extensive, encompassing or eliminating one or the 
other. The disease model of addiction may become more parsimonious if 
it can be shown to be grounded in the subjective experience of the 
treatment provider, rather than objective and empirical findings. 
Current approaches to addiction treatment may stem from the 
practitioner's experience of treatment and recovery and lower treatment 
success rates as a result. Approaches based on the free-will perspective may 
increase treatment success rates. Consequently, governmental, legal, and 
medical-policy decisions regarding addiction may stem more from the 
subjective experience of treatment providers and their own recovery 
process instead of from scientific findings. This may provide needed 
evidence to change ineffective policies as a result. Additionally, treatment 
policy may be rooted in spiritual thinking and as a result of this First 
Amendment rights issues may be effected as government entangles itself 
in religious belief systems under the guise of engaging in strictly clinical 
efforts. An example of this final point may be found government 
supported and court-ordered treatment programs, (Weisner, 1990; 
Fillmore & Kelso 1987c; Luff, 1989; Dolan, 1988; see also Ditman et al., 
1967; and Swenson. et al., 1981). 
Rationale for Independent Variables 
In order to investigate the factors which may -explain variance in 
beliefs about the etiology of addiction a discussion of the independent 
variables listed in the research question is now presented. These variables 
10 
have to do with (1) spiritual thinking, (2) health locus-of-control 
orientation, and (3) the demographic characteristics of addiction treatment 
providers. 
Spiri turll-Thinking Variable 
Rationale 
Many addiction treatment providers are addicts in recovery and 
have been in AA, (Schaler, 1991a). These individuals have strong beliefs 
regarding the etiology of addiction. Since a spiritual conversion experience 
is an integral part of the AA experience, spiritual thinking may be related 
to beliefs about addiction, (Rice, 1944; Sessions, 1957; Klausner, 1964,; 
Jones, 1970; Horton, 1973; Leach & Norris, 1977; Whitley, 1977; Rippere, 
1980; Greil & Rudy, 1983; Antze, 1987; Wilson & Jung, 1987; Kurtz, 1988; 
Dolan, 1988; Luff, 1989; Brown & Peterson, 1991; O'ConneU, 1991). 
"The major force dealing with alcoholism today is Alcoholics 
Anonymous. All good treatment facilities and treatment programs aim at 
getting the patient into AA," (Madsen, 1988, p. 26). AA has been described 
as a religious conversion experience by anthropologists (Antze, 1987) as 
well as by the courts (Luff, 1989; Dolan, 1988). AA literature counsels 
participants to "turn their lives over to a Higher Power." This "Higher 
Power" can be anything, as long as it is not the self. Behavior change in 
AA and similar 12-step programs is contingent upon a change in identity 
and attribution. For example, as McClelland (1972) wrote, 
[t]o join it [AA], an alcoholic must admit his complete weakness and 
inadequacy and accept wholeheartedly the belief that to live a 
normal life he must be utterly dependent on a power greater than 
himself. In other words, he must accept the power of God as a 
substitute for the power of the bottle to enhance his sense of potency. 
11 
God 'inspirits' him, strengthening him in place of liquor. (p. 301-
302) 
Or as Thune (1977) describes it, "A.A.'s 'treatment,' then, involves 
the systematic manipulation of symbolic elements within an individual's 
life to provide a new vision of that life, and of his world. This provides 
new coherence, meaning and implications for behaviors," (p. 88). 
And according to Vaillant (1983), 
[AA] ... effectively mobilizes the poorly understood ingredients 
present in increased religious involvement. AA ... 'converts' 
individuals from one belief system to another. It is a paradox that a 
major goal of AA-a strictly moral and religious system ? has been 
to view alcohol abuse as a medical illness, not a moral failing. (p. 
194) 
Characteristics of Spiritual Thinking in AA 
"Spiritual thinking" is a broad term. Its use as an independent 
variable in this study was defined in terms of how it occurs in the 
philosophy of AA, and is thereby related to beliefs regarding addiction, 
(Bales, 1944; Tiebout, 1953; Stewart, 1955; Trice, 1957, 1959; Cohen, 1962; 
Eckhardt, 1967; Donovan, 1984;). There are four characteristics of spiritual 
thinking in AA philosophy. 
Kurtz studied AA (1988) and traced the "evolution of AA spirituality 
back to a set of four discoveries made by the first members," (O'Connell, 
1991). He asserts that: 
The spiritual is essential to being fully human but the spiritual is 
different[;] Spirituality involves mystery and miracle rather than 
magic[;] The spiritual spirituality include[s] an emphasis on being 
-~- --~ 
12 
teachable and a willingness to admit that one does not have all the 
answers[;] Spirituality is pervasive. (O'Connell, 1991, p. 2) 
Kurtz further describes four elements in the stories told by AA 
members which are "the primary way in which sobriety, or spirituality, is 
not only transmitted but grown into [in AA}," (O'Connell, 1991). These 
spiritual elements are termed "release," "gratitude," "humility" and 
"tolerance," (O'Connell, 1991; E. Kurtz, personal communication, January 
2, 1992; Kurtz & Ketcham, 1992). "Release" pertains to truth-telling. 
"Gratitude" refers to the unearned "gift" from God of release from 
alcoholism. "Tolerance" refers to the appreciation of individual 
differences among AA group members. "Humility" refers to the telling of 
one's story or experience of trouble in life, particularly with alcohol. 
According to Kurtz, 
[m)ore than any other person, the alcoholic has come close to 
discovering magic. For the alcoholic, alcohol is [emphasis in 
original] magic. In recovery, once the person ceases to realize that 
recovery is miracle and there is an air of mystery to it, and starts 
seeking the magic, almost certainly such a person will go back to the 
booze because nothing is as magical as alcohol is to the alcoholic. 
(O'Connell, 1991, p. 2) 
Evidence of Spiritual Thinkint; in AA 
Three popular books used in AA that are "approved literature" by 
Alcoholics Anonymous General Service Conference - "the big book," 
(Alcoholics Anonymous World Services, 1976), "As Bill Sees It," 
(Alcoholics Anonymous World Services, 1967), and "Carne to Believe," 
(Alcoholics Anonymous World Services, 1973), a collection of anecdotes 
describing "the spiritual adventure of A.A. as experienced by individual 
13 
members," express the spiritual thinking of AA members as characterized 
by Kurtz. As further evidence of spiritual thinking found in AA the 
following passages are presented, excerpted from "the big book," as it is 
called in AA, the "bible" of AA, (Alcoholics Anonymous World Services, 
1976). Note not only the relationship with God but also the relationship 
advocated towards self: 
The central factor of our lives today is the absolute certainty that our 
Creator has entered into our hearts and lives in a way which is 
indeed miraculous. He has commenced to accomplish those things 
for us which we could never do by ourselves .... The delusion that we 
are like other people, or presently may be, has to be 
smashed. ... Whether such a person [those who are unable to drink 
moderately] can quit upon a non-spiritual basis depends upon the 
extent to which he has already lost the power to choose whether he 
will drink or not .. .. Lack of power, that was our dilemma. We had to 
find a power by which we could live, and it had to be a Power 
greater than ourselves [emphasis in original] .... [the big book's) ... main 
object is to enable you to find a Power greater than yourself which 
will solve your problem ....W e agnostics and atheists were sticking to 
the idea that self-sufficiency would solve our problems. ...O ur ideas 
did not work. But the God idea did. ...W hen we became alcoholics, 
crushed by a self-imposed crisis we could not postpone or evade, we 
had to fearlessly face the proposition that either God is everything or 
else He is nothing. God eith.er is, or He isn't. What was our choice 
to be?. .. The first requirement is that we be convinced that an.y life 
run on self-will can hardly be a success. ... The alcoholic is an extreme 
example of self-will run riot. ... Relieve me of the bondage of 
14 
self. ... Being convinced that self, manifested in various ways, was 
what had defeated us. ... [W]e have been not only mentally and physi~ 
cally ill, we have been spiritually sick. When the spiritual malady is 
overcome, we straighten out mentally and physically. ... We trust 
infinite God rather than our finite selves. .. Faith did for us what we 
could not do for ourselves. ... We hope that you are convinced now 
that God can remove whatever self-will has blocked you off from 
Him. ... We ask ourselves for freedom from self-will, and are careful 
to make no requests for ourselves only. ... The main thing is that he 
be willing to believe in a Power gyeater than himself and that he 
live by spiritual principles [emphasis in original]. (Alcoholics 
Anonymous World Services, 1976, pps. 25, 30, 34, 45, 52, 53, 60, 62, 63, 
64,65,68,70,71,87,93) 
Examples of the Four Characteristics of Spiritual Thinking in AA. 
Each of the following examples contain a reference to "God" or the 
"Higher Power," as God is often referred to in AA They are characterized 
by the general qualities of "miracle" and "mystery,'' and the four categories 
of "release," "humility," "gratitude," and "tolerance." These statements 
have been slightly modified from AA literature to improve clarity, 
(adapted from Alcoholics Anonymous World Services, 1967, 1973, 1976; 
Kurtz, 1988). 
Gratitude. Two examples of spiritual beliefs found in these books 
and characterized by gratitude are the following: "The central factor of my 
life today is the absolute certainty that my Creator has entered into my 
heart and life in a way which is indeed miraculous." "When I make right 
decisions in my life I believe it is important to thank God for giving me the 
courage and the grace to act in this way." 
15 
Tolerance. Two examples of spiritual beliefs found in these books 
and characterized by tolerance are the following: "I believe that people 
who have done wrong to me are perhaps spiritually sick. I think it is best 
to ask God to help me show them the same tolerance, pity, and patience 
that I should give to a sick friend." "I have no desire to convince anyone 
that there is only one way by which faith can be acquired. All of us, 
whatever our race, creed, color, or beliefs, are the children of a living 
Creator, with whom we may form a simple, understandable relationship, 
as soon as we are willing enough to try." 
Humility. Two examples of spiritual beliefs found in these books 
and characterized by humility are the following: "First of all, in order to 
begin solving my problems, I had to quit playing God. 1 had to realize that I 
was not God." (According to Kurtz, the idea that the alcoholic is not God 
pervades all AA philosophy and literature.) "I seek through prayer and 
meditation to improve my conscious contact with God as I understand 
Him, praying only for knowledge of His will and the power to carry that 
out." 
Release. Finally, two examples of spiritual beliefs found in these 
books and characterized by release are the following: "My 'Higher Power' 
has mysteriously accomplished those things in my life which I could never 
do by myself." "I got positive results in my life when I laid aside prejudice 
and expressed a willingness to believe in a Power greater than myself, even 
though it is impossible for me to fully define or comprehend that Power, 
which is God." 
To summarize the rationale for using spiritual thinking as an 
independent variable in this study, it is important to consider the 
following: Drug addicts who have been in AA appear to attribute their 
16 
recove.ry from addiction to a "Higher Power," a "power greater than 
themselves," "God," or anything other than self. Many addiction 
treatment providers are addicts in recovery who have had experience in 
AA. Experience in AA has been shown to explain variance in beliefs 
regarding addiction, (Schaler, 1991a). The extent to which addiction 
treatment providers engage in spiritual thinking may explain variance in 
belief regarding the etiology of addiction because the disease-model 
perspective strongly advocates the attribution of addictive behavior to a 
factor other than self too, i.e., the disease process, (Bailey, 1970; 
Christiansen et al., 1980). Addiction treatment providers who attribute 
their recovery from addiction to a spiritual "Higher Power" may attribute 
the inability to control addiction to a non-self factor such as a physiological 
disease. The specific characteristics of spiritual thinking as it occurs in AA 
needs to be taken into account when measuring spiritual thinking among 
addiction-treatment providers in order to assess its influence accurately. 
Implications of Spiritual Thinking for Explaining Beliefs About Addiction 
The implications for understanding the role of spiritual thinking in 
explaining variation in beliefs regarding the etiology of addiction are wide-
ra nging. Results may suggest that one perspective on the etiology of 
addiction is rooted in spiritual experience rather than empirical findings. 
This approach to treating addiction may be inappropriate for many clients 
who do not share these spiritual beliefs. Medical health-insurance 
coverage for spiritual conversion and reinforcement may not be 
warranted. Governmental involvement in treatment as well as 
involvement by the courts, e.g., court-ordered attendance in AA for 
driving-while-intoxicated offenses, may be a violation of First 
Amendment rights. Secular alternatives to AA may be given more 
17 
opportunity to exist within the addiction-treatment domain, (Trimpey, 
1989; Christopher, 1988). Spiritual thinking may lower self-efficacy, 
(Bandura, 1986; Wallston, 1992). 
The Multidimensional Health Locus-of-Control Scales Variable 
Rationale 
The Multidimensional Health Locus of Control scales (MHLC) were 
used in this study to assess the extent to which subjects believe they are 
responsible for, or in control of, their own personal state of health and 
illness, or attribute this experience of health and illness to chance factors or 
people outside of themselves, (Wallston et al, 1978). The MHLC consists of 
three independent scales. They each measure beliefs along three 
dimensions: The Internal Health Locus of Control dimension (IHLC) 
measures the extent to which people believe their behavior alone can 
determine their state of health or illness. People scoring high as internals 
on this scale believe their own behavior is responsible for their health or 
sickness. The Powerful Others Health Locus of Control dimension (PHLC) 
measures the extent to which people attribute external control for health or 
illness to powerful others, e.g., medical doctors. The Chance Locus of 
Control dimension (CHLC) measures the extent to which people attribute 
external control for health or illness to chance, fate, or luck. 
People who believe that recovery from addiction is only possible by 
calling it an uncontrollable disease are expected to score high on the CHLC 
scale. If they believe that a doctor or medical treatment is necessary for 
recovery from addiction they are expected to score high on the PHLC scale. 
If they tend to believe that addiction is within their personal control, they 
are expected to score low on the IHLC scale. In turn, their relative scores 
on the MHLC scales are expected to predict their beliefs about the etiology 
18 
of addiction. This is because what they tend to believe to be true about 
themselves is likely extend to what they tend to believe is true for others. 
In other words, they may "preach what they practice." Table 1 illustrates 
this relationship. 
Thus, as Table 1 shows, those treatment providers who believe in 
the free-will model of addiction see addiction as a volitional event while 
those who believe in the disease model of addiction see addiction as 
devoid of volition, i.e., they believe in the loss-of-control theory regarding 
addiction. The free-will modelist tends to view addiction as an internal 
locus-of-control phenomenon, i.e., volition is an act of self. The disease 
modelist tends to view addiction as an external locus-of-control 
phenomenon, i.e, the drug or the physiological disease or dependency 
controls drug ingestion, not the will. 
Along these same lines, the free-will modelist attributes the 
addiction to self factors, and the disease modelist attributes both the cause 
and the cure to factors external to self, Le, the disease, "higher power, 
and/or doctors. The dimensions of the MHLC scales that are likely to 
confirm these dichotomies would be the IHLC scale for the free.-will 
modelist, i.e, free-will modelists are likely to score high on this dimension. 
The CHLC and the PHLC dimensions of the MHLC scales are likely to be 
telling for the disease modelist, i.e, they are likely to score high on these 
dimensions. Finally, we see the relationship between these models, beliefs 
and attributions in light of the different treatment providers' hypothesized 
beliefs about addiction for self and others, i.e, what they tend to believe as 
true for themselves is likely to be what they believe to be true for others. 
19 
Table 1. 
Addiction Models, Beliefs, and Attributions of Treatment Providers 
Free Will Model Disease Model 
i a 
Belief about c:> Addiction is Addiction is loss 
addiction ? volitional of volitional control 
Locus of control ? Internal External 
Addiction <> Self and Disease and/o r drug 
attribution ? personal values fate/chance &/or 
doctors 
Relevant MHLC <> IHLC PHLC&CHLC 
scales ? (hi~h scores) (high scores) 
Personal ? "I can control my "I cannot control my 
beliefs about ? addiction. Therefore, addiction. Therefore, 
addiction c::> addicts can control addicts cannot control 
for others? ? their addiction." their addiction." 
In Table 1 we see this displayed as a statement for free-will modelists in the 
following way: "I can control my addiction, therefore, addicts can control 
their addiction." For the disease modelists the statement reads: "I cannot 
control my addiction, therefore, addicts cannot control their addiction." 
Relationship of the MHLC to the Concept of Self-Efficacy 
It is reasonable to assume that what one believes to be true about 
one's own ability is likely to be related to one's beliefs about the abilities of 
others. Self-efficacy research (Bandura, 1977) has shown that what people 
believe to be true about their ability to perform a specific behavior is related 
20 
to whether the behavior will actually be performed or not. Treatment 
providers who subscribe to the free-will perspective of addiction may have 
high self-efficacy in relation to addiction, be more internal in their health 
locus-of-control orientation and believe that what is true for themselves is 
true for others. 
Addicts are viewed by free-will modelists as using drugs to cope with 
environmental or psychological experience, (Schaler, 1991b). Addicts can 
engage in other behaviors to deal with the stressful event facilitating drug 
use, e.g., find new coping skills, change social context, change self-talk, 
exercise, relax, etc. Since most treatment providers are addicts in recovery, 
theoretically they have learned to cope with stressful events in new ways, 
i.e., drug-free or moderated drug use. Moreover, expectancy, or beliefs 
regarding alcohol presence in beverages has been shown to be related to 
alcohol consumption among alcoholics even when the beverages 
contained no alcohol, (Marlatt et al., 1973; Collins et al., 1990). The MHLC 
scales may allow for the assessment of differences between those treatment 
providers who are in recovery versus those who are not along diverse 
dimensions. 
These ideas appear to support findings by those who have 
challenged the loss~of-control theory of alcoholism. The apparent 
helplessness of chronic drunkenness and drug addiction can be viewed as 
learned behaviors, a function of expectancy and belief. If people believe 
they are helpless or powerless with regard to their beha viorctl capabilities, 
chances are they will then act this way. If treatment providers attribute 
their state of health or illness to powerful others and/ or God as in the 
"higher power" of AA, they probably will encourage their clients to do the 
21 
same, which may reinforce pre-existing irrational beliefs in the client 
regarding his or her own sense of powerlessness or learned helplessness. 
Seligman (1975) believes that helplessness is a learned behavior 
caused by learning that responding is independent of reinforcement; 
so the model suggests that the cause of depression is the belief that 
action is futile .... [T]he depressed patient believes or has learned that 
he cannot control those elements of his life that relieve suffering, 
bring gratification, or provide, nurture - in short, he believes that he 
is helpless. (p. 93) 
When people believe that effort and reward are unrelated, 
helplessness and depression may result. If effort towards a specific goal 
creates an experience that people seek to avoid, they stop efforting. They 
believe that their effort is a futile one. 
This theory has been reformulated to transfer attribution of help-
lessness to futility of effort experience to "beliefs that one cannot produce 
the required performances," (Bandura, 1986, p. 447; see also Hill & Larson, 
1992). Applied to theories of loss-of-control and addiction, if a person 
believes he or she cannot control addiction-then he or she won't. The 
AA approach to alcoholism/ addiction recovery not only stresses the 
development of spiritual thinking, herewith defined as the attribution of 
personal experience to a metaphysical, non-self power. It also stresses the 
idea that self effort can never be successful in the achievement of recovery. 
This idea would appear to lower feelings of self-efficacy. 
Bandura (1977) has found that self-efficacy expectation is related to 
outcome: "An outcome expectancy is defined here as a person's estimate 
that a given behavior will lead to certain outcomes. An efficacy 
expectation is the conviction that one can successfully execute the behavior 
22 
required to produce the outcomes/' (p. 79). Seligman (1975) has found that 
there is relationship between the futility of well-meaning effort that fails 
and depression, which he calls "learned helplessness." 
Locus-of-control orientation., self-efficacy, outcome expectancy, and 
attribution are related concepts. Outcome expectancies are a priori 
expectations, about behavioral outcome, e.g., expectation of success or 
failure. Attribution theory has focused on a posteriori attributions for 
outcome, i.e., reasons for success or failure. 
Table 2 shows an attribution matrix that includes locus-of-control 
orientation and self-efficacy/ outcome-expectancy attributions. These 
relationships are important and relevant to the research question asked in 
this study because the relationship between attributions in the form of 
spiritual thinking and health locus-of-control orientation are being studied 
in light of their ability to predict beliefs about addiction. 
Ability and effort are internal factors. They refer to the belief that a 
person possesses both the ability and effort (or lack thereof) to achieve a 
specific goal. Examples of this belief are found in the following statements: 
"I have the ability to moderate my addiction. All I need to do is put in the 
effort to do so." Or: "No matter how hard I may try (effort), I am unable to 
moderate my addiction to alcohol because I have a genetically-determined 
inability to control my drinking." Ability is more or less a stable 
phenomenon, i.e., it is hard to change. Effort can vary and change 
depending on a person's interest and motivation. 
Difficulty of a task and fate or chance factors are viewed as external 
to the experience of self. Examples of these beliefs or attributions are found 
in the following statements: "Responsible drinking is too difficult a task 
23 
Table 2. 
The Relationship Between Self-Efficacy Expectation, Locus of Control 
Orientation, and Outcome-Expectancy Attribution 
A priori Locus of A posteriori 
(Outcome Control (Attributions for 
expectancies) Dimension success or failure) 
? I u 
High is Internal is Ability Effort 
Self- ? related<> Locus of? related<> stable unstable 
Efficacy to Control ln fiu:to[ fattO[ 
MHLC scale<> lHLC ? Self Self 
Low is External is Difficulty Fate/ 
related related Chance 
Self- c:, to Locus ofc:> to stable unstable 
Efficacy L-:> Control ? fa~ta, fa,tgrs 
MHLC scale~ CHLC & PHLCc:> Non self Non self 
for me to engage in because I lack the ability and/or effort to do so. I must 
turn my life over to God or my Higher Power in order to achieve sobriety. 
I cannot do it on my own." 
Difficulty is a relatively stable attributional factor beyond an 
individual's control. God is an unstable attributional factor in the sense 
that God does not always effect a person's experience in the way he or she 
may expect. For example, a person may turn his or her life over to God or 
the Higher Power and theoretically succeed or fail at achieving sobriety 
because God or the Higher Power "wants" the person to fail or succeed at 
the task. 
24 
The matrix in Table 2 may be applied to beliefs about the etiology of 
addiction in the following way: People who attribute addiction to ability 
and effort may see it as a phenomenon within the domain of volition or 
willfulness. These are internal locus-of-control beliefs because ability and 
effort are within the domain of self. People believing they can overcome 
addiction through their own efforts are expressing a high self-efficacy 
expectancy, i.e., they believe they have the ability to change behavior. 
Whether they believe they actually will change the behavior or not is an 
outcome expectancy. 
Believing that addicts cannot moderate or change addiction 
behavior on their own, i.e., they believe addiction is a disease independent 
of volition, a disease that only God or the Higher Power of AA can help 
them with, is an external locus-of-control orientation along PHLC and 
CHLC dimensions, expressing low self-efficacy. Ability factors into the 
belief in that they may attribute addiction to a lack of ability to engage in 
moderate drug-taking behavior. The more outcome expectancy is 
attributed to disease, i.e., difficulty, and God, it appears the less it would be 
attributed to ability and effort. Outcome expectancy could be high in this 
case. For example, some people are more likely to achieve sobriety if they 
" turn their life over to a Higher Power," as in AA. This is an external 
locus-of-control orientation with high-outcome expectancy and low self-
efficacy. A person can believe in God and have high self-efficacy, as in the 
statement "I believe God gives me the strength to help myself." 
Implications 
Addicts are people who may have learned to become helpless in life, 
they may have low feelings of self-efficacy, and they may tend to rely on 
the use of drugs to create (and avoid) certain experiences undoubtedly 
25 
associated with helplessness. The addict may believe he or she lacks the 
ability to overcome a certain experience (the difficulty is too great), effort 
decreases (learned helplessness) and the drug is relied on to create an 
experience the addict believes he or she could not create on his or her own, 
i.e., to avoid one experience and create another more pleasurable one. 
Disease-model approaches to treatment, such as are practiced in AA, may 
reinforce this sense of powerlessness or low self-efficacy in relation to 
addiction. The beliefs regarding self-efficacy may be "preached'' to the 
client in treatment for addiction. Thus, they may constitute beliefs about 
addiction.. 
The most pronounced implication of investigating this relationship 
is that if health locus-of-control orientation is related to beliefs about 
addiction, and thes: beliefs about addiction lack empirical validity, we may 
understand more about why the theories are perpetuated and recognize a 
need to change them. Moreover, beliefs about the etiology of addiction 
may signal the health locus-of-control orientation of the treatment 
provider and allow for provider-training programs to address and 
influence this orientation, thereby helping both provider and client. 
Demographic Variables 
Rationale 
Age. The rationale for using the demographic independent 
variables was as follows: The age of subjects could influence their beliefs 
about the etiology of addiction, (Stall, 1986). Many addicts appear to 
"mature out" of their addictions, (Fillmore, 1987a; Biernacki, 1986; 
Erickson et al., 1987; Tuchfield, 1981; Ojesjo, 1984). Older treatment 
providers may understand this phenomenon better than younger ones, 
i.e., they can "look back" and see how they've changed. Moreover, dif-
26 
ferent stages in human development may accompany differing 
perspectives on addiction. For example, a middle-aged treatment provider 
has a different perspective on life in general than a provider in his or her 
twenties, and likewise may have a different belief about addiction and its 
causes. 
Gender. The gender of the subjects being studied could also account 
for variance in beliefs regarding addiction. Males and females appear to 
differ in genetic susceptibility to alcoholism according to some researchers, 
in addition to their metabolism of alcohol, (Fillmore, 1987a, 1987b; 
Fillmore & Midanik, 1984; Kendler, 1992; McGue et al, 1992; Pickens, 1991; 
Wanberg, 1970). Providers may have varying understandings and beliefs 
about these differences accordingly. Moreover, psychosocial theorists 
postulate developmental differences according to gender. The political 
environment of women differs from that of men, which may be correlated 
with addiction frequency and account for differing perspectives on 
addiction. For example, a self-help, alternative offshoot of AA has been 
established throughout the U.S. recently to address the addiction problems 
of women, e.g., Women for Sobriety, (Kirkpatrick, 1986; Gelman et al., 
1991). Furthermore, higher numbers of women are certified as addiction-
treatment providers than men, (Schaler, 1991a). 
Race/Ethnicity. Race/ethnicity variables were explored because 
beliefs about addiction may vary by race/ ethnicity, (Barnett, 1955; Caetano, 
1989; Herd, 1989). For example, African-American treatment providers 
may feel less powerful in the world than white treatment providers based 
on their experience of racism, (Schaler, 1989d). This sense of powerlessness 
may be related to their beliefs about the etiology of addiction as well as a 
general sense of powerlessness in the world and their own personal health. 
27 
Many people believe that addiction problems are more prevalent in lower 
socio-economic level black populations than white. These differences may 
influence the beliefs of treatment providers regarding the etiology of 
addiction, whether the rates of addiction are different or not because the 
belief is that the rates of addiction are different. 
Marital and Educational Status. The marital and educational status 
of subjects could bear on beliefs regarding addiction for several reasons: If 
treatment providers are happily married they may have a different world 
view than those who are single, divorced or widowed. They may have had 
different reasons for using drugs and alcohol themselves, reasons related 
to their experience of marriage, which may lend to a happier or dissatisfied 
outlook on life, and bear on the perception of others, i.e., empathy, notably 
in relation to those in treatment with a similar or different marital status. 
Their associations and memories regarding drug use and marriage may 
vary according to their own family experiences, e.g., they may be adult 
children of alcoholic parents. 
Those with higher levels of education may be more exposed to and 
cognizant of scientific theories and beliefs regarding the etiology of 
addiction than those with lower levels of education who may base their 
beliefs more on anecdotal evidence, i.e., subjective stories about addiction 
and recovery versus objective research, (Fingarette, 1988). Many addiction 
treatment providers move into their profession based on their own 
experience of recovery and not necessarily as a result of higher education. 
Moreover, many treatment clinics place a higher value on providers who 
are in recovery rather than educational status when hiring. Their level of 
education may thus account for variation in beliefs about the etiology of 
addiction. 
28 
Religious Affiliation. Religious affiliation is a relevant 
demographic variable because different religions advocate differing beliefs 
regarding the proper role of alcohol and drugs in a person's life, as well as 
the abuse of drugs, (Skolnick, 1958; Glassner & Berg, 1980, 1984; Barnett, 
1955; Mirels & Garrett, 1971). Skolnick (1958) tested the hypothesis that 
different religious ideas are more influential in an individual's drinking 
practices than others. He found that "[t)he development of drinking 
behaviors is differentiated along religious lines," (Skolnick, 1958, p. 466). 
Some religions insist on abstinence, e.g., Muslim. Some view the 
use of psychedelic drugs, e.g., peyote, as an essential part of religious 
practice and experience. Jewish and Black Muslim groups regard 
alcoholism and drug addiction as decidedly willful behaviors and urge 
recovery through mental discipline and moderation of intake, (Szasz, 
1985). Many people in these two groups oppose the disease model of 
addiction because they believe it diminishes self-efficacy. Irish Catholics, 
having been exposed to a multitude of people with similar ethnic and 
religious backgrounds, may tend to view addiction, especially alcoholism, 
from a decidedly genetic-predisposition perspective, (Vaillant, 1983). 
Treatment providers may vary by religious affiliation in terms of how they 
view the etiology of addiction based on their own religious upbringing as 
well as their current religious identifications. Moreover, scores on a 
Protestant Ethic Scale (Mirels & Garrett, 1971) were found to be associated 
with authoritarianism and an internal locus-of-control orientation. 
Religious factors are related to health, (Levin & Tobin, 1992; Levin & 
Vanderpool, 1991; Vanderpool & Levin, 1990; Levin et al., 1988; Levin & 
Vanderpool, 1989; Schiller & Levin, 1988; Levin & Schiller,1987). 
29 
Certification, AA Status, Recovery Status, AA Experience. 
Treatment provider certification and past experience in AA alone and 
together have explained variance in beliefs regarding addiction, (Schaler, 
1991a). Factors such as current alcoholic/ drug addict-in-recovery status, 
experience in AA and related groups like Narcotics Anonymous (NA), as 
well as treatment programs in general, plus length. of time in these 
programs, may be able to explain variance in beliefs about the etiology of 
addiction in ways not previously discovered. Those who have been in AA 
for longer periods of time may have stronger beliefs about addiction as a 
disease characterized by loss of control than those who have been in 
treatment for shorter periods of time. Also, the type of treatment 
recovering addicts received may have influenced their beliefs about 
addiction in general. Those who gave up alcohol or drug addiction on 
their own, without treatment, or those who learned either on their own, 
or from a controlled-drinking oriented treatment program, may have 
learned to moderate their drug ingestion, and this in tum may be related to 
their beliefs about the etiology of addiction, especially when compared to 
those in recovery who have been through abstinence-oriented treatment 
programs, or who believe those treatment programs oriented from a 
disease-model perspective "saved their life." 
Abstinence Status and Number of Drinks/Drugs Ingested /Week. 
The drinking/ drug-taking status variable is used because those providers 
who believe in the disease concept of addiction tend to believe that 
abstinence is the best preventive treatment program for addicts. McBride 
(1991) found that length of AA attendance and abstinence among 
alcoholics was related. 
30 
Those who believe in the "free-will model of addiction" tend to 
believe that controlled-drinking and drug-taking is not only possible but 
therapeutically feasible. Thus, their beliefs about the etiology of addiction 
may vary accordingly. 
A request for amount of alcohol and drugs consumed may predict 
beliefs regarding addiction. Heavy drinkers and drug users may believe 
they can control their drug use more than those who are abstinent can. 
Professional-Group Affiliation. Various professional treatment-
provider organizations appear to have been established along specific 
philosophical lines regarding the etiology of addiction. For example, 
Rational Recovery Systems has explicitly separated itself from disease-
model approaches and 12-step programs, making a point to define its 
philosophy as secular in nature. Beliefs of the National Association of 
Alcoholism and Drug Abuse Counselors appear to be more in line with the 
disease model of addiction. The philosophical orientation of members of 
the Society of Psychologists in Addictive Behaviors is unknown. Since at 
least two of these groups are explicit in their identification with specific 
beliefs regarding the etiology of addiction, it seems reasonable to conclude 
that membe:rship in these organizations may predict a significant amount 
of variance in beliefs regarding addiction. 
By examining these various factors with regard to their ability to 
explain beliefs about the etiology of addiction we may be in a better 
position to examine the efficacy of treatment policy in general. The 
training of treatment providers could be modified, both generally and 
specifically. Related as well are new areas of research that may open up as a 
result for further investigation. 
31 
Recovery Beliefs 
There exist today discrepancies regarding addiction-treatment 
efficacy, i.e., what constitutes proper treatment, success and failure, (Chick 
et al., 1988; Edwards, et al., 1977). For example, from the disease-model 
perspective an addict is never cured but in a state of perpetual recovery. 
From a free-will perspective, achieving a state of controlled drinking is a 
sign of treatment success. The former is more absolute in defining 
treatment success. Any return to drug use is considered treatment failure. 
The latter utilizes more flexible measures of treatment success. Therefore, 
it may be useful to know just how efficacious addiction treatment is 
according to treatment providers. These beliefs about treatment success 
can be compared with empirical findings and stimulate further 
investigations into reasons for possible discrepancies. 
Rationale for Population 
Addiction-treatment providers are an appropriate population to 
study regarding variance in beliefs about the etiology of addiction because 
they are often considered "experts" on addiction. Their beliefs influence 
the beliefs of their patients. "Matching" between treatment providers and 
patients has been shown to predict treatment outcome (Glaser, 1980; Glaser 
et al., 1981; Sells, 1981). Drug policy is influenced by treatment-provider 
beliefs regarding the etiology of addiction because their opinion as experts 
is sought after by policy-makers. Additionally, treatment providers base 
their beliefs on their work with patients, as well as their own experience of 
recovery. The implication of examining the beliefs of treatment providers 
is that their beliefs regarding the etiology of addiction may not match 
empirical findings regarding addiction. Treatment policy ma.y need to be 
32 
changed because the influence of treatment provider beliefs may stem 
from subjective rather than objective experience. 
The present study concerns factors that may explain beliefs regarding 
the etiology addiction. Investigations of this sort among addiction-
treatment providers appears rare. Moreover, experts in the field have 
decried the lack of research attention given to those wh.o allegedly know 
addicts best, namely, addiction-treatment providers. 
For example, responding to critics of the disease model of 
alcoholism, Vaillant (1990) wrote: 
[T}he philosopher Herbert Fingarette, the psychoanalyst Thomas 
Szasz, the sociologist and theoretician Robin Room, and 
provocative, thoughtful psychologists like Stanton Peele and 
Nicholas Heather have every qualification but one for explaining 
why alcoholism is not a disease - they have never worked in an 
alcoholic clinic. Why. .. do experienced alcohol workers and 
recovering akoholics ... accept the view that alcoholism is a disease? 
Why is it mainly less competent people, the active alcoholics, who 
agree with Professor Fingarette that they are just 'heavy drinkers'? 
(p. 4) 
Treatment providers are slightly internal in personal and ideological 
locus-of-control orientation and tend to believe, as Vaillant asserts, that 
alcoholism is beyond the volitional control of the alcoholic, i.e., the loss-of-
control theory of the disease concept of alcoholism, (Schaler 1991 a). Many 
treatment providers are alcoholics-in-recovery and these findings replicate 
those of locus-of-control studies on alcoholics and drug addicts in general, 
(Butts & Chotlos, 1973; Berzins & Ross, 1973; Calicchia, 1974; Christiansen 
et al., 1980; Distefano et al., 1972; Donovan & O'Leary, 1978; Goss & 
33 
Morosko, 1970; Gozali & Sloan, 1971; Gross & Nerviano, 1972; Nowicki & 
Hopper, 1974; Rohsenow &. O'Leary, 1978; Worell & Tumilty, 1981). 
Schaler (1991a) found that wh.eitheir afoo!lmliism-ltreaitm,e,rd p,mviiders 
have been in AA in the past or not ,expilains variance i.n t'kei.r beli,eJs about 
alcoholics' ability to control drinking, as does their .certificatiion status. 
Together, these two factors appear r,elated to beliefs about alcohoUcs? ability 
to control their drinking. Treatment JPlfO\nide~s who hm1,e had paisit 
experience in AA tend to believe in the dis?ease model of alcoholism,, as do 
those who are certified. Treatment providers who have not be,en in AA in 
the past tend to view alcoholism more as a ?volitional behavior., as do those 
who have not been certified. 
Alcoholism counselors in recovery themiselv.es may w,eU perpetuate 
the loss-of-control theory of alcoholism because they have been taught to 
believe through their experience in AA that their sobriety is dep endent 
upon this belief. They may have a :sit1mn,g i:tfao,to:g:ical/em,oltional :invest-
ment in this particular point of view, Tr,eatment p.NJvide,rs w ho have 
achieved certification status may have been pressured into believing in the 
disease model of alcoholism and/ or addiction in order to pass the 
certification examination. 
Conceptual Definitiom'S 
In light of the research question., sev.ernl terms used throughout this 
inquiry require conceptual definition because these terms 'Vary in meaning 
according to beliefs about the etiok~1gr 1olf addkiticom,. They ,mr,e clarified and 
defined here for the purposes of this study. The term'S indude "the disease 
model of addiction," "the free-will model of addiction," "spiriitual 
thinking," "self-efficacy," "addiction/' I/recovery," ''disease/' "behavior, " 
"health locus of control," and "attr.ibu:tion." 
34 
The Disease Model of Addiction 
The disease model of addiction refers to the idea that addiction is an 
involuntary behavior characterized by "loss of control," (Jellinek, 1960). 
The Free-Will Model of Addiction 
The free-will model of addiction refers to the idea that addiction is a 
voluntary behavior characterized by choice and responsibility. 
Spiritual Thinking 
Spiritual thinking refers to any belief in a metaphysical power said 
to influence personal experience characterized by feelings of release, 
gratitude, tolerance and humility. In this study, with regard to spiritual 
beliefs, the terms "Higher Power" and "God" are used synonymously. 
Self-Efficacy 
Self-efficacy refers to the behavioral capability people believe they 
possess to effect a specific behavior. "Perceived self-efficacy is a judgment 
of one's capability to accomplish a certain level of performance, whereas an 
outcome expectation is a judgment of the likely consequence such 
behavior will produce," (Bandura, 1986, p. 391). 
It is concerned not with the skills one has but with judgments of 
what one can do with whatever skills one possesses. ... Perceived self-
efficacy is a judgment of one's capability to accomplish a certain level 
of performance, whereas an outcome expectation is a judgment of 
the likely consequence such behavior will produce. For example, 
the belief that one can high jump six feet is an efficacy judgment; 
the anticipated social recognition, applause, trophies, and self-
satisfactions for such a performance constitute the outcome 
expectations. ... Strength of self~efficacy is not necessarily linearly 
related to choice behavior. (Bandura, 1977, p. 193) 
35 
"Perceived self-efficacy is concerned with generative capabilities not 
with component acts," (Bandura, 1986). 
Strecher et al. (1986) have pointed out that 
it is important to understand that the concept of self-efficacy relates 
to beliefs about capabilities of performing specific behaviors in 
particular situations; self-efficacy does not refer to a personality 
characteristic or a global trait that operates independently of 
contextual factors. An individual's efficacy expectations will vary 
greatly depending on the particular task and context which confronts 
him/her. It is therefore inappropriate to characterize a person as 
having 'high' or 'low' self-efficacy without reference to the specific 
behavior and circumstance with which the efficacy judgment is 
associated [emphasis in original]. (p. 74) 
Addiction 
The word "addiction" comes from the Latin "dicere" (infinitive 
form) and, combined with the preposition "ad," means "to say yes to," 
"consent." Consent implies voluntary acceptance, (Schaler, 1991b; 1989a). 
Drui Addict 
Within the context of this study, an individual referred to as an 
alcoholic or d rug addict is one whose drug "consumption consistently has 
a negative influence on important components of his daily life," (Miller & 
Mastria, 1977; Donovan & Marlatt, 1980). 
Recovery 
Recovery refers to that state in which an alcoholic or drug addict is 
either abstinent or has achieved a state of moderate or controlled drinking 
or drug taking. 
36 
Disease and Behavior 
The terms "disease" and ''behavior" are often used together in 
discussions of addiction. For this reason the two will be clarified under the 
same sub-heading. 
A disease process involves a pathological lesion of the physical body 
and is generally considered to be outside of a person's control, (Gerhardt, 
1989; Reznek, 1987). Stedman's Medical Dictionary (1976) defines disease 
as "1. Morbus; illness; sickness; an interruption, cessation, or disorder of 
body functions, systems, or organs." There is no reference to behavior as a 
disease process, apparently the definition being strictly limited to a 
phenomena of the body. Behavior, according to Webster's, refers to 
deportment, or mode of conduct, (New World Dictionaries, 1983). 
According to psychiatrist Thomas Szasz (1987): 
[B]y behavior we mean the person's 'mode of conducting himself' or 
his 'deportment'. . the name we attach to a living being's conduct in 
the daily pursuit of life. ... [B]odily movements that are the products 
of neurophysiological discharges or reflexes are not behavior. ... The 
point is that behavior implies action, and action implies conduct 
pursued by an agent seeking to attain a goal. (p. 343) 
And philosopher Herbert Fingarette echoes the sentiment: 
A pattern of conduct must be distinguished from a mere sequence of 
reflex-like reactions. A reflex knee jerk is not conduct. If we regard 
something as a pattern of conduct. .. we assume that it is mediated by 
the mind, that it reflects consideration of reasons and preferences, 
the election of a preferred means to the end, and the election of the 
end itself from among alternatives. The complex, purposeful, and 
often ingenious projects with which many an addict may be 
37 
occupied in his daily hustling to maintain his drug supply are 
examples of conduct, not automatic reflex reactions to a singly 
biological cause. (Fingarette, 1975, p. 435) 
In order to further clarify the differences between a behavior and a 
disease the following example is given: Smoking is a behavior that may 
lead to the disease called cancer. Smoking is within volitional control, 
cancer is not. Heavy drinking of beverage alcohol is a behavior that may 
lead to the disease called cirrhosis of the liver. Drinking is the behavior, 
cirrhosis the disease. Cirrhosis, that is, the actual physiological pathology, 
cannot be controlled through an act of will. 
Health Locus of Control 
Health locus of control refers to the belief or expectancy a person has 
with regard to health and illness attribution, i.e., factors outside or external 
to personal control versus those causally within the domain of volition or 
willfulness. These attributions include expectancies regarding behavior-
reinforcement contingencies, the extent to which a particular rein-
forcement is valued by the individual, and the context within which 
reinforcement is likely to occur, (Rotter, 1966). "[T]he meaning of locus of 
control for the alcoholic is primarily associated with his attitudes toward 
his drinking rather than his general sense of control over his life," (Worell 
& Tumilty, 1981, p. 331). 
Attribution 
Attribution theorists address the various attributions that people 
make with regard to explaining why they either succeeded or failed at 
specific tasks. "As in attribution theory proper, there is no one complete 
and systematic attributional theory," (Antaki & Brewin, 1982, p. 14). People 
tend to make attributions in four are.as: ability, effort, difficulty of the task, 
38 
and fate, (chance, or luck). Ability and effort are attributions of personal 
cau se and lie within the domain of self, or volitional control. Difficulty 
and chance or fate are attributions based on environmental cause, external 
to the domain of self, and thereby outside of direct volitional control. 
Ability is viewed as a fixed, or stable domain that is relatively 
unchangeable. Effort refers to the effort a person is willing to engage in, in 
order to succeed at a particular goal. It is considered a changeable, or 
unstable factor, i.e., a function of will. 
Some tasks are so difficult that regardless of ability and effort a per-
son cannot succeed at them simply because they are too difficult. Likewise 
some tasks are so easy that success is attributed by an individual to lack of 
difficulty or ease. Difficulty is a fixed, stable domain. The individual 
cannot change it. 
The attributional domain of fate, chance, or luck, has to do with 
factors that are completely outside of the individual's control, ability, 
effort. This domain is unpredictable and therefore highly unstable. 
Because this study is concerned with spiritual thinking in terms of an 
attributional relationship with God or the "Higher Power," as it is referred 
to in AA, the domain will be referred to as ''God." Referring to God as an 
"unstable domain'' does not mean that God is stable or unstable. It means 
that God effect, as an expectancy or attribution, varies, e.g., "God often does 
not affect my life in the way I expect." 
Recapitulation of Research Interest 
Vaillant's question and concern (1990) suggested the population for 
the present study: Addiction-treatment providers. Those who have 
worked with addicts in a treatment clinic undoubtedly have strong beliefs 
regarding addiction and control. The question this inquiry sought to 
39 
answer was this: What are the factors that account for variation in beliefs 
among addiction treatment providers about the etiology of addiction? 
AA stresses a religious conversion experience, in addition to 
advocating strong beliefs regarding lorus of control orientation. Three sub-
questions followed to specify these factors: (a) Do spiritual beliefs of 
treatment providers explain variance in beliefs regarding the etiology of 
addiction among treatment providers? And, (b) does the health locus-of-
control orientation of treatment providers explain variation in beliefs 
regarding the etiology of addiction? Additionally, the research interest 
includes {c) whether the following demog?raphic characteristics of addiction 
treatment providers are able to account for variance in beliefs regarding 
addiction: Do their age, gender, race/ ethnicity, educational status, marital 
status, religious affiliation, certification-as-treatment-provider status, alco-
holic/ addict in recovery status, past and present experience in 12-step 
and/ or other treatment programs, plus length of time in these programs, 
as well as their current drinking or drug-taking status, i.e., whether they 
are abstinent or not, and their professional-group affiliation explain 
variation in beliefs regarding the etiology of addiction? 
40 
CHAPTER II 
REVIEW OF THE LITERATURE 
This study investigates the beliefs of addiction-treatment providers. 
This section of the study traces the history of beliefs regarding addiction in 
America, and discusses various paradigms used to explain addiction since 
colonial limes. 
The section begins by identifying three models of addiction 
attribution. These are the "maturationist model of addiction," (also 
known as "the medical model" and "the disease model"); the "behaviorist 
model of addiction," (also known as "the moralistic model" and "the 
criminal model"), (Schaler, 1991b; Alexander, 1987); and the 
"interactionist model of addiction," (also known as "the free-will model" 
and "the adaptive model"), (Schaler, 1991b; Alexander, 1987). 
Each of these models flourished during certain historical periods. A 
review of these periods in light of the beliefs about addiction follows a 
discussion of the models. Finally, a review of health locus-of-control 
research is presented. 
Three Models of Addiction Beliefs 
It is not the intent of this review to summarize and comment on 
each of the extensive writings concerning models of addiction and their 
relation to behavior change. Models of alcoholism and addiction have 
been studied and debated for some time now. The summary and 
distillation of beliefs regarding addiction that follows are interpretations of 
selected writings on the topic, (Jessor, 1958; MacAndrew & Garfinkel, 1962; 
Mulford & Miller, 1964; Pattison, 1966; Siegler et al., 1968; Verden et al., 
1969; Bateson, 1971; Robinson, 1972; Overton & Reese, 1973; Szasz, 1973; 
Hershon, 1974; Kj0lstad, 1974; Engel, 1977; Keller, 1976; Pattison, 1976; 
41 
Kendell, 1979; Peele, 1981; Keller, 1982; Marlatt & Gordon, 1985; 
Fingarette, 1985c; Prochaska & DiClemente, 1986; Peele, 1986; Caetano, 
1987; Alexander, 1987; Fillmore & Kelso, 1987; Musto, 1987; Segal, 1987; 
Alexander & Schweighofer, 1988; Peele, 1988a, 1988b, 1988c; Fillmore, 1988; 
Beasley, 1988; Fingarette, 1988; Bennett, 1988; Faulkner et al., 1988; Room, 
1988, 1989; Gerhardt, 1989; Heather & Robertson, 1989; Peele, 1989; 
Brisbane, 1989; Wallace, 1989a, 1989b; Gorman, 1989; Goodyear, 1989; 
Siegel, 1989; Gorman, 1989, 1990; Cohen, 1990; Miller & Gold, 1990; Vatz 
& Weinberg, 1990; Erickson, 1990; Alexander, 1990a, 1990b; Lieber, 1990; 
Siegel, 1990; Harcum, 1991; Peele, 1990a, 1991; Szasz, 1991.; Rather, 1991; 
Akers, 1991; Maltzman, 1991; Musto, 1991; Schaler, 1991b; Peele, 1992; 
Morgenstern & McCrady, 1992; Davidson, 1992a, 1992b; Prochaska et al., 
1992; Heather, 1992; Orford, 1992; Stockwell, 1992). 
Past, current, and conflicting perspectives on addiction can be 
distilled and organized into three ,explanatory paradigms, herewith termed 
the "maturationist," (medical or disease), "behaviorist," (moralistic or 
criminal) and the "interactionist," (free-will or adaptive) models. People 
use these models to express specific beliefs regarding addiction, specifically 
in terms of the relationship of self to its environment. Metaphors are used 
to describe this relationship. 
The models can also be interpreted as explaining addiction according 
to different understandings of the nature-nurture controversy of human 
development. Maturationists tend to favor the "nature" side. 
Behaviorists explain development from the "nurture" side. Interactionists 
encompass a more equitable combination of the forces. 
Interactionists differ from maturationists and behaviorists in two 
important ways: The roles of volition and self-determination are a central 
42 
component of human development according to the interactionist. 
Maturationists and behaviorists place little emphasis on volition and self-
determination. They tend to be deterministic and mechanistic in their 
thinking, (Barrett, 1979). 
The Maturationist Paradigm 
From the maturationist perspective, the. propensity for, and 
engagement in, addiction evolves through a centrifugal process of 
psychological and/or physiological maturation. A "pre-programmed" 
movement of human development occurs from "within" the organism 
"out." The capacity for addiction is preformed in a Platonic sense, (Room, 
1983). It lies dormant within the organismic self. Environmental 
conditions are either favorable or unfavorable to the maturation of this 
potential. 
According to this perspective, the predetermined addiction is eithe,r 
psychological or physiological in nature. Psychologically-based addiction is 
secondary to a primary physiological process. The reverse is true too. 
According to a Gallup poll taken in 1987, dose to 90 percent of the 
American public believe that alcoholism is a disease, a sign of the 
maturationist point of view, (Peele, 1989). According to a poll of 601 
residents financed by the U.S. federal government in 1990, conducted by 
the District of Columbia's Office of Criminal Justice Plans and Analysis "in 
conjunction with similar polls in five states, as part of a national effort to 
monitor and evaluate drug control strategies,. .. 66 percent of residents 
polled say addiction should be viewed as an illness," (Wheeler, 1990). 
Advocates of the maturationist model use the metaphor of an 
unfolding flower to explain addiction. They are likely to agree with the 
following statements: The oak tree resides in the acorn. It cannot be 
43 
otherwise. The acorn cannot produce a ma,ple or a pine. The acorn may 
grow to be strong or weak as a tree-oak is it's destiny. The shape or form 
it assumes is a function of the environment. The quality of it's being as a 
species is predetermined. It lies mysteriously within the acorn as potential. 
Similarly, drug addicts are, according to the maturationist's belief, 
psychologically or physiologically destined to become drug addicts. The 
metaphorical "soil" and "climate," "water" and "light conditions," affect 
maturation towards addiction accordingly. Addiction is prevented and 
controlled through abstinence-an environmental constraint. Yet, the 
addict is still considered an addict, even when deprived of the drug that is 
said to overtly define the addiction, (Peele et al., 1991). Addiction is a 
primary psychological or physiological fault manifested through the use of 
the drug. 
Volition is an insignificant part of this model. Choice has little to do 
with addiction. A contradiction here is that abstinence is a volitional act, 
(Fingarette, 1985a). 
A psychoanalytic perspective on addiction, which may view 
addiction as an underlying symptom of "psychopathology," is an example 
of a maturationist perspective. Here, psychological functions are the 
primary origins of addictive behavior, (Berger, 1991). Unresolved. 
intrapsychic conflicts, originating for example in "pre-oedipal experiences," 
are manifestations of substance abuse and/ or addiction. 
From the psychoanalytic point of view, addiction may not be a 
strictly medical phenomenon. It also may not embody the disease-model 
notion of "loss of control." However, from a psychoanalytic perspective, 
addiction is predetermined in a psychological sense. Addiction is an acting 
out of early, unresolved intrapsychic conflict. 
44 
Minimal interaction with the environment catalyzes this acting out. 
The addiction functions in a centrifugal manner, from within the 
"unconscious" domain of the individual's psyche. Eventually it becomes 
expressed through some sort of interaction with the environment. So 
powerful is the preprogrammed-psydtlc influence that the "patient" is 
often considered incapable of resolving the intrapsychic conflict, despite his 
or her best intentions to do so. Moreover, some psychoanalytic therapists 
believe that addiction should never be the reason for going through 
psychoanalytic treatment, (L. Berger, personal communication, November 
11, 1992). 
The medical model of addiction is also maturationist. From this 
point of view, the potential for addiction is a physiological phenomenon, 
often genetically determined. Some proponents of this model adamantly 
assert that physiological defects always precede psychological components 
of the addiction and never vice-versa, (Milam & Ketcham, 1983). 
The genetic theories of alcoholism are clearly maturationist models. 
Often the belief here is that a defective gene causes neurological disability. 
This disability may involve a malabsorption of essential neurotransmitters 
at the synaptic gap. As a result, abnormally-low levels of a specific 
neurotransmitter are absorbed, e.g., dopamine or serotonin, which may 
cause an experience of depression. Alcohol alleviates the depression, 
(Ballenger et al., 1979; Goodwin, 1988; Blum et al., 1990). 
The problem with the genetically-determined neurotransmitter 
malabsorption "matures out" of the individual at a particular age, or 
through a minimal interaction with the environment. In the latter case, 
the ingestion of a minimal quantity of mood-altering drugs could trigger a 
dormant problem, or exacerbate a currently active one. Here, the disease 
45 
concept of loss-of-control applies. Since the problem with 
neurotransmitter absorption is a function of the autonomic nervous 
system, it is beyond the volitional control of the individual. Therefore, the 
person is counseled towards abstinence. 
The maturationist perspective based on a physiological theory of 
etiology, often referred to as the "disease model," does not necessarily have 
to be grounded in genetic theory. Some researchers believe the interaction 
of the person's physiology with the chemicals of the mood-altering drug 
produces a biologically-driven addiction that is independent of anything 
predetermined. Once this interaction occurs, the motivation for addiction 
becomes a primary and biological force, driven by the addict's physiology, 
not will. Thus, the addiction attribution is ironically "inside" the 
individual, yet beyond his or her control, and centrifugal in nature, i.e., it 
"moves from inside out." 
When addiction is attributed to physiological processes, be these 
genetic or otherwise, the model is medical or disease in nature. Thus, we 
have the "disease model of addiction," based on the maturationist 
perspective. Yet, we must also include the psychoanalytic point of view, 
even though it is psychological, not physiological. It still offers a 
predetermined, maturationist explanation for addiction, not necessarily 
characterized by loss-of-control. 
Clearly, the maturationist model of addiction represents the nature 
side of the nature-nurture controversy. The development of addiction 
occurs through a "biological clock of maturation." Heredity is responsible 
for well over 50 percent of the interaction between the individual and his 
or her environment. Once set into motion, the addiction is generally 
viewed as beyond the volitional control of the person. 
9?  
46 
The Behaviorist Paradigm 
The second model often used to explain addiction is the behaviorist 
model, (e.g., Blakey & Baker, 1980). Here, addiction is a learned behavior. 
This behavior occurs through a passive relationship of the organism to its 
environment. The environment accounts for well over 50 percent of 
addiction. 
From the behaviorist perspective, addiction is the acquisition of spe-
cific standards of behavior. The behaviorist and moralistic models are 
similar in the sense that advocates for both view the environment as the 
primary cause of addictive behavior. The behaviorist explains addiction in 
terms of an active-environment (stimulus)-passive-organism (response) 
relationship. The moralist sees the environment as causing the addiction 
through the individual's ingestion of a universally-addicting substance, 
i.e., alcohol or "addictive" drugs. The moralist also believes that a lack of 
"proper" values causes the ingestion of drugs. People in the environment 
should instill their "good" values into the drug addict, or potential d rug 
addict. 
From a strictly behaviorist point of view, the passive relationship 
with a stimulus-environment motivates the organism to learn addiction. 
Environment shapes behavior. Drug experience is self-rewarding. 
Reinforcement is the foundation for continued use, i.e., the addiction. 
Drug euphoria reduces a painful experience. It is rewarding and 
reinforcing in its "power" to remove noxious stimuli, i.e., negative 
reinforcement. The drug and the environment are "the power." 
According to the opponent-process theory, drug addiction exists as a 
combination of mechanized polar experiences reinforcing one another, 
47 
(Solomon & Corbit, 1974). The drug experience is self-reinforcing. It is 
deterministic, producing two opposing experiences. 
For example, cocaine produces an experience of euphoria. In the 
early stages of cocaine use, a relatively small amount of the drug produces 
a strong feeling of euphoria. Soon thereafter, drug tolerance develops. 
Increasing amounts of cocaine are required to produce the previous 
experience of euphoria. 
This tolerance is psychological or physiological. Physiological 
tolerance means that increasing amounts of the drug are ingested to create 
an earlier physiological reaction. Psychologically, the euphoria may 
become "normalized." It loses its novel nature. The amount of drug 
needed to produce euphoria increases as the experience of euphoria 
decreases. The decrease in euphoria motivates the individual to use more 
of the drug. As tolerance develops, individuals "need" more of the drug to 
produce euphoria. Psychologically or physiologically, the addiction cycle is 
established. 
This psychological opponent-process exists in an "addiction" to non-
drug activities too. Sky diving is an example. A person experiences 
anxiety before jumping from the plane. An experience of euphoria follows 
the anxiety upon descent. The feeling of euphoria motivates the attempt 
to t.ry it again. The anxiety before the jump decreases, as the euphoria 
during the jump and descent increases, (Feldman, 1990). 
In the sky-diving example, the anxiety decreases as the euphoria 
increases. In the cocaine example, tolerance and quantity of cocaine 
increase as the euphoria or quality of the drug experience decreases. In 
both cases, one experience, be it psychological or physiological, conditions 
48 
an opposing experience. The reduction of one type of experience creates an 
increase in the opposing one. This establishes the addiction. 
Behaviorists use the "black box" and the "potter's clay" metaphors. 
The person is like a black box. There is nothing "inside." Performed 
behaviors define the person. There is no mind, no self?directed sense of 
will or meaning. Cognitive?behaviorists condition thoughts like 
behaviors, (Marlatt & Gordon, 1985). The environment is the primary 
executor of acquired behavior. The environment "shapes" the addictive 
behavior the way a potter fashions a lump of day. 
In the maturationist model the environment is passive and the self 
is active. In the behaviorist model the environment is active and the 
organism is passive. Behaviorists use aversion training and punishment 
to treat addiction. They manipulate changes in reinforcement-contingency 
schedules too, (Cohen et al., 1971a; Cohen et al, 1971b). 
Classical and operant conditioning principles apply here. The addict 
pairs drug use and reward. The addict creates reward through drug 
ingestion. Drugs cause reward. Repetition reinforces reward. Repetition 
establishes the addiction. Environmental factors create the addiction. The 
"nurture" side of the nature-nurture controversy reigns in this 
perspective. 
The Interactionist Paradigm 
In the interactionist model, the interaction between self and 
environment creates the addiction. "Why" the individual interacts with 
the environment in a particular way concerns the maturationist. "How" 
the individual interacts with environment concerns the interactionist. 
The meaning of the contact between individual and environment plays a 
key role in determining the potential for addictive behavior. 
49 
Addiction is a dynamic process, according to the interactionist. It is 
not static, predetermined or dependent on optimal environmental 
conditions to unfold. Volition and "meaning-making" play a central role, 
(Fingarette, 1985a; Schaler, 1991b; Kegan, 1982). Addiction is a choice, not 
a disease, (Schaler, 1989c). The interactionist attends to individual 
differences in cognitive ability as well as environmental conditions that 
provoke meaningful interaction with self. Some interactionists question 
the very existence of an entity called addiction, (Szasz, 1989). Some appear 
to combine elements of spiritualism, "systemic determinism," and 
stoicism, (Bateson, 1971; Brundage, 1985). 
The "camera-lens metaphor" is a way of understanding the 
inte.ractionist's beliefs about addiction. The nervous system of the body is 
like a lens, modulating experience as self and environment interact. The 
self is like the film in a camera. The self organizes experience here a.nd 
creates meaning. The self is not the brain. The self defines experience as "I 
am ." 
Individual physiological differences affect the experience of self. 
They do not create it. The quality of a camera lens affects the image of the 
environment transposed to the film. When the image is unpleasant, the 
self uses drugs to modify the lens. 
The self is the executor of experience in this model, not the nervous 
system. Drug use may or may not be an effective way to modify the lens. 
The assessment of drug effectiveness and the price of drug use are moral, 
not medical, judgments. 
The recommended therapy for the person who uses drugs is: (1) A 
matter of choice; 2) concerned with awareness and responsibility; 3) a 
process of values clarification; 4) a means of support to achieve specific 
so 
behavior goals; and 5) an educational process that involves the learning of 
coping strategies, (Schaler, 1991b). 
Psychotherapeutic models employing the interactionist perspective 
include those based in existential phenomenology, e.g., gestalt therapy, 
(Perls, 1947; Perls et al., 1951); and other forms of therapy that eschew the 
medical and behaviorist models, (Szasz, 1965). Therapy is not a form of 
"treatment," where one party does something to the other. It is a 
contractual, not a medical, relationship, (Szasz, 1965). 
From the interactionist perspective, the self strives to attain valued 
levels of cognitive development. These values are a function of self-
environment interaction. A pre?set standard that mechanistically matures 
according to individual age with minimal environmental involvement 
does not determine the addiction. People create addiction. They do not 
release it. An active environment does not shape a passive organism into 
creating addiction. 
From the interactionist perspective, drug addiction is not a disease 
defined by a physical lesion of the body. It is a behavior and as such a 
willful act based on the drug user's personal values. Thus, from this 
perspective, it does not make sense to speak of "treating" individuals 
because they are addicts, or, to treat them for their addiction, since drug 
addiction is a behavior based on moral choices. "Bad values" do not need 
medicine, according to the interactionist, (Szasz, 1972; Schaler, 1991b). 
Drugs given to an addict to inhibit euphoria from an opiate, (e.g., 
naloxone HCL), or to make them feel nauseated when they drink alcohol, 
(e.g., disulfarim), influence and control behavior, but do not cure it. The 
interactionist differentiates between what a drug does to the body and how 
the drug gets into the body, (Szasz, 1989). 
51 
Heroin addicts, maturationists often claim, are like diabetics. 
Medical modelists give methadone, a synthetic opioid, to heroin addicts on 
this basis, (despite the fact that heroin addicts do not suffer from an 
inability to produce methadone). The interactionist says the analogy is not 
reciprocal, (Schaler, 1989a). Diabetics are not like drug addicts. 
It may be useful to imagine the following scenario to appreciate this 
important distinction between maturationist and interactionist: A drug 
addict is in one jail cell and a diabetic in another. Deprive the heroin 
addict of his heroin. Deprive the diabetic of his insulin. The diabetic gets 
sicker and eventually dies. The drug addict gets better and lives. Insulin 
helps the diabetic. Lack of methadone or heroin helps the heroin addict,  
(N. Borelli, personal communication, 1989). 
In the interactionist model, nature and nurture are mutually 
inclusive. Self is the executor of experience. A hierarchical system of 
values formed through a reciprocal relationship of self and environment 
creates addiction. 
The interactionist model of addiction is perhaps the least popular of 
the three. The focus on personal responsibility for the addiction may 
account for this. 
Summarx 
In summary, the three models of addiction differ according to how 
the individual interacts with the environment. In the maturationist 
model, self and its cognitive components emerge from a mysterious and 
unconscious "within," maturing in a centrifugal manner, nurtured by 
environmental situations and conditions that enhance or restrict 
maturation. The environment plays a minimal yet critical role in 
development. Addiction "unfolds," psychologically or physiologically. 
52 
The behaviorist model sees addktion as an outcome of self in 
passive, yet direct, relationship with environmental stimuli. Addiction is 
a function of a centripetal relationsih.iip witt:h the ,en.v.b."Oiiilment, tlhe ,opjposite 
of the maturationist perspective. Environment acts on. the :seU. 
Free will and self determination concern the internctionisit. The self 
chooses to engage in addictive behavior to either adapt to environmental 
experience, or because drugs enhance a :sense of meani,m,g illil the w,odd. 
Addiction is not a treatable entity. Rather.,, addic,tion i-s a mm.al choice 
individuals make based on multitudinous existenit.ia[ factors. 
The next section of this review focuses on how Americans have 
viewed addiction over the past 200 y1e:a1ns. 'The 'three models of addu,otion 
are used to organize shifts in beliefs r,egardin,g addkition. 
A Historical Trace of Beliefs Regarding the Etiology of Addiction 
Public attitudes towards alcoholism and drug addiction have gone 
through several radical changes in America ,owec !the past ltwo :tmndr,ed 
years. The attributions regarding addiction prob1ems, ws well as beliefs 
regarding etiology, took three directions: (a) 1ntera-ctkm with the sodal 
environment, (the interactionist paradigm), caused the problems rela,ted to 
addiction; (b) The drug itself, (the b~havi((J)ri:St 0)1" mornllislt ]Paradi,gm) 
caused the problem; (c) The physiology or ithe ?'tmconscious" mind of the 
drug user, (the maturationist or medical paradigm), -caused the problem. 
This section will describe the various beliefs regarding addiction, 
which has primarily concerned alcoh,oll use~ a 1km;g these \three attributional 
dimensions, from a historical context. This revtew does not discuss a 
fourth and relatively recent model, the biopsychosocial model, (Engle, 
1977). It is a combination of the three models addressed in detail. 
53 
Overview 
According to Levine (1978), 
[t]he idea that alcoholism is a progressive disease-the chief 
symptom of which is loss of control over drinking behavior, and 
whose only remedy is abstinence from all alcoholic beverages-is 
now about 175 or 200 years old, but no older. (p. 143) 
The concept of and belief in alcohol addiction continued and 
extended to opium addiction. Proponents of the medical model of 
addiction, while appearing to have, distanced themselves from the 
moralistic stance of temperance days, are similar in their views of the 
teetotaler philosophy of that period. 
For example, the medical modelists of today counsel addicts to be 
abstinent to prevent and treat problems with alcohol and other drugs. 
Temperance advocates counseled alcoholics and non-alcoholics alike to do 
the same. This belief is contrary to findings that controlled-drinking and 
moderate drug ingestion are equally if not at times more effective in 
controlling the problems associated with addiction, (Pattison, 1966, 1976; 
Miller & Caddy, 1977; Miller, 1983; Marlatt, 1983; Sanchez-Craig, 1984; 
Erickson et al., 1987; Roizen 1987; Peele, 1992). 
As Levine (1978) has pointed out, 
[t]he most important difference between temperance thought and 
the 'new disease conception' is the location of the source of 
addiction. The Temperance Movement found the source of 
addiction in the drug itself-alcohol was viewed as an inherently 
addicting substance, much as heroin is today. Post-Prohibition 
thought locates the source of addiction in the individual body-only 
54 
some people, it is argued, for reasons yet unknown, become addicted 
to alcohol. (p. 144) 
The medical modelists of today attributes addiction problems to the 
physiology of the addict. They assert that addiction has nothing to do with 
morality or personal values. Both the medical and moralistic modelist of 
temperance days believe in the concept of loss of control, a concept that 
developed as a result of the repeal of Prohibition laws and the founding of 
Alcoholics Anonymous during the mid 1930s. These are the two models 
that have dominated beliefs regarding alcoholism and addiction since the 
early part of the 19th century. 
Colonial Period 
During colonial times in America there was no such phenomena as 
alcoholism, alcoholics, or drug addicts. "'Addicted' meant habituated, and 
one was habituated to drunkenness, not to liquor," (Levine, 1978, p. 147). 
The Puritan Cotton Mather called alcohol the "good creature of God.f' 
Ministers and physicians alike encouraged people to use it. People of the 
time considered alcohol a general panacea for psychological and physical 
ailments. "New England's Puritan ministers praised alcohol but 
denounced drunkenness as a sinful and wilful (sic) misuse of the 'Good 
Creature,"' (Levine, 1984, p. 110). Drinkers and their drink did not cause 
the problems associated with drunkenness. Bad company and social 
interaction caused them, (Levine, 1978; Fingarette, 1988). 
When a person had a problem with alcohol, people of colonial times 
considered this to be a function of the particular crowd the individual 
socialized with. They blamed the tavern he or she frequented and the 
social interaction that occurred there. 
55 
Gradually, a moralistic stance regarding habitual drunkenness, based 
in religious dogma, developed. The writings of Puritans around the end of 
the 17th century and the beginning of the 18th century ushered in a new 
era regarding drunkenness. Cotton Mather began to change his views, and 
called drunkenness "this engine of the Devil," (Levine, 1978). Increase 
Mather, his father, attributed the difficulty in giving up the habit of 
drunkenness to "sin," (Levine, 1978). 
Terms such as "craving" and "overwhelming desire to drink," as an 
inner experience that drove the drunkard to drink, terms clearly related to 
the 19th and 20th century concept of "loss of control," were not used to 
explain the colonial drunkard's "sinful" habit. The "sin" in this case, was 
the drunkard's "love of 'excess' drink to the point of 
drunkenness .... Drunkenness was a choice, albeit a sinful one, which some 
individuals make," (Levine, 1978, pp. 148-149). Desire and will were 
synonymous. This idea regarding the role of will in explaining 
drunkenness is in sharp contrast to the 20th century notion of the disease 
of alcoholism as characterized by uloss of control" or will. 
The interactionist and moralistic views of drunkenness during 
colonial times, uniting the ideas of "desire" and "will," viewed 
drunkenness as a natural behavior, as natural as any sinful pursuit of 
pleasure. This interactionist and moralistic model appear to have 
prevailed until the mid-18th century when physicians began to look for 
distinctions between "desire" and "will" as explanations for deviant 
behavior, behavior they considered unnatural, (Levine, 1978; Grob, 1981). 
Ben.i amin Rush and the Medicalization of Socially-Deviant BehaviQr 
Benjamin Rush (1746-1813), a physician and signer of the 
Declaration of Independence, and a man generally known today as the 
56 
"father of American psychiatry," solidified this new way of defining 
drunken deviance in 1784 and declared that alcoholism was a "disease," 
and a disease of the will at that. As Levine (1978) writes, 
Rush's contribution to a new model of habitual drunkenness was 
fourfold : First, he identified the causal agent-spirituous liquors; 
second, he clearly described the drunkard's condition as loss of 
control over drinking behavior-as compulsive activity; third, he 
declared the condition to be a disease; and fourth, he prescribed total 
abstinence as the only way to cure the drunkard. (p. 152) 
Writings by Rush marked a shift in beliefs about drunkenness, 
(Rush, 1981 ). Similar writings appeared around the same time in England 
by Thomas Trotter, a physician in Edinburgh, where Rush received his 
medical degree: "In medical language, I consider drunkennes.s, strictly 
speaking, to be a disease; produced by a remote cause, and giving birth to 
actions and movements in the living body, that disorder the functions of 
health," (Trotter, 1813, p. B2). 
The categorization of alcoholism as a disease by Rush heralded a 
new era in the medicalizing of social deviance, (Szasz, 1970). While he had 
no scientific evidence to support his claim that alcoholism was a disease, 
Rush was a powerful rhetorician and managed to influence public opin-
ion, (Szasz, 1970; Levine, 1978; Fingarette, 1988). Chronic drunkards 
allegedly had an unknown, physiological disease that made them drink. 
The "good creature of God" had clearly become the "demon rum," (Levine, 
1978; Szasz, 1970; Fingarette, 1988; Blumberg & Pittman, 1991; Blumberg, 
1978). 
Yet, a curious union of moralism and medicine occurred 
simultaneously. "Health and wealth" were synonymous with temperance, 
57 
and disease with intemperance, according to Rush's "moral and physical 
thermometer," (Rush, 1981). The "thermometer," a figure in Rush's 
original text, was "a scale of the progress of Temperance and 
Intemperance-Liquors with effects in their usual order (sic)." Water was 
at the "highest temperature," followed by milk, water and "small" beer, 
associated with "serenity of mind, reputation, long life, & happiness." 
Cider, "perry," wine, "porter," and strong beer flowed down the 
thermometer to increasingly "cold" temperatures and caused 
"cheerfulness, strength, and nourishment, when taken only in small 
quantities, and at meals." FinaHy, a variety of hard liquors of the time 
described "below zero," and caused various vices, diseases, and 
punishments, (Rush, 1981). 
As Blumberg and Pittman (1991) point out, Rush believed 
that because spirits were no longer primarily used medicinally by 
physicians, but had become a beverage used by the general 
population; new diseases had appeared as well as new symptoms of 
old diseases. ... Rush had come to the conclusion that, in general, 
spirituous liquors are not necessary nor useful under any 
circumstances. He saw spirituous liquors as undesirable to human 
society not only in a general way, but also as a threat to the 
Republic. ... He argued that 'a people corrupted with strong drink 
cannot long be a free people (his emphasis), for the use of spirituous 
liquors will corrupt the rules of the community and so corrupt the 
laws that they make.' (pp. 31-32) 
None of these descriptions had anything to do with empirical 
medicine. They were moral judgments disguised as medical ones. Szasz 
58 
(1970) explains that " ...R ush did not recognize that drinking was a medical 
problem; he defined it as one," [emphasis in original] (p. 141). 
An interesting exam.pie of Rush's tendency to medicalize socially 
deviant behavior was his "discovery" in 1792 of a disease he called 
"negritude," (Rush, 1799). A black slave by the name of Henry Moss had 
consulted him for white spots that appeared on his arm, a condition 
known today as vitiligo, which involves a loss of pigmentation in the skin. 
Rush diagnosed the man as experiencing a spontaneous cure of his 
''blackness." He claimed that white skin was the natural state of skin color 
for people and that blacks were suffering from a congenital form of leprosy 
called negritude, which caused their skin to be dark in color. 
What is particularly fascinating about this "diagnosis" is that Rush 
professed great compassion towards blacks. He said "I love even the name 
'Africa''', (Comer, 1948). However, he argued that blacks and white should 
not intermarry because negritude would spread hereditarily, (Szasz, 1970). 
The Temperance Movement 
From Rush's time onward, alcohol gradually became regarded as a 
universally-addicting substance capable of corrupting and thereby 
"diseasing" any person, regardless of moral standing. Thus, the blame for 
alcohol-related problems shifted from ''bad company" to a mysterious 
diseased state within the individual, to the beverage itself. Rush asserted 
that abstinence was the only way to treat the disease of alcoholism. 
These ideas gathered momentum among members of the 
temperance movement. The idea of temperance was in the early days of 
the movement was ambiguous. Temperance referred to moderation, or 
control in relation to drinking beer and wine, and abstinence in relation to 
59 
distilled liquors, (Levine, 1984). Rush advocated abstinence, and leaders in 
the Temperance Movement claimed him as their founder: 
His writings on the relationship between intemperance and ardent 
spirits, his descriptions of the individual and social consequences of 
the use of liquor, as well as his recommendation of total abstinence, 
formed part of the essential core of temperance ideology throughout 
the 19th century. (Levine, 1978, p. 153) 
The idea that drunkards could not control their drinking began to 
spread through public testimonials. "By about the mid-1830s, certain 
assumptions about the inner experience of the drunkard had become 
central to temperance thought. The desire for alcohol was seen as 
'overpowering,' and frequently labeled a disease," (Levine, 1978, p. 154). 
The notion that drunkenness was a hereditary disease also emerged. 
Nineteenth-century Americans believed in a particular version of 
the heritability of acquired characteristics. The disease of the parents 
would be passed on to later generations, but it was thought the traits 
could be unacquired as well, over several more generations. Thus 
liquor could be viewed as the cause of habitual drunkenness because 
any individual may have been weakened by his or her ancestors' 
drinking habits. (Levine, 1978, pp. 156-157) 
The truth, in terms of the Temperance Movement's perception of 
drunkenness was this: Drunkenness was a sin and a disease-a sin first, 
then a disease, (Levine, 1978, p. 157). Good morals, which equaled 
abstinence, protected individuals from getting the disease and cured them 
if they had succumbed to the disease. Drunkenness was a disease caused 
and perpetuated by bad morals. Good morals maintained sobriety and 
temperance. 
60 
Interestingly, Temperance leaders despised moderate drinkers more 
than habitual drunkards, who were more the object of pity. Clearly, 
moderate drinkers exercised discretion and autonomy. They could control 
their drinking through will power and in so doing ma.y have discredited 
the claims of the Temperance leaders to the contrary. 
The attitude of those members of the Temperance Movement is an 
example of the behaviorist and moralist paradigm. They based their goal 
to change the drinking behavior of people solely on the belief that alcohol, 
a purely environmental agent, and "wrong morals" were the cause of 
drunkenness. They had the "right" values and were out to impose their 
values on the individual. The link with the disease-model perspective is 
curious. The movement admitted its roots in the writings and beliefs of 
Benjamin Rush. It viewed drunkenness as a disease, second to it being a 
sin. 
Since alcohol was the source of all sorts of domestic problems, the 
focus of members of the Temperance Movement shifted towards the end 
of the 19th century. Prior to this time, the focus of the group was on 
"affiliative reform." This interest became secondary to one of "coercive 
reform," and the eventual establishment of Prohibition. In other words, 
the motivation to change behavior was first to absorb sinners into the 
"sanctuary of the flock." Then, it became a campaign against evil. 
According to Gusfield, (1963): 
The champion of assimilative reform viewed the drinker as part of a 
social system in which the reformer's culture was dominant. On 
this assumption his invitation to the drinker to reform made sense. 
The champion of coercive reform cannot make this assumption. He 
sees the object of reform as someone who rejects the social 
61 
dominance of the. reformer and denies the legitimacy of his life style. 
Since the dominance of his culture and the social status of his group 
are denied, the coercive reformer turns to law and force as ways to 
affirm it. (p. 7) 
Medical rhetoric was often used to achieve these ends. According to 
Bakalar and Grinspoon (l9 S4), 
(t]he campaign against alcohol, like other antidrug campaigns, was 
also a movement for public health reform. Often parallels were 
drawn between drunkenness and cholera, the most terrifying 
epidemic disease of the nineteenth century; like cholera, alcohol 
abuse was regarded as a symptom of social disorder as well as a 
disease-something that required indirect solutions. The teaching 
of physiology and hygiene in public schools was promoted mainly by 
temperance reformers and prohibitionists; much more space in 
school textbooks was devoted to the dangers of alcohol in the 1880s 
than in the 1930s. (Sometimes lurid misinformation was 
introduced into this educational material-for example, the 
assertion that alcohol, could burn the throat or cause spontaneous 
combustion in a drunkard. Parallels with: more recent antidrug 
campaigns are evident.) (p. 83) 
Prohibition, Repeal, and the Birth of Alcoholics Anonymous 
The culmination of Temperance Movement political lobbying 
resulted in the establishment of Prohibition in 1919. The Volstead Act 
(1920) gave Congress and the states the power to enforce the 18th 
Amendment, which prohibited the manufacture and sale of alcoholic 
beverages, (Mitchell & Stein, 1983). 
62 
The rationale for Prohibition appears based in the belief that all 
drinkers would eventually drink uncontrollably. Drinking led to 
drunkenness, a state of "moral turpitude." Abstinence for all was the cure 
for alcohol addiction. Again, there was no scientific evidence to support 
this belief. This was the result of a moralistic, not a scientific, campaign. 
The incidents of and problems associated with heavy drinking de-
creased during Prohibition, (Musto, 1987; Bakalar & Grinspoon, 1984), but 
not necessarily as a because of it, (Levine, 1984). The law against the sale 
and possession of alcoholic beverages became impossible to enforce. Crime 
rates associated with illegal distribution rose dramatically and public 
demand increased such that the will of the people demanded a change in 
the law. Big business gave generous amounts of money to support the 
cause for repeal for two reasons: (a) Wealthy business people believed that 
repeal would facilitate liquor tax increases and thereby reduce personal 
income tax; and (b) the corporate rich believed and feared that "disrespect 
for prohibition was producing widespread disrespect for all law including 
property law," (Levine, 1984, 115). Prohibition was repealed in 1933. 
Repeal decriminalized alcoholism through its subsequent medicalization, 
(Cahalan, 1988). 
Once again, public beliefs and attitudes about alcohol and drinking 
changed. Most people did not seem to subscribe to the Temperance belief 
that alcohol was a universally-addicting substance. Many people clearly 
drank without problems, including heavy drinkers. Additionally, people 
believed they had a right to drink without governmental interference. The 
idea of free will in relation to alcohol emerged. 
One present day erroneous view of the 19th century temperance is 
that it was condemnatory and unsympathetic to the inebriate. In 
fact, the opposite was true: temperance supporters were the most 
sympathetic and helpful and are the true forerunners of both 
Alcoholics Anonymous and of most contemporary forms of 
alcoholism treatment. (Levine, 1984, p. 112) 
Temperance beliefs about alcohol lost their popularity, (Fingarette, 
1988; Peele, 1989). A new way of viewing alcoholism appeared by 1935 
with the founding of Alcoholics Anonymous (AA), a self-help spiritual 
fellowship of recovering alcoholics committed to helping one another 
maintain sobriety, (Ritchie, 1948; W., 1949; Thompson, 1952; Ripley & 
Jackson, 1959; Tiebout, 1961; C., 1965; Leach & Norris, 1977; Kurtz, 1988; 
Makela, I 991). 
Following the teachings of Dr. William Silkworth, Wilson and 
Smith [the founders of AA] maintained that people who became 
alcoholics had a disease-they had something wrong with their 
bodies which eventually made them unable to control their 
drinking .... 
The brilliantly originaJ contribution of the founders of 
Alcoholic Anonymous was to marry this 'new disease conception' to 
a remarkable organizational form: a self-help network of 'recovered' 
alcoholics who frankly discussed their drinking and their lives, who 
helped each othe?r to stay off alcohol, who went to other alcoholics 
offering help and a program that worked to maintain sobriety, and 
improve one's life, and who did this 'anonymously'. (Levine, 1984, 
p. 116) 
AA became "a power greater than self," (Donovan, 1984), and united 
with professional forms of treatment for alcoholism, (Miller & Mahler, 
1991). Members believed then, (and today), that alcohol was addicting to 
64 
only a small part of the general population. This figure is estimated to be 
approximately 10 percent today, (Cahalan, 1970). Most people, they 
believed, could drink without problems. Physiological differences shared 
by alcoholics allegedly prevented them from being able to drink in a 
responsible manner. For them, "Prohibition" in the form of complete 
abstinence from alcoholic beverages was the only way of controlling their 
drinking behavior. The maturationist perspective was reborn. 
AA has been analyzed by sociologists as a cult, based on its ideology 
and methodology. Alexander & Rollins (1984) analyzed it as such in light 
of Lifton's eight brainwashing techniques used by the communist Chinese 
in their "thought reform" campaigns. These include "milieu control, 
mystical manipulation, demand for purity, cult of confession, sacred 
science, loading the language, doctrine over person, and dispensing of 
existence," (Lifton, 1961; Alexander & Rollins, 1984). All of these 
techniques seemed to be operating in the AA experience of treatment for 
alcoholism, according to the authors. However, Sadler (1977) qualifies the 
description of AA as a cult by focusing on such elements as voluntarism, 
powerlessness, the interactional context of the AA meeting, and the 
egalitarian nature of the group. She cautions against applying 
"anthropological labels such as 'crisis cult' that were devised to categorize 
specific nonwestern phenomena" to urban, western peoples in groups such 
as AA, (Sadle.r, 1977, p. 210). 
Loss-of-Control Theory and the Disease Concept of Alcoholism 
This etiological paradigm found new support in E.M. Jellinek's work 
at Yale University, (Jellinek, 1946; 1952). He described behavioral patterns 
of drinking similar to those proposed by AA. He wrote of specific stages in 
the development of drinking which he characterized by Greek letters, 
65 
(1960). He named one group of alcoh.olk s ,,.gammau itypes and d iaimed they 
manifested a drinking behavior refoned boas !loss-of-control11 again an idea 
that originated in AA. 
Loss-of-control refers to the tend ency for one drink of akoho[ to set 
into motion a physiological chain r,eaction among akoholirc.s .alleg,edly 
making it impossible for them to e,cerdse volitional OOlmltrol over drinking. 
This concept proved to be the cornier:sitone upon which the dis.ease concept 
of alcoholism and addiction rest, (see also Keller, 1972, 1976,, 1982; Ludwig 
& Wikler, 1974). 
Recovered alcoholics in ALoohoHcs Anonymous speak of 'loss of 
control' to denote that stage in the developm,en.t olf their drinking 
history when the ingestion of one alaohoH.c drinlk sets up a chain 
reaction so that they are umabl,e to adhere to :their intention to 'have 
one or two drinks only' but continue to inges:t :mior,e .and more-
often with quite some difficulty and disgust-contrary to ib111.eir 
volition. (Jellinek, 1960, p. 40 
Rush's Thermometer. .. {wasl striki;rngly similar in purpose and form 
to such later illustrations as E.M. JeHinek's ,gir.aph .. ,.of it:he phrases of 
alcohol addiction. ... The illustrations frt{j)m both eras explained 
alcoholism as a progressive and cumulative process, throug'h which 
alcoholics passed in a generaUy predictable IS'.eqttence of s\teps. In all 
these illustrations, clearly defined stages o:f problem. drinking had 
corresponding social and physical 1conse.quences. (Lender ,& 
Karnchanapee, 1977, p. 1354-1360) 
Through intense public relation ,campaigns initiated by members of 
AA, Marty Mann, an early member oJ AA and ?ounder ,of the National 
Council on Alcoholism, and the Y,aiie Center e:sta1b:l:i:shed by JeUineik, Mark 
66 
Keller, editor of the Quarterly Journal of Studies on Alcohol, and Selden 
Bacon, a director of the Yale center, the "alcoholism movement'' was 
established, (Levine, 1984). Alcoholism was finally accepted as a disease 
characterized by loss-of-control behavior by the American Medical 
Association in 1954, (Cahalan, 1988; see also Criteria Committee, National 
Council on Alcoholism, 1972; American Medical Association, 1967). By 
1964 there was '1ittle solid evidence of the degree of public acceptance of 
the illness concept, or of its attitudinal and behavioral correlates," 
(Mulford & Miller, 1964; Verden et al., 1969). The American Medical 
Association issued the following statement (1967): 
Alcoholism is an illness characterized by preoccupation with alcohol 
and loss of control over its consumptions such as to lead usually to 
intoxication if drinking is begun; by chronicity; by progression; and 
by tendency toward relapse. It is typically associated with physical 
disability and impaired emotional, occupational, and/ or social 
adjustments as a direct consequence of persistent and excessive use. 
(p. 6) 
Numerous medical and psychiatric associations adopted the disease 
model of alcoholism world-wide. The model covers numerous 
"addictions" including drug addiction, (Peele, 1989). 
Caetano (1987) studied public opinion and beliefs "about alcoholism, 
treatment and stigma surrounding the alcoholic." Approximately 90 
percent of those studied believed that alcoholism was a disease, and 
[c]onceptions about alcoholism [were]. .. not entirely consistent in the 
public's mind; the disease concept may be contradicted and 
supported at the same time. With regard to alcoholism this 
contradiction is most often represented by the public's under-
67 
standing of alcoholism as a disease and as a sign of moral weakness. 
(p. 158) 
An example of this latter point is evident when Congress passed a 
law, following the Supreme Court's ruling in Trnynor v. Turnage (1988), 
prohibiting the alcoholism of a veteran seeking education benefits from 
being labeled "willful misconduct," yet would not allow this prohibition to 
apply to drug addiction because Congress construed this as rewarding the 
addict for his or her illegal drug use, (Schaler, 1989b). 
Genetic Studies 
Belief in the disease model of alcoholism and drug addiction has 
been bolstered by studies on adopted twins of alcoholic parents, and 
recently through investigations concerning linkage and association of the 
D2 allele of the dopamine receptor gene among alcoholic populations, 
although the findings yield opposite results, (Gordis et al., 1990; Blum et 
al., 1990; Bolos et al., 1990; Gelemter et al., 1991; Parsian et al., 1991; 
Conneally, 1991; Cloninger, 1991; Comings et al., 1991; Noble et al., 1991; 
Brown, 1991). Some researchers assert there are metabolic differences 
between alcoholics and normal drinkers, brain wave differences between 
these two groups, and serological markers for alcoholism, etc., (Goodwin, 
1988; Kissin, 1983; Milam & Ketcham, 1983; Vaillant, 1983; Cloninger et 
al., 1981; Hill et al., 1975). 
Genetic theories of alcoholism have focused on adoption (Cloninger 
et al., 1981; Cadoret & Gath, 1978; Schuckit et al., 1972) and twin studies, 
(Heath et al., 1991a, 1991b; Pickens, et al., 1991; McGue et al., 1992). In the 
adoption studies, sons whose biological fathers were classified as alcoholic 
were put up for adoption and incidents of alcoholism in this group were 
68 
compared with sons whose biological fathers were not alcoholic. A 
representative study of this sort is discussed by Fingarette (1988). 
Goodwin et al. (1973) found that approximately 18 percent of the 
sons whose biological fathers were alcoholic became alcoholics themselves, 
while only five percent of the adopted sons whose biological fathers were 
not alcoholic became alcoholics. Thus, sons of alcoholics were 3.6 times 
more likely to become alcoholics than sons whose fathers were not 
alcoholics. This difference was found to be statistically significant and 
many people use this as evidence to assert that alcoholism is a genetic 
disease. 
As Fingarette points out (1988), this conclusion depends on how one 
interprets the numbers. If 18 percent of the adoptees became alcoholic, 82 
percent of the sons whose biological fathers were alcoholic did not become 
alcoholics. In other words, four out of five sons of alcoholic fathers do not 
become alcoholic. Either the genes are not always transmitted, or if they 
are, environmental factors can override the influence of the genes. The 
difficulty with such studies is explaining how genetics can account for the 
fact that sons of alcoholic fathers don't become alcoholic themselves, and 
sons of non-alcoholic fathers do. 
A study by Blum et al. (1990) set off a wave of controversy regarding 
the genetic basis of alcoholism that is still unresolved. Blum et al. (1990) 
probed nine? different genes hypothesized to be linked to alcoholism and 
found that the Al allele of the dopamine D2 was significantly related to 
alcoholism, while the eight other genes were found to be unrelated. They 
studied the DNA of brain tissue taken from 70 unrelated cadavers and 
found that the allele of the dopamine receptor gene predicted 69 percent of 
the alcoholics and 20 percent of the non-alcoholic controls. The difference 
69 
was statistically significant. The authors concluded that the dopamine D2 
receptor gene is strongly associated with alcoholism. 
Peele (1990b) asserted that Blum et al.'s study is more disconfirming 
than confirming, i.e., eight genes were disconfirmed. Bolos et al. (1990) 
attempted to replicate the finding by Blum et al. and used a more 
scientifically-rigorous methodology, i.e., living subjects with pedigree and 
higher reliability of alcoholism diagnoses. Not only did they fail to 
replicate the finding by Blum, but they found a higher incidence of the 
dopamine receptor gene in the control group! 
The allele of the dopamine gene seems distantly related, or 
associated, but not linked. Moreover, the gene is equally associated with 
many other forms of deviant behavior and disorders, not just alcoholism. 
This being the case, and the other genes hypothesized as involved 
eliminated through the Blum study, there is no direct evidence to 
implicate gene linkage. 
However, the twin studies do continue to suggest involvement 
between genes and alcoholism, in the minds of many researchers. For 
example, Kendler et al. (1992) recently reported "that at least half of the 
total liability to alcoholism is a result of genetic factors." They asserted that 
53 to 61 percent of the variance in alcohol-dependency status is explained 
by "additive genetic factors" among monozygotic and dizygotic twins. 
Controversy continues regarding these conclusions, (see also Vatz & 
Weinberg, 1988). For example, authors of a recent study assert that additive 
genetic factors are responsible for alcoholism among female, monozygotic 
twins, (Kendler et al., 1992). 
Alcohol-dependency status was operationally defined using the 
Diagnostic and Statistical Manunl of Mental Disorders, Third 
70 
Edition, Revised (DSM-III-R) diagnosis of alcohol dependency. Yet, 
according to the DSM-III-R, "(tJhere are three main patterns of 
chronic Alcohol... Dependence [and] ... [i]t is a mistake to associate one 
of these particular patterns exclusively with 'alcoholism."' 
Alcoholism is defined there in terms of "impaired control," a con-
cept stemming from the "loss of control" theory. This theory was 
disproven years ago. Moreover, tolerance varies, i.e., some heavy 
drinkers do not develop it, just as some do not crave alcohol and 
experience withdrawal. 
The definitions of alcoholism created by the authors on the 
basis of DSM-111-R and "impaired control," namely, "(1) narrow-
only alcoholism with dependence-tolerance; (2) intermediate-alco-
holism with or without dependence-tolerance ... ; and (3) broad-
akoholism with or without dependence-tolerance or problem 
drinking,'' are so vague they are meaningless. Thus, their con? 
cl usi ons regarding a prediction is not one of genetics and alcoholism 
but a measure of correlation between female twins and the beliefs of 
researchers assigning them to capricious "alcoholisms," which 
appear to have virtually nothing in common. 
To make matters even worse, this conceptualization of 
alcoholism includes "anti-alcoholism," or, the putative "correlation 
of liability. .. or vulnerability to alcoholism." This concept seems 
especially far-fetched in relation to drinking behavior, which by 
definition is volitional, and thereby based on moral and 
environmental factors. 
On the one hand, the authors' classifications of alcoholism are 
based on alcohol dependence (which, insofar as "dependence" rests 
71 
on loss-of-control, does not ,exist), "non-dependence" and "non-
tolerance," (whatever they are), and problem drinking, a subjective 
and arbitrary assessment. On the other hand these variables are 
tested as part of an imaginary continuum of liability to vulnerability 
to alcoholism. The model simply doesn't make sense. 
The fact that correlation does not equal causation, that 
mechanisms by which biology translates into behavior are 
unknown, that the putative gene(s) allegedly responsible for 
alroholism is not always transmitted, (39 to 47 percent of the time 
according to the present study), that the effect of an alcoholism gene 
can be overridden by environmental factors, and that just because 
something is genetic does not mean that it is a disease, e.g., skin 
color, all notwithstanding - JAMA readers are presented with the 
findings of a study in which the only reliable and constant variable, 
twin status, is allegedly correlated with a non-existent entity called 
"liability to vulnerability" for varying degrees of alcohol 
dependency. ...,  (Schaler:, in press). 
(The lead author of this twin study was asked to respond to these 
criticisms by the editors of the Journal of the Americnn Medical 
Association.) 
I agree with you that there remains no broad consensus in the 
research community about the proper definition for alcoholism. It 
is in fact not clear that there is on unambiguous manner in which to 
discriminate the broad spectrum of drinking problems into those 
with and without "alcoholism." However, we dealt with this 
problem in our study by examining three divergent definitions of 
alcoholism. The fact that the results of our twin modeling were 
72 
consistent across these widely differing definitions led us to have 
more confidence in the overall results. 
You are correct that our conclusions about the role played by 
genetic factors in "alcoholism" derive from our observation in 
identical and fraternal twins. We and others in the literature have 
extensively examined the strengths and limitations of twin research. 
While obviously not approaching laboratory-based research in the 
kind of experimental control that is possible, twin studies remain 
one of the most valuable methods in human research for 
quantitating (sic) the role of genetic and environmental factors. 
Previous studies of potential problems with the twin method 
(especially the equal environment assumption) in our hands have 
suggested that, at least as a first approximation, twin studies are 
likely to provide valid estimates of the importance of genetic factors 
in human traits. 
The liability threshold model that you criticize has been 
widely used in genetic epidemiology. Again, there are limitations; 
but these have been relatively well understood. I think the evidence 
strongly suggests that, although this may not be precisely correct, it is 
nonetheless a reasonable approximation toward reality for complex 
multifactorial traits like alcoholism. I disagree with you that 
looking at the resemblance for lack of alcoholism is improper. In 
fact, that is one great strength of a population-based twin study, 
which can examine all four cells of a 2X2 table. Your understand of 
heritability statistics is incomplete. It is not that the putative genes 
are not always transmitted. All genes except those that are sex 
linked are transmitted from parents to offspring at meiosis with a 
73 
probability of 50%. What heritability means is the total variance in 
this putative liability that is due to additive genetic factors. I 
certainly agree that correlation does not equal causation, but other 
hypotheses to explain the excess similarity in MZ versus DZ twins in 
our twin study and other are much less plausible than that genetic 
factors are so involved. (K. Kendler, personal communication, 
January 7, 1993). 
At least two additional points should be understood in the 
evaluation and interpretation of genetic studies on alcoholism involving 
twins (a) Identical twins elicit similar responses from their environments, 
which may account for personality similarities not attributable to genetic 
factors; and (b) these studies are always environmentally dependent in the 
sense that both twins are living in similar environments. For example, if 
one of the monozygotic twins discussed by Kendler above lived in an 
Islamic country, where alcohol was prohibited, the alcoholism would not 
be concordant, (H. Fingarette, personal communication, January, 1993). 
Current Beliefs and Controversy 
Alcohol addiction is called a disease by the federal government, 
characterized by loss-of-control behavior with a physiological etiology in-
dependent of volition. According to Otis R. Bowen, a former Secretary of 
Health and Human Services, 
millions of children have a genetic predisposition to 
alcoholism[,]. .. alcohol use by young people has been found to be a 
'gateway' drug preceding other drug use ... [and] about 1 out of every 
15 kids will eventually become an alcoholic. ... [A]lcoholism is a 
disease, and this disease is highly treatable. (Bowen, 1988, pp. 559, 
563) 
74 
For people with this disease called addiction, the only treatment is 
abstinence. If they drink or ingest an addictive drug, a physiological 
reaction with alcohol or the drug occurs, rendering them incapable of 
controlling their drug-taking behavior. 
Today, biomedical and psychosocial scientists define two sides of a 
controversy centered around loss-of-control theory and addiction, 
(Fillmore & Sigvardsson, 1988). The former assert that genetics and 
physiological differences account for a disease called alcohol addiction, (e.g., 
Goodwin, 1988; Blum et al., 1990; Tabakoff & Hoffman, 1988; etc.). The 
latter reject the idea that addicts constitute a homogeneous group. They 
hold that expectancy, individual differences, personal values, and 
environmental factors are the key correlates to heavy drinking and drug 
taking, (e.g., Merry, 1966; Marlatt, 1973; Paredes, 1973; Tuchfield, 1981). 
Biomedical researchers reject the genetic claims, (Lester, 1989; Bolos et al., 
1990; Billings, 1990). Social scientists and psychiatrists reject strictly 
psychological theories, (Maltzman, 1991; Madsen, 1988; Vaillant, 1983; 
Milam & Ketcham, 1983; Prince et al., 1966). 
While the genetic theories are often invoked to defend the disease 
concept of alcoholism, the findings currently suggest association only, and 
no linkage. Moreover, that alcoholism or addiction for that matter may 
have a genetic association does not necessariJy mean that the addiction is a 
disease, (Friedman et al., 1989; Maltzman, 1991). For example, skin color is 
genetically determined. It is not a disease. The issue at stake as to whether 
alcoholism or drug addiction is a disease or not has to do with the accuracy 
of the loss-of-control theory. Will theory and disease-model theory appear 
to be mutually exclusive. 
75 
Sociologists regard the disease of alcoholism as a human 
construction based on desire for social control, (Room, 1983; Fillmore, 
1988). Disease modelists counter by saying that while alcoholism may not 
be a real disease., utility warrants labeling it as such, (I<issin, 1983; Vaillant, 
1990). Others believe this does more harm than good (Szasz, 1972; 
Fingarette, 1988; Alexander, 1990a, 1990b; Peele et al., 1991; Crawford et al., 
1989; Fillmore & Kelso, 1987; Heather et al., 1982). 
Evidence Against the Loss-of-Control Theory 
Researchers have challenged the lack of volition or willfulness 
theory. Davies (1962) published results of a long-term follow-up study of 
patients treated for alcoholism. The findings were confirmed and 
extended, (Kendell, 1965). Abstinence, long considered the only cure for 
alcoholism, was questioned as the only form of treatment when seven out 
of ninety-three male alcoholics studied exhibited a pattern of normal 
drinking. Physiological differences purported present in alcoholics did not 
seem to affect their ability to control drinking. The fact that alcoholics 
returned to moderate? drinking suggested that loss-of-control was not 
operational. The finding was criticized on the basis that the individuals 
who returned to drinking were not really alcoholics, (Roizen, 1987). 
Four years later a study by Merry (1966) supported Davies's findings. 
Alcoholics who were unaware they were drinking alcohol did not develop 
an uncontrollable desire to drink more, undermining the assertion by 
supporters of the disease model that a small amount of alcohol triggers 
uncontrollable craving. If alcoholics truly experience loss-of-control then 
the subjects of the study should have reported higher craving whether they 
believed their beverages contained alcohol or not. 
76 
Cohen et al. (l971) tested health chronic alcoholics who "were 
hospitalized and given . ? 
access to substantial quantities of alcohol m an 
effort to limit their drink? . ? ? 
mg by the apphcation of contingency 
management procedures," (p. 434). 
Whereas add?i c tio n 1? s usually considered in such terms as crav.m g 
and loss of contr0  l th , ese are concepts whi? ch can nei? ther be d e fi ned  
operationally nor mani. pulated expen?m entally. ...T he resu 1 ts ... m?  th1? s 
paper provide an experimental analysis of schedule-controlled 
drinking. They indicate that, despite its physiological determinants, 
excessive drinking can be governed by reinforcement contingencies, 
variables which can be manipulated more readily than craving and 
anxiety. (Cohen et al., 1971, P? 442) 
Gottheil et al. {1972, 1973a, 1973b) tested alcoholics' ability to resist 
available alcohol and found that many alcoholics did not drink all 
available alcohol when given ample opportunity to do so. 
The data are not consistent with the theoretical position that 
drinking by the alcoholic necessarily results in irresistible craving, 
more drinking, and loss of control. Some of the patients did not 
drink at all, some drank heavily and then stopped, and some were 
able to drink moderately and also stop. Even among heavy drinkers, 
the alcohol intake varied from day to day, drinks could be resisted 
after large amounts had been ingested, and abstinent days alternated 
with drinking days. 
The patients who stopped drinking appeared to tolerate this 
rather well and did not express any strong craving for alcohol. 
Moreover, while resisting further alcohol, they slept better than they 
had while drinking, their self-esteem increased, they tended to 
71 
experience le?s s d.l scornfort, and there was no si. gni. f.i cant change m.  
withdrawal or . . 
- sociahzation. (p. 421) 
Sobell et al. 0 972) found that the loss-of-control theory was based 
more on belief in the the ory by alcoholics who had been taught to bel.i eve 
the theory was true, than in evidence that alcoholics would actually drink 
out of control. TheY  asserted that belief in the di?c tum can become a self-
fulfilling prophecy. 
Engle and w?1i r1a rns (1972) found that the desire for alcohol 
increased when alcoholics had been informed that they had been given 
alcohol when in fact they h a d not. 
The increased desire for alcohol was evidently based on the 
information provided or knowledge of its presence rather than on 
an actual physical presence and chemical effect upon the organism. 
No evidence was found for a physiological relation between one 
drink of alcohol and an increased desire for alcohol in the alcoholic. 
(Engle & Williams, 1972, p. 1103) 
Faillace et al. (1972) found no difference in giving alcohol in 
progressively reduced amounts for up to 32 days to alcoholics compared 
with giving no alcohol to alcoholics after six months. As the authors 
wrote, 
ld]ata indicate that in a controlled drinking environment, 
administering alcohol to alcoholics does not have a detrimental 
effect: in fact the findings suggest that such patients fare at least as 
well, if not better, than other alcoholics who do not receive the 
beverage. (p. 89) 
According to the loss-of-control theory, those with the disease of 
78 
alcoholism cannot plan their drinking especially when going through a 
period of excessive craving. Yet, leading alcoholism researchers found 
alcoholics bought and stockpiled alcohol to be able to get as drunk as they 
wanted even while undergoing withdrawal from previous binges. In 
other words, they could control their drinking for psychological reasons; 
their drinking behavior was not determined by a physiologically 
uncontrollable force, sparked by the use of alcohol, (Mello & Mendelson, 
1972): 
It is important to emphasize that even in the unrestricted alcohol-
access situation, no subject drank all the alcohol available or tried to 
'drink to oblivion.' These data are inconsistent with predictions 
from the craving hypothesis so often invoked to account for an 
alcoholic's perpetuation of drinking. No empirical support has been 
provided for the notion of craving by directly observing alcoholic 
subjects in a situation where they can choose to drink alcohol in any 
volume at any time by working at a simple task. There has been no 
confirmation of the notion that once drinking starts, it proceeds 
autonomously. (pp. 159-160) 
A significant experiment in 1973 supported these findings by 
showing that alcoholics' drinking is correlated with their beliefs about 
alcohol and drinking. Marlatt et al. {1973) successfully disguised beverages 
containing and not contain ing alcohol among a randomly assigned group 
of sixty-four alcoholic and social drinkers (the control group) asked to 
participate in a "taste-rating task." One group of subjects was given a 
beverage with alcohol but was told that although it tasted like alcohol it 
actually contained none. Subjects in another group were given a beverage 
with no alcohol (tonic) but were told that it did contain alcohol. " [T]he 
79 
consumption rates were higher in those conditions in which subjects were 
led to believe that they would consume alcohol, regardless of the actual 
beverage administered," (Marlatt et al., 1973, p. 240). The finding was 
obtained among both alcoholic and social drinker subjects. Marlatt's 
experiment suggests that according to their findings the ability of alcoholics 
to stop drinking alcohol is not determined by a physiological reaction to 
alcohol. A psychological fact - the belief that they were drinking alcohol -
was operationally significant, not alcohol itself, (Schaler, 1991b). 
Similar findings have been reported in studies of cocaine addiction, 
(Erickson et al., 1987; Erickson & Alexander, 1989). Erickson et al. (1987) 
concluded after reviewing many studies on cocaine that most social-
recreational users are able to maintain a low-to-mod.erate use 
pattern without escalating to dependency and that users can essentially 
"treat themselves." They state "[mlany users particubuly a,ppreciated that 
they could benefit from the various appealing effects of cocaine without a 
feeling of loss-of-control," (p. 81). 
They cite in support a study by Spotts and Shontz (1980) that 
provides "the most in-depth profile of intravenous cocaine users to date." 
Furthermore, "[m]ost users felt a powerful attachment to cocaine, but not 
to the extent of absolute necessity. [A]ll agreed that cocaine is not physically 
addicting. .. [andJ many reported temporary tolerance," (Erickson, et al., 1987, 
p. 53). 
In a study by Siegel (1984) of 118 users, 99 of whom were social-
recreational users, described by Erickson et al. as the only longitudinal 
study of cocaine users in North America, "all users reported episodes of 
cocaine abstinence." Similar findings are increasingly being published in 
reputable journals. 
80 
These results thus further support the hypothesis that drug use is a 
function of psychological, not physiological, variables. Even the use of 
heroin, long considered "the hardest drug," can be controlled for 
psychological and environmental reasons that are important to heroin 
addicts. 
A notable study of 943 randomly selected Vietnam veterans, 495 of 
whom "represented a 'drug-positive' sample whose urine samples had 
been positive for opiates at the time of departure" from Vietnam, was 
commissioned by the U.S. Department of Defense a'nd led by Robins and 
colleagues (1975; Robins, 1978). The study shows that only 14 percent of 
those who used heroin in Vietnam became re-addicted after returning to 
the United States. Robins's findings support the theory that drug use is a 
function of environmental stress, which in this example ceased when the 
veterans left Vietnam. Veterans said they used heroin to cope with the 
harrowing experience of war: 
[I}t does seem clear that the opiates are not so addictive that use is 
necessarily followed by addiction nor that once addicted, an 
individual is necessarily addicted permanently. At least in certain 
circumstances, individuals can use narcotics regularly and even 
become addicted to them but yet be able to avoid use in other social 
circumstances .... How generalizable these results are is currently 
unknown. No previous study has had so large and so unbiased a 
sample of heroin users. (p. 961) 
The role of environment in explaining addiction has also been 
supported by Alexander et al. (1980) who studied the differences in 
morphine consumption among rats in two different environments, (see 
also Chein et al., 1964; Zinberg et al., 1978; Biernacki, 1986). Caged rats 
81 
consumed a significantly greater amount of morphine solution than rats 
in an open environment, "rat park," where rats were free to be themselves. 
These studies support the idea that drug-taking behavior is a 
function of expectancy and environment, not physiology, i.e., the 
interactionist model of addiction. For if loss-of-control theory is true, 
alcoholics should have responded consistently to beverages containing 
alcohol, regardless of what they were told. Heroin addicts should not have 
given up their addiction so easily through change of an environment. 
And cocaine addicts should not be able to moderate their addiction. 
Moreover, that alcoholics have been shown to moderate or control their 
drinking undermines the theory that abstinence is the only way of treating 
alcoholism, (Institute of Medicine, 1990; Roizen, 1987; Marlatt & Gordon, 
1985; Miller, 1983; Heather & Robertson, 1981; Pattison et al., 1977; Miller 
& Caddy, 1977; Edwards et al., 1977; Bigelow et al., 1972; Pattison, 1976, 
1966; Sobell et al., 1972). Additionally, studies on spontaneous remission 
among alcoholics report that alcoholics choose to give up drinking based 
on significant life events, (Tuchfield, 1981; Roizen et al, 1978). 
These studies and experiments, stemming from the original cases 
published by Davies, have formed the basis of a psycho-social explanatory 
model for alcoholism called the free-will model or adaptive model 
(Schaler, 1991b: Alexander, 1990a, 1990b, 1987). Unlike the disease model, 
wherein physiological processes are seen as governing cognitive processes, 
the free-will model views cognitive processes as governing factors in the 
decision to drink or not. This role of the volitional element as absent in 
drinking behavior is an important factor in categorizing alcoholism as a 
disease. Beliefs regarding addiction are viewed as more potent in 
explaining addiction than the drug itself. 
82 
Regardless of wh th 
e er drug addiction is explained as a medical 
disease, moral problem 
or Volitional event, most would agree that 
addiction affects cogniti ? ? 
ve functioning and behavior m general. 
Controversy regarding 1 . . . exp anatory models for understanding addiction 
concerns a drug's relation sh 1. p to cognitive processes, specr? r?1 ca 11 y vo1 1? t1? on, 
not the e.ffect of the d rug on the body per se. That alcohol affects cogni? ti? ve 
processes is without con  t roversy, or so it appears. The extent to which 1. t 
affects these processes is anothe r matter. 
Learning Theory Perspectives on Addiction 
Keller, a leading defender of the disease model of alcoholism, 
amended the loss-of-control theory (1972), after experiments like Davies's, 
Merry's and Mello and Mendelson's emerged . He defined alcoholism as a 
"learned addiction," addiction as a ''learned or conditioned response," and 
loss-of-control as a "conditional symptom, arising because alcoholism is a 
learned process." He termed the alcoholic a person who has 
become disabled from choosing invariably whether he will 
drink. ...H is learning to become an alcoholic was almost certainly 
unconscious. ... (T)he fact that he sometimes can choose not to drink, 
or that he sometimes can drink moderately, does not alter the fact 
that he is an alcohol addict; that he has the disease we conveniently 
call alcoholism. (Keller, 1972, pp. 160-165) 
The fact that alcohol and other mood~altering drugs affect a change 
in cognitive and/ or behavioral processes through the experience of 
intoxication begs the following questions: (1) What is the behavior, 
cognitive state or process that a person seeks to change or cease through 
mood altering drugs?; and, (2) what is the behavior, cognitive state or 
83 
process that a person experiences or seeks to create or experience through 
intoxication? 
Learning theorists addressed alcoholism in the 1950s, (Shoben, 1956; 
Conger, 1956; Kingham, 1958). Kepner (1 %4) examined the application of 
learning theory then to the treatment of alcoholism. Alcoholism was then 
viewed by treatment professionals as "primarily functional, i.e., a product 
of experience rather than of organic or inherited factors" (Kepner, 1964, p. 
279), and alcohol seen as offering two sources of reward: (1) creation of 
pleasure and (2) escape from discomfort. Problems-in-living resulting 
from prolonged and heavy drinking were explained in terms of gradient-
of-reinforcement principle. The belief was that "immediate rewards are 
stronger reinforcing agents than delayed rewards," (Kepner, 1964, p. 281). 
Successful treatment of heavy drinkers involved learning new responses, 
in addition to that of sobriety, to increase self-knowledge, (Kepner, 1964). 
Reference to self-concept emerged, (Vanderpool, 1969; Berg, 1971). Along 
with it, researchers appeared to focus on the role of experience attribution 
in attempts to further understand and help the heavy drinker and/ or drug 
addict, (Donovan & Marlatt, 1980). 
Locus-of-control (LOC) refers to the belief or expectancy a person has 
with regard to reinforcement and experience attribution, i.e., factors 
outside or external to personal control versus those causally within the 
domain of volition or willfulness. These attributions include expectancies 
regarding behavior reinforcement contingencies, the extent to which a 
particular reinforcement is valued by the individual, and the context 
within which reinforcement is likely to occur, (Rotter, 1966). 
LOC theory developed through Rotter' s (1966) social learning theory 
and has bee-n applied to the study of alcoholism and addiction in general: 
84 
In social learning theory, a reinforcement acts to strengthen an 
expectancy [emphasis in original} that a particular behavior or event 
will be followed by that reinforcement in the future. Once an 
expectancy for such a behavior-reinforcement sequence is built up 
the failure of the reinforcement to occur will reduce or extinguish 
the expectancy. (Rotter, 1966, p. 2) 
When social learning theory is applied to the study of drug addiction 
we may find that the expectancy regarding reinforcement through the drug 
experience is more important than the physiological effects of the drugs 
themselves. 
As Wallston has recently written (1992), Rotter's social 
learning theory is an expectancy-?value theory, not simply a theory 
about expectancies .... The basic proposition behind Rotter's (1954) 
version of SLT  is that the potential for a person to engage in a set of 
functionally related behaviors in a given psychological situation is a 
joint function of (1) the person's expectancy that the behaviors will 
lead to a particular outcome in that situation and (2) the value of the 
outcome to the person in that situation. The language in that 
formulation is context-specific, but Rotter believed the theory could 
operate on at least two levels, only one of which was specific to a 
given situation. The other, broader level was one that could be 
generalized across situations, and contained such constructs as 'need 
potential,' 'freedom of movement,' and need value.' It was the 
introduction of LOC as a generalized expectancy [emphasis in the 
original] that captured the imagination of researchers around the 
world. A generalized expectancy is something the person carries 
from one situation to the next. It is more trait-like than state-like 
85 
and is therefore akin to a 'personality' dimension. (Wallston, 1992, 
p. 184) 
Some researchers seem to disagree with this latter statement by 
Wallston and view locus-of-control orientation as a flexible personality 
dimension: 
[L)ocus of control as a personality characteristic is in part actively 
organized by the individual, not passively accrued ... .In short, to 
study and understand a person, we need to know the 
situation,. .. dispositional characteristics, ... how he/s he views his/her 
potential impact on the particular situational-dispositional 
choices. .. faced. It is this latter 'choice of an illusion' role which is 
embodied in a constructed cognitive view of internality-externality 
attributions. (Tyler et al., 1979, p. 34) 
Wallston (1992) has recently asserted that too much focus in locus-
of-control research has been directed towards the "locus" of control and not 
enough emphasis has been placed on the context within which a particular 
behavior is being studied, as well as the value of the behavior, e.g., health 
behavior: 
The construct of LOC plays a far less significant role in predicting 
health-directed behavior than does either health value by itself or 
other control-related expectancy constructs, such as self-efficacy ...,  
mastery. .. , or perceived competence.... (Wallston, 1992, p. 185) 
The more a health outcome or experience is valued, the more likely 
an individual will engage in a health behavior to create the valued 
outcome, the more likely the outcome is to occur. Just because a person 
engages in a health-enhancing behavior does not necessarily mean that the 
person values that behavior or experience (outcome), (Smith & Wallston, 
86 
1992; see Harrison et al., 1992 for meta-analysis of studies of the Health 
Belief Model). 
Rotter's 1-E Scale measured locus-of-control along a single 
dimension. Individuals who scored high on this scale were considered 
external in locus-of-control orientation, i.e., they attribute responsibility for 
their experience to factors outside of their personal control. There appear 
to be at least two ways an awareness of locus-of-control orientation can be 
utilized from a therapeutic point of view: (1) An external locus-of-control 
o rientation can be changed to an internal one, thereby assisting in the 
development of personal empowerment to change behavior; (2) Locus-of-
control orientation, be it external or internal, can be matched with a 
similar behavioral-treatment orientation in order to assist with behavior 
change (similia sirnilibus curentur, a dictum of homeopathic medicine 
meaning "let likes be cured by likes). 
The study of LOC orientation in health and illness settings appears 
to have developed out of work conducted by Seeman and Evans (1962). 
They examined the WC orientation of hospitalized tuberculosis patients 
before Rotter's 1-E Scale was published and found that 
patients who held internal locus-of-control beliefs knew more about 
their own condition, questioned doctors and nurses more, and 
expressed less satisfaction with the amount of feedback or 
information they were getting about their condition from the 
hospital personnel than did external patients. (Wallston & 
Wallston, 1981, p. 190) 
Other studies confirmed the finding that "internals" were more 
knowledgeable about their illness than were externals, (Wallston & 
Wallston, 1981). The individualizing of patient treatment based on LOC 
87 
beliefs was considered a potentially important utilization of the concept by 
1973, (Wallston & Wallston, 1973). Wallston and Wallston (1981) believed 
that insufficient attention had been paid to interaction of specific treatment 
and locus-of-control beliefs in health care settings and initiated a great deal 
of research in this area. 
Twenty-four studies were published on LOC research on alcoholic 
populations between 1970 and 1975 and only one prior to 1970. 
Conclusions regarding control orientation among alcoholic populations 
remain unclear, (Rohsenow & O'Leary, 1978). Moreover, as Worell & 
Tumilty (1981) stated: "Rotter's I-E Scale .. .is predicated on the assumption 
that 1-E derives from social reinforcement, [and thus] may be of 
questionable relevance in populations defined as dependent on addictive 
substances," (p. 322). 
At first glance, it appears that alcoholics and other drug addicts 
would be external in their LOC or ientation because of their alleged 
dependent relationship on a substance external to self. Contrary to 
researchers' expectations, alcoholics tended to score in the internal 
direction on Rotter's I-E Scale, (Goss & Morosko, 1970; Gozali & Sloan, 
1971; Distefano et al., 1972; Gross & Nerviano, 1972; Costello & Manders, 
1974). Moreover, Chess et al. (1971) found that increased field 
independence in an alcoholic group was accompanied by an increase in 
internal locus-of-control orientation and not associated with increased 
arousal. 
Similar findings have been reported in studies on the LOC 
orientation of opiate addicts, (Berzins & Ross, 1973; Calicchia, 1979). 
Strassberg & Robinson (1974) found that LOC was not significantly related 
with either age of length of drug use among drug users. A recent study by 
88 
Haynes & Ayliffe (1991) of substance "misusers" compared this group with 
"non-misusers." Substance misusers scored significantly higher on 
external LOC than non-misusers. 
According to a review of the literature on LOC research on alcoholic 
populations by Rohsenow and O'Leary (1978), 
better designed studies. . .find no difference or externality in 
alcoholics. Some studies show alcoholics to become more internal 
in locus of control over treatment while others show no significant 
change. It is not known whether change toward internality is 
related to treatment success. ... (p. 73) 
Goss & Morosko (1970) explained the internality orientation among 
alcoholics this way: 
Perhaps it is possible that .alcoholic patients do understand the 
contingency between their behavior and what for them is a preferred 
source of reinforcement - alcohol. Chatlos and Deiter (1959) have 
pointed out that alcohol may become the instrument to modify 
unpleasant feeling states. ...P ast experience provides the problem 
drinker with the knowledge necessary to regulate the way he feels at 
any moment.. .. This sense of personal control may in part account 
for the guilt and self-blame that many alcoholics engage in. (pp. 190, 
191) 
Berzins & Ross (1973) echo the opinion: 
[T]he crucial ingredient that differentiates the reinforcement 
histories of addicts from those of nonaddicts obviously refers to the 
drug experience itself. Opiate addicts have extensive experience 
with 'self-control' via opiates; each administration of the drug 
enables the addict to achieve control over anxieties, conflicts, 
89 
impulses, moods, bodily states, and so on. .. .In other words, repeated 
experiences with drugs not only may lead to physiological 
dependency but also can plausibly produce in the addict a 
generalized belief that he controls the reinforcements important to 
him. This belief need have no intrinsic basis in the person's social 
reinforcement history. (p. 92) 
Marshall (1991) suggested that self-blame is positively related to 
internality. And Amos Gunsberg, a psychotherapist, has this to say about 
drug addicts with an internal LOC orientation: 
They are endeavoring to maintain that simply by fantasizing they 
create their own reality, and it is this so-called 'reality' that everyone 
else is supposed to recognize about them. Their use of the drug is 
not to change the internal sensation they are providing for 
themselves, but to blank out any information to the contrary. The 
usual fantasy is they are some kind of god. (A. Gunsberg, personal 
communication, July 4, 1992) 
Wallston (1992) seems to hold a similar point of view when he 
suggests that an "overinflated sense of self-mastery" cou.ld lead to a greater 
in tern al LOC. 
Nowicki & Hopper (1974) challenged the internality-orientation 
findings on alcoholics and drug addicts for failing to account for sex., age 
and population differences and they reported higher externality among 
female alcoholics needing inpatient treatment. 
Other studies found no significant differences in orientation 
between alcoholic and control groups, or higher externality among 
alcoholics, (Butts & Ch.otlos, 1973). Problems encountered in the study of 
alcoholics continue to include the difficulty of defining alcoholism. 
90 
Alcoholics are a heterogeneous group and the criteria for deciding who fits 
the category varies. 
Worell & Tumilty (1981) developed the Alcoholic Responsibility 
Scale (ARS) as a situation-specific LOC scale for alcoholic populations. The 
scale is similar to the Rotter 1-E Scale in design, i.e., the higher the score, 
the more external the subject is, the more drinking is attributed to external 
forces such as fate, luck, powerful others, etc., instead of self. Administered 
in conjunction with a biographical information sheet, the Personality 
Research Form AA (Jackson, 1967), the Shipley Institute of Living Scale 
(1940), a Parent Behavior Form (Worell & Worell, 1972), the Multiple 
Affect Adjective Check List (Zuckerman & Lubin, 1965), and the Rotter I-E 
Scale to 79 consecutive male admissions to the Alcohol Treatment 
Program at the Veterans Medical Center in Lexington, Kentucky, Worell & 
Tumilty (1981) found that 
(t)he relatively more external alcoholic (as measured by the ARS) 
tended to be taller, to have had a father with a drinking problem, to 
be a spree rather than an everyday drinker, to have been treated 
more often for alcoholism, to have experienced hostile paternal 
control and lax maternal control, to score higher on the personality 
trait of autonomy but lower on sentience, to be experiencing higher 
levels of depression and hostility, and to do more poorly on his job 
performance. It would appear that a fuller description of the more 
external alcoholic is provided by the ARS than by the Rotter I-E 
Scale .... The superior construct validity of the ARS, as compared with 
the Rotter I-E Scale, suggests that the meaning of locus-of-control for 
the alcoholic is primarily associated with his attitudes toward his 
91 
drinking rather than his general sense of control over his life. (pp. 
329-331) 
These results appear to coincide with those of O'Leary et al. (1974) 
who "found that alcoholics havinJg aiiil. external locus-of-control are more 
depressed, anxious and socially introverted according to the Minnesota 
Multiphasic Personality Inventory (MMPJI) than are alcoholics having an 
internal locus-of-control," (O'Leary e:t al, '197,'8, p . ll!S'tl)li))" 
The finding by Worell & Tumilty (1981) that ,external 1ocu:s-of-
control orientation is associated wffh a father who had a d rinking problem 
does not appear to be confirmed in a recent sturdy by Chunchm e't ,at (1990). 
They studied 497 students in introductory psychology dasses and found no 
"significant relationship between 1paren taJ aloo1ilcolism and either locus-of-
control or self-esteem," (Churchill et al., 1990, p. 375). 
Donovan & O'Leary (1978) developed a drinl<lng-.~elated 1locus-of-
control scale (ORIE) and discovered ,a s1ignificanlt dlfforen:ce be'lw1e,en 
alcoholics and nonalcoholics using this new scale whRe Rotter's I-E Scale 
demonstrated no such difference. They found that 
[a]koholics have an external 1ocus-of-control ,conoerning their 
drinking that corresponds closely wiith that of individuals who have 
an external locus-of-control acoordin;g t,o ltbe I-E scale. Aloohrolics 
having an external locus-of-control according t,o if:he DR.IE .scale 
appear to perceive that significant events in life are beyond itheir 
control, determined more by ohance than by per'S'.ona!l i!lil.itfa\live or 
the influence of significant others. ... [TJhey feel they havre minimal 
control over internal (intrapersonal) and e:diental (inte:rfYersonal) 
sources of stress[,]. .. appear to experience a gr,ea:ter degree of 
depressionl,] ... tend to report more psy,chophysiological 
92 
manifestations related to depression, and are more self-critical, more 
pessimistic - with periodic thoughts of suicide - and more indecisive 
and behaviorally inhibited. (Donovan & O'Leary (1978, pp. 776, 777) 
As O'Leary et al. (1978) wrote: 
It appears that alcoholics' locus-of-control is related to the perceived 
benefits of drinking. Alcoholics having an external locus-of-control 
appear to have developed a dependence on alcohol to enhance their 
perception of control in interpersonal function. This finding is 
consistent with McClelland et al.' s (1972) proposition that alcohol 
tends to increase personal feelings of power and control. (p. 1504) 
Wallston & Wallston (1981) are dear to point out that motivation to 
control one's behavior "should not be confused with locus-of-control, the 
expectancy that one's behavior is or is not directly related to one's outcome, 
(i.e., reinforcements)/' (p. 191). Citing a study by Kirscht (1972), they clarify 
this distinction: "[M]otivation for control tend[s] to account for 
relationship to perception of vulnerability to specific diseases whereas 
expectancy [i]s more related to a belief that health can be determined by 
personal actions," (Wallston & Wallston, 1981, p. 191). 
Wallston & Wallston's interest in relating LOC to health-care 
situations appears to have developed after observations they made of 
classes for newly diagnosed diabetic patients and their families. They 
interpreted the efforts of teachers in these classes as attempts to teach an 
internal WC to patients. In 1973, they conceptualized the intent of many 
health education efforts as internality training programs, (Wallston & 
Wallston, 1981). Additionally, they rationalized the use of locus-of-control 
in a health care context on the basis of Rotter's recommendation that 
93 
situation or context be taken into account when devising measures of 
expectancy, (Rotter, 1960; 1966). 
Wallston, Wallston et al. (1976) developed "[t]he original health-
related locus-of-control scale (the HLC Scale), ... a generalized expectancy 
measure, cutting across many health-related settings and behaviors, 
consist[ing] of 11 items in a 6-point Likert format,'' (Wallston & Wallston, 
1981, p. 192-193). High scores on this scale indicate highly external beliefs: 
Individuals with scores above the median ... [are] labeled 'health-
externals'; they ... [are) presumed to have generalized expectancies 
that the factors that determine their health are ones over which they 
have little control (i.e., external factors such as luck, fate, chance, or 
powerful others). At the other end of the dimension, scoring below 
the medianr .. [are] the 'health-internals,' who believe that locus-of-
control for health is internal and that one stays or becomes healthy 
or sick as a result of his or her own behavior. The mean score for 
the original developmental sample was 35.57, with a standard 
deviation of 6.22. The alpha ... of the scale (.72) appeared respectable 
and the HLC Scales did not reflect a social desirability bias, as 
evidenced by a -.01 correlation with the Marlowe-Crowne Social 
Desirability Scale. (Wallston & Wallston, 1981, p. 192-193) 
Subsequent reliability calculations of the HLC dropped from the 
original alpha of .72 to .30-.59 and Wallston & Wallston began to 
reconsider LOC as a multidimensional concept as were others with regard 
to the I-E scale, (e.g., Gurin et al., 1969). 
Levenson (1973; 1974; 1975) questioned the unidimensional nature 
of LOC and proposed studying externality by examining "fate and chance 
expectations separately from external control by powerful others," 
94 
(Wallston & Wallston, 1981). She developed the first multidimensional 
LOC scale with these ideas in mind. It consisted of "three 8-item Likert 
Scales (Internal, Powerful others, and Chance - the I, P, & C Scales) to 
measure generalized locus-of-control beliefs and demonstrated initial 
evidence of their discriminant validity," (Wallston & Wallston, 1981, p. 
194). This scale was a multidimensional locus-of-control scale but did not 
include health-specific items. 
An example of the use of Levenson's HLC scale was reported by 
Sherman et al., (1973). Here, "[t]he relationship between Dogmatism and 
three subscales of Levenson's Locus-of-control measure was examined 
with 36 female undergraduates as subjects," (p. 749). The authors 
attempted to replicate a study conducted by Clouser and Hjelle (1970) who 
argued "that a closed belief system and externality are both associated with 
anxiety and susceptibility to influence by external sources of power," 
(Sherman et al., 1973, p. 749). 
Clouser and Hjelle used Rotter's 1-E scale and found a small positive 
relationship between the dogmatism scale and Rotter' s scale. Sherman et 
al. (1973), based on Levenson's argument that LOC orientation was a 
multidimensional concept, sought to replicate Clouser and Hjelle findings 
using the multidimensional scale proposed by Levenson. They believed 
the multidimensional LOC construct developed by Levenson might 
provide "a more precise understanding of the relationship between the 
variables. . .. [T]he results indicate some support for the view that internals 
are people who assess and evaluate information independently of a variety 
of external sources of influence," (Sherman et al., 1973, pp. 749, 750). 
The Wallston et al. (1978) Multidimensional Health Locus-of-
control Scales (MHLC) was based on Levenson's scale - applied to health-
95 
related expectancies. Items from the original HLC were used and fit into 
the three dimensions developed by Levenson, i.e., internal, powerful 
others, and chance, (see Wallston & Wallston, 1981, for detailed description 
of the transformation of the original HLC to MHLC). 
The MHLC uses a total of 18 personally-worded items "to reflect 
beliefs about 'self,"' along three separate dimensions: lnternality (IHLC); 
Chance Externality (CHLC); and Powerful Others Externality (PHLC). Two 
equivalent forms of the MHLC were developed, Form A and B, and both 
use a 6-point Likert format, (Wallston & Wallston, 1981; Wallston et al., 
1978). 
The. sample used for the original MHLC study was persons over 16 
years of age waiting at gates in a metropolitan airport (N=l 15): 
Alpha reliabilities for the MLHC scales (six-item forms) ranged from 
.673 to .767 and, when Forms A & B were combined into 12-item 
scales, the alpha reliabilities increased (.830 to .854). These figures 
compared quite favorably to Levenson's 8-item I, P, & C scales (alpha 
reliabilities= .508 to .733) ....[ T]he mean scores of Form A and Form B 
of each MHLC scale were nearly identical. (Wallston et al., 1978, p. 
163) 
The PHLC scale correlated with Levenson's P scale and the CHLC 
scale correlated with Levenson's C scale. The IHLC likewise correlated 
with the I scale and the CHLC correlated significantly with the p scale and 
negatively with the I scale. Factor analysis confirmed the three dimensions 
without error, (Wallston et al., 1978). 
The MHLC was deemed a useful measure, however, the external 
classification now became meaningless as it had been transformed into two 
96 
distinct dimensions - the powerful others and the chance locus-of-control 
orientations, (Wallston & Wallston, 1981). 
The mean scores for MHLC scales summarized across types of 
subjects as of 1981 were as follows: Healthy adults (N=1287), scored 25.55 
on the IHLC scale, 16.21 on the CHLC scale, and 19.16 on the PHLC scale. 
Persons engaged in preventive health behaviors (N=720) scored 27.38 on 
the IHLC scale, 15.52 on the CHLC scale, and 18.44 on the PHLC scale, 
(Wallston & Wallston, 1981, p. 204.) The MHLC scales produced no 
significant correlations with gender and "only one scale, Form A of the 
PHLC, correlated significantly with age (r=. 198, p<.05) or educational level 
(r=-.222, p<.05)," (Wallston et al., 1978, pp., 165,167). 
The overwhelming preponderance of predictions in the right 
direction strongly supports the idea that negative experiences over 
which there is little control are conducive to the development of 
high beliefs in external control (both chance and powerful others) 
and low belief in internal control (health-specific and 
general). ... [T)hese findings are not to be taken lightly. (Wallston & 
Wallston, 1981, p. 211) 
Suggested use of the MHLC Scale is as an independent variable 
predicting health behavior, alone or in combination with other related 
variables, or as a dependent variable measuring treatment outcomes. 
Wallston, Maides, & Wallston, (1976), assert "there is no theoretical reason 
to expect locus-of-control to predict to health behavior, unless it is used in 
combination with a measure of health value," and "[i]n general, health 
locus-of-control beliefs should predict to health behavior only under high-
health-value conditions," (Wallston & Wallston, 1981, p 206). The MHLC 
may be used as three separate scales, singularly, or in combination with 
97 
one another. "It is inappropriate to use IHLC, CHLC, and PHLC scores to 
produce a single overall score," (Wallston & Wallston, 1981, p. 207). 
Joe et al., (1979) used the MHLC to test the hypothesis 
that externals would report more life changes that required 
adjustment and more perceived as being uncontrollable, i.e., person 
not being able to influence, direct, command, etc., than internals, 
and uncontrollable life changes and not controllable events would 
be associated with psychiatric symptoms. (p. 333) 
They found that 
external subjects did not report a significantly greater number of life 
changes than internal subjects. They did, however, report more life 
changes as uncontrollable than did internal 
subjects. ... [U]ncontrollable, not controllable life changes. .. were 
associated with psychiatric symptoms. (p. 334). 
These authors interpreted their findings as suggesting that 
not high levels of change per se [emphasis in original) but life 
changes perceived as uncontrollable brought on the psychiatric 
symptoms. .. [and] that the ,external individual will interpret more 
life changes as being uncontrollable and thus be more susceptible to 
the negative effects of these changes. (p. 334) 
Hartke & Kunce (1982) investigated the statistical independence of 
the three subscales in a validity generalization sample. Their results 
s upported the multi-dimensionality of the locus-of-control concept and "a 
hypothesis that one's educational level may play a significant role in 
reducing one's dependency on powerful others or fa te," (p. 595). 
?wallston et al. (1983) investigated the extent that individ uals' 
expectancies about their control over their health relates to their preference 
98 
to get actively involved in their own health care. They did this by studying 
the inter-relationship between the MHLC and the Krantz Health Opinion 
Survey (KHOS). While the former is purportedly a measure of beliefs and 
expectancies about control over one's health (an outcome), the latter is 
designed to measure attitudes or preferences relating to health care 
delivery, which is a process, not an outcome. 
They found that 
persons who believe their health is controlled by powerful others 
are less likely to agree with items advocating self-treatment or with 
the active behavioral involvement of patients in medical care. 
Similarly, persons who believe that their own behavior affects their 
health, (internal locus-of-control) have more positive attitudes 
toward self-treatment and active involvement in their own 
care .... [T]his study suggests that individuals' expectations about 
control over their health are related to their preferences for control 
over their health care. (Wallston et al., 1983, pp. 381, 383) 
Ludenia and Russell (1983) studied the relationship between health 
locus-of-control beliefs and the MMPI with an alcoholic population. No 
other studies of health locus-of-control orientations of alcoholics had been 
conducted prior to their work. 
Alcoholics scored significantly higher on the IHLC and PHLC scales 
than a normative sample of health adults and significant correlations were 
found between dimensions of perceived locus-of-control and various 
personality characteristics. The CHLC was most strongly related to the 
MMPI subscales. 
Their results support previous studies of alcoholics with Rotter's 1-E 
scale showing that alcoholics were more internal in their LOC orientation, 
99 
however Ludenia and Russell also found that alcoholics "were also more 
prone to attribute responsibility for personal health to the influence of 
power others," (p. 627). 
Dimensions of perceived health locus-of-control were found to be 
related to the following personality characteristics: Those alcoholics who 
are high on internality manifest fewer somatic complaints and focus less 
attention on bodily function, are more active and energetic. The PHLC 
dimension had fewer MMPI correlates, however, 
persons who believe that health is determined largely by powerful 
others appear to be more conforming and tolerant of 
authority. ... (A]lcoholics who are defined as relatively high on the 
chance dimension are characterized as exhibiting more somatic 
concern, anxiety, suspiciousness, social alienation, and generally 
more clinical pathology. (Ludenia & Russell, 1983, p. 627) 
In a study of religion and the MHLC Scale, Levin and Schiller (1986) 
reported that 
from a sample of adults (N=909) ...n onchurch-affiliated had a higher 
mean score than church people on the baseline 'chance' scale (17.3 vs 
16.0) ... (and] analyses of variance gave differences. .. across 
denominations on baseline 'internal' and 'powerful others' scales. 
The highest internal scores were among Mormons (29.5), 
Episcopalians (29.3), and Catholics (28.4) ....T he highest powerful-
others score was among Presbyterians (22.7), adherents to a tradition 
founded in reverence to 'presbyters' or powerful church 
elders. .. Subjects reporting no affiliation had the lowest powerful-
others scores (16.5) .... [T]raining in self-care skills both increased the 
internal score. .. and decreased the powerful others score ... but only for 
100 
subjects reporting a religious affiliation. (Levin & Schiller, 1986, p. 
26) 
The authors concluded that a relationship exists between health 
locus-of-control orientation and religious attachments which also modifies 
health education. 
Cooper and Fraboni (1988) found some problems with the MHLC 
when a factor analysis failed to replicate the original multidimensional 
construct and suggested that a return be made to the earlier 
internal/e xternal model and additional alternate forms be added to 
increase reliability. The PHLC and CHLC scales lacked distinctiveness and 
the authors suggested combining the two dimensions as one external 
dimension and combining Forms A and B to increase reliability. They 
particularly cautioned against the use of a multidimensional concept over 
a simpler dichotomous one when applied to a homogeneous population. 
The psychometric characteristics of the MHLC scales among 
psychiatric patients were assessed by Wall et al. (1989). The alpha 
reliabilities and intercorrelations originally reported by Wallston et al. 
(1978) were confirmed in a sample study of 60 psychiatric patients recently 
discharged from inpatient or day hospital psychiatric facilities. The MHLC 
scales were used because, according to the authors of the study, 
{u]nlike symptoms of medical illness, psychiatric symptoms may be 
misperceived by both patients and their families as characterological 
failings .... The MHLC scales may be a useful research tool for better 
delineating psychiatric patients' attributions about the contribution 
of self and other to their psychiatric health. (Wall et al., 1989, p. 94) 
Because these authors found that the combined forms (A and 
B) [of the MHLC Scale] yielded a clearer separation of the scales, as 
101 
well as more robust alpha reliabilities than the separate forms ... [they] 
recommend use of the combined form in a psychiatric population. 
(p. 97) 
Marshall et al. (1990) compared two forms of multidimensional 
health locus-of-control instruments - the MHLC by Wallston et al. (1978) 
and one by Lau, (1982; Lau & Ware, 1981), by examining their internal 
consistency reliability and factor structures, as well as by evaluating the 
convergence and divergence of the constructs assessed by the two 
instruments, in a study of Veterans Administration medical outpatients 
(N=181}. The Lau-Ware HLC scale is a 
20-item version of the complete 27-item instrument. .. composed of 
subscales assessing the degree to which individuals attribute health 
outcomes to Self-Control (7 items), Provider Control (6 items), and 
Chance (3 items). The instrument also includes a 4-item scale 
assessing General Health Threat, the extent to which individuals 
regard health outcomes as threatening. (Marshall et al., 1990, p. 183) 
Their results supported the multidimensionality of the MHLC as 
developed by Wallston et al. (1978) and found "little support for the a 
priori typology proposed by Lau (Lau, 1982; Lau & Ware, 1981)," (Marshall 
et al., 1990, p. 186). The authors assert that the Wallston and Lau-Ware 
MHLC scales 
are not interchangeable measures of HLC beliefs. Correlations 
between relevant subscales of the two measures, although 
statistically significant, were not robust ... [F)ailure to find strong 
evidence of convergent validity appears attributable to the low 
internal consistency of the Lau-Ware subscales. (p. 188) 
102 
The authors also found that the PHLC of the Wallston et al. MHLC 
is not an undifferentiated dimensions: "[BJeliefs regarding professional 
and nonprofessional control over health outcomes are empirically 
distinct," (p. 188), e.g., professional caregivers versus nonprofessionals such 
as family and friends. 
The independence of the three dimensions of Wallston et al.'s (1978) 
MHLC was supported in a study of multidimensional health locus-of-
control of health professionals by Eachus, (1990). Most MHLC orientation 
studies have focused on the locus-of-control orientation of patients. This 
study differed by focusing on the health locus control orientation of health 
professionals. MHLC scores for 169 health professionals composed of 
student physiotherapists, chartered physiotherapists, and nurses were 
compared with UK norms (N=1400). The independence of the 
multidimensional scales was supported. MHLC "beliefs in health 
professionals does appear to differ from those of their prospective clients," 
(Eachus, 1990,p. 762). 
Recently, Wallston (1992) has de-emphasized the utility of relying 
on the, MHLC to predict health behaviors. He suggests that more research 
focus be directed on the extent to which an individual values a particular 
health experience. To this end we need to assess the individual's perceived 
competence and self~efficacy with regard to achieving health behavior 
change rather than simply the locus-of-control. 
Self-efficacy refers to the belief a person has with regard to his or her 
ability to perform a specific behavior. The ooncept was developed by 
Bandura (1977; 1978; 1983; 1984; 1986), based on Rotter's social learning 
theory (1966), has been examined and tested in diverse ways (Wilson, 1978; 
Kazdin, 1978; Weinberg et al., 1979; Donovan & Marlatt, 1980; 
I 
103 
DiClemente, 1981; Maddux et al., 1982; Goldfried & Robins, 1982; Davis & 
Yates, 1982; Strecher et al, 1986; Solomon & Annis, 1989; Sexton et al., 
1992), challenged as inconsistent (Kirsch, 1985) and "unacceptably flawed," 
(Wolpe, 1978), considered "conceptually problematic'' despite the fact that 
these same researchers concede that "self-efficacy ratings on specific 
behavioral tasks are accurate predictors of subsequent behavioral 
performance on those tasks," (Eastman & Marzillier, 1984), applied to 
theories of treatment for alcoholism (Clifford, 1983), applied to human 
psychopharmacology and alcohol research (Maisto et al., 1981) and health 
generally, including the Health Belief Model, (Rosenstock et al., 1988; 
O'Leary, 1992). 
Referring to Bandura's self-efficacy and other "newer scales" such as 
indices of "perceived competence" (Smith et al., 1991), Wallston {1992) 
writes that 
when. .. [he is] asked for advice by other researchers as to which 
measure they should employ to assess health control 
expectancies,. .. [he] advise[s] them to use one of these newer scales 
rather than the MHLC. LOC is part of the larger, more important, 
construct, perceived control, but only a small part. (p. 194) 
Wallston appears to be referring these scales in terms of their 
relative abilities to predict behaviors. The ability of a self-efficacy scale 
compared to the MHLC scale in terms of their relative abilities to predict 
general health-related beliefs may indicate that the MHLC scale is in fact 
superior in this regard. The key here is differentiating between behavior 
and beliefs as dependent variables. 
104 
Summary 
Three models of addiction have been extracted from the various 
writings on addiction paradigms. These are the maturationist, behaviorist, 
and the interactionist models. Each model is defined in terms of the 
organism's relationship with his or her environment, and as such, is 
linked to the nature-nurture controversy of human development. 
The history of beliefs regarding alcoholism and addiction were 
traced over the past two hundred years in America. Shifts in public and 
professional perceptions of addiction have occurred and can be grouped 
according to the three models described. In colonial times, the 
interactionist view seemed to prevail. Benjamin Rush marked the 
beginning of the medicalization of social deviation when he announced 
that alcoholism was a disease. Rush's ideas fueled the development of the 
Temperance Movement, which combined a medical and moralistic 
perspective on alcoholism and addiction. The idea that alcohol and other 
drugs were universally-addicting substances lend support to the idea that 
environment was solely responsible for addiction, i.e., a behaviorist 
approach. 
The repeal of alcohol prohibition ushered in a new era in terms of 
beliefs that alcoholism and subsequently other addictions were diseases. 
The disease model gathered new momentum with the work of Alcoholics 
Anonymous, a spiritual self-help fellowship, and the work of E.M. Jellinek. 
The disease model and the moralistic model are strongly intertwined . The 
disease concept strengthened genetic research on alcoholism and the 
maturationist perspective was given new credibility. The loss-of-control 
theory was integrally bound to the maturationist/medical model of 
addiction and behaviorists challenged the loss-of control theory. These 
105 
experiments showed no evidence to support the loss-of control theory. 
Addiction was found to be correlated with environmental and expectancy 
factors. Behaviorists seized on the expectancy findings, along with findings 
that alcoholics were able to return to moderate drinking. Controlled-
drinking programs emerged and struck a great deal of controversy among 
abstinence-oriented medical modelists and members of AA. These 
findings were also seized upon by a new school of interactionists who 
shifted away from a strictly behaviorist point of view addiction and have 
written extensively in terms of existential factors related to addiction, in 
addition to focusing on the role of will, self-determination, and the 
creation of meaning through d rug experience. 
Cognitive behaviorists focused on applying locus-of-control 
principles to addictive behavior. A review of locus-of-control research and 
its evolution into health-locus-of-control studies was traced and applied to 
addiction research. 
There appears to be a relationship between historical and 
contemporary views of alcoholism and addiction and individual 
attributions regarding the etiology of addiction. Interactionists appear to 
attribute drunkenness and addiction to social interaction and internalaself 
factors. Behaviorists and moralists tend to attribute drunkenness and 
addiction to expectancy and environment in the first case, and lack of 
spiritually-correct values in the second. In the latter case, there appears to 
be a link between sinfulness and addiction as a disease. Finally, 
maturationists seem to maintain the idea that addiction is a disease 
characterized by loss-of-control, physiological and genetic factors. This 
belief, as well as the behaviorist/moralistic beliefs, tend to dominate the 
beliefs about addiction today. 
106 
Levine (1978) found a relationship between moralistic views on 
addiction during the Temperance era and disease-model perspectives on 
alcoholism and addiction that resurfaced immediately following the 
Repeal of Prohibition in the 1930s. Since religious thinking was an integral 
part of Temperance thinking, and Temperance philosophy grew out of the 
medical model of alcoholism espoused by Benjamin Rush, and into the 
medical model renewed by E.M. Jellinek, it may be interesting to 
investigate whether or not those people who subscribe to the disease 
model of addiction also tend to be spiritual thinkers. Since interactionists 
tend to shun both Temperance and medical explanations for addiction, it 
might also be interesting to investigate whether or not those who disagree 
with these two approaches also tend to be more secular in their thinking in 
,I,  . 
general. 
-
107 
CHAPTER III 
METHOD 
This study investigates the beliefs of addiction-treatment providers 
regarding the etiology of addiction. This section of the study describes the 
procedures used to investigate these beliefs. 
The first part of the section details the scales used in this survey. 
These include the Addiction Belief Scale (ABS), the Multi-dimensional 
Health Locus of Control Scale (MHLC), and the Spiritual Belief Scale (SBS). 
The reliability statistics for these instruments are provided in this section. 
Demographic characteristics of respondents are also provided here. 
Finally, the statistical methods used to answer the research questions are 
described at the end of this section. 
Procedure 
The research questions were investigated through the use of a 
survey sent to addiction-treatment providers around the United States, 
Canada, and Australia. A total of 511 seven-page surveys (Appendix A) 
with cover letter (Appendix B) were mailed to addiction-treatment 
providers in the U.S., Canada and Australia. Table 3 lists the distribution 
of surveys by professional-group affiliation and return rate. 
Two hundred instruments were distributed to a random sample of 
members of the National Association of Alcoholism and Drug Abuse 
Counselors (NAADAC), the largest association of alcoholism counselors in 
the United States. 
One hundred forty-four instruments were mailed to the complete 
list of treatment providers serving as supervisors for Rational Recovery 
Systems (RRS) groups, a national, secular-based alternative to AA groups 
currently undergoing rapid growth and expansion throughout the U.S. 
108 
Table 3. 
Distribution of the Addiction Belief Study Survey by Professional Group.s 
Mailed Returned 
NAADAC 200 104 
SPAB 1 67 98 
RRS 1 44 91 
1 2 
Total 511 327 '
Total Surveys Used for Addiction Belief Study 3 295
Note. 1 64 percent return rate. 2Two respondents cut off the group-
identifying number, therefore, it was impossible to determine which group 
they belonged to. 3 32 respondents indicated they were not addiction-
treatment providers, therefore their surveys were discarded. 
One hundred sixty-seven instruments were mailed to addiction-
treatment providers who are members of the Society for Psychologists in 
Addictive Behaviors (SPAB), a national organization. The 
secretary/ treasurer of SPA B hand-picked these members on the basis of 
their having listed themselves as treatment providers. 
Each participant received a letter introducing the study, the in-
strument and instructions. A self-addressed stamped envelope was 
included along with a request that participants return the instrument as 
soon as possible. Confidentiality was guaranteed in the introductory letter. 
Subjects were instructed not to write their name anywhere on the survey. 
Each survey sent out had a handwritten number in the upper-right hand 
corner of the first page corresponding to a number on the mailing list of 
109 
participants. As surveys were returned, this number was cut off and 
discarded, and the name of the participant was crossed off the mailing list. 
Those remaining names not crossed off after two weeks were sent 
reminder postcards (Appendix C). 
Completed and returned surveys totaled 327 and were received by 
mail within two months of the initial mailing, constituting a 64 percent 
return rate. Of these, 32 respondents indicated they were not addiction-
treatment providers, therefore, 295 addiction-treatment providers 
established the primary sample studied, (N=295). 
Description of Scales Used in the Survey 
This next part of the section describes the inst.rumen ts used to assess 
beliefs of addiction-treatment providers. These instruments include the 
Addiction Belief Scale (ABS), the Multi-dimensional Health Locus of 
Control scales (MHLC), the Spiritual Belief Scale (SBS), a request for 
demographic information, a fifth question requesting the percentage of 
drug addicts respondents believed got over their addiction without any 
form of medical or 12-step type treatment, and an invitation for comments 
on the survey. 
The method for establishing validity of the ABS and the SBS is 
described here, as well as the reliability statistics for the ABS, MHLC and 
the SBS. Finally, a description of statistical procedures used to analyze the 
data in light of the research questions is presented at the end of the method 
section. 
110 
The Addiction Belief Scale (ABS) 
The first part of the instrument was composed of 18 statements 
representing beliefs regarding the etiology of drug addiction and addicts' 
ability to control their addiction, (Table 4). Eighteen items were devised 
and served as the criterion measure. These items were based in part on a 
chart in a book by Peele et al. (1991), a section entitled "Ten Assumptions 
that Distinguish the Life Process Program from the Disease Model." They 
represent the beliefs of two sides of the controversy concerning the etiology 
of addiction, i.e., it is primarily a volitional behavior that people develop 
as a way of coping with their life, or, it is a primary and uncontrollable 
disease from which other problems-in-living stern. 
Nine items were statements characterizing a belief in the disease 
model of addiction. Nine items were statements characterizing belief in 
the free-will model of addiction. The statements representing the two 
perspectives are marked by brackets in Table 4. 
The 18 items were presented in random order to avoid a patterned 
response. Subjects were asked to mark the extent to which they agreed or 
disagreed with each statement along a five-point Likert scale ranging from 
"strongly disagree," "disagree," and "uncertain," to "agree," and "strongly 
agree." The stronger the belief in a disease-model item, the higher the 
score for that item. The stronger the belief in a free-will item, the lower 
the score for that item. Thus, disease-model items were scored "five" for 
"strongly agree" and "one" for "strongly disagree." Free-will model items 
were scored "one" for "strongly agree" and "five" for "strongly disagree." 
The higher the degree of belief in the disease model of addiction, the 
higher their total score. 
111 
Table 4. 
The Addiction Belief Scale (ABS) 
[Al) Most addicts don't know they have a problem and must be forced to 
recognize they are addicts. [Disease model] 
[A2] Addicts cannot control themselves when they drink or take drugs. 
[Disease model} 
[A3] The only solution to drug addiction and/ or alcoholism is treatment. 
[Disease model] 
[A4] The best way to overcome addiction is by relying on your own 
willpower. [Free-will model] 
[AS] Addiction is an all-or-nothing disease: A person cannot be a temporary 
drug addict with a mild drinking or drug problem. [Disease model] 
[A6] People can stop relying on drugs or alcohol as they develop new 
ways to deal with life. [Free-will model) 
[A7) Addiction has more to do with the environments people live in, 
than the drugs they are addicted to. [Free-will model] 
[A8] People often outgrow drug and alcohol addiction. [Free-will model] 
[A9] The most important step in overcoming an addiction is to acknowledge 
that you are powerless and can't control it. [Disease model] 
[AlO] Abstinence is the only way to control alcoholism/drug addiction. 
[Disease model] 
[Al 1] Physiology, not psychology~ determines whether one drinker will 
become addicted to alcohol and another will not. [Disease model] 
[A12] Alcoholics and drug addicts can learn to moderate their drinking or cut 
down on their drug use. [Free-will model] 
[A13] People become addicted to drugs/ alcohol when life is going badly for 
them. [Free-will model] 
[A14] The fact that alcoholism runs in families means that it is a genetic 
disease. [Disease model] 
[A15) You have to rely on yourself to overcome an addiction such as 
alcoholism. [Free-will model] 
[Al6} Drug addicts and alcoholics can find their own ways out of addiction, 
without outside help, given the opportunity. [Free-will model] 
[A17] People who are drug addicted can never outgrow addiction and are 
always in danger of relapsing. [Disease model] 
[A18] Drug addiction is a way of life people rely on to cope with the world. 
[Free-will model] 
Note. a=.91, (standardized item a=.91, 11=266), mean=54.12, (SD=13.55, 
n=295). 
112 
The highest possible score for each item was five and for the 18 
items, 90. The median score was 45. Scores above the median suggested a 
stronger belief in the disease model of addiction. Those scores below the 
median suggested a stronger belief in the free-will model of addiction. 
The Addiction Belief Scale (ABS) was examined by two scholars who 
have written extensively on issues involving the disease model of 
addiction controversy and are widely-recognized experts in the field of 
alcohol and drug research for content validity-Dr. Kaye Fillmore, 
sociologist, of the University of California-San Francisco, (see Fillmore & 
Sigvardsson, 1988), and Dr. Stanton Peele, a social-clinical psychologist 
from Morristown, New Jersey, (see Peele et al., 1991). Their criticism, 
comments, and suggestions were incorporated in the development of the 
ABS. 
Cronbach's alpha was calculated for the ABS and a=.91, 
(standardized item a=.91, 11=266). The reliabiability statistics for the ABS, 
SBS, and MHLC scales are listed in Table 5. 
The Spiritual Belief Scale (SBS) 
The second part of the survey instrument included eight items 
m easuring spiritual thinking, the Spiritual Belief Scale (SBS), shown in 
Table 6. These items were adapted from the examples listed in the 
"spiritual-thinking variable" section and are characterized by humility, 
tolerance, release, and gratitude. Each contained a reference to God or 
"spiritual health." Each of these qualities or characteristics were expressed 
in two statements in the questionnaire. The beliefs from AA were 
operationalized so that while they are characteristic of AA philosophy they 
are also representative of spiritual thinking for people who are not 
associated with AA. 
113 
Table 5. 
Reliabilities and Means for the ABS, SBS. and MHLC Scales 
a n Mean SD 
ABS 1 . 91 266 54.12 1 13.55
SBS .92 280 24.272 2 8.55
MHLC Scales 
IHLC .66 284 20.762 3.142 
PHLC .57 284 14.841 1 3.14
CHI.C .63 282 13. 021 1 2.96
Note. 1N=295, 2N=294. 
Items 1 and 2 in Table 6 express the release element: The original 
representative-belief statements extracted from Alcoholics Anonymous 
literature were: "My 'Higher Power' has mysteriously accomplished those 
things in my life which I could never do by myself." "I got positive results 
in my life when I laid aside prejudice and expressed a willingness to 
believe in a Power greater than myself, even though it is impossible for me 
to fully define or comprehend that Power, which is God." The SBS 
statements were: "I feel that in many ways turning my life over to God has 
actually set me free." "I know that all the best things in my life have come 
to me through God." 
Items 3 and 4 in Table 6 express the gratitude element. The original 
representative-belief statements extracted from Alcoholics Anonymous 
literature were: "The central factor of my life today is the absolute certainty 
that my Creator has entered into my heart and life in a way which is 
114 
Table 6. 
The Spiritual Belief Scale (SBS) 
St. I feel that in many ways turning my life over to God has actually set 
me free. [Release] 
52. I know that all the best things in my life have come to me through God. 
[Release] 
S3. I believe I am blessed by God with many gifts I do not deserve. 
[Gratitude] 
S4. I feel it is important to thank God when I manage to do the right thing. 
[Gratitude] 
S5. It's only when I stop trying to play God that I can begin to learn what 
God wants for me. [Humility] 
56. I know I am able to meet life' s challenges only with God's help. 
[Humility] 
57. I know that forgiving those who have hurt me is important for my 
spiritual health. [Tolerance] 
58. I believe there are many ways to know God and that my way is not 
the only way. [Tolerance] 
Note. a=.92, (standardized item a=.91, n=280), mean=24.27., (SD=8.55, 
n=294). 
115 
indeed miraculous." "When I make right decisions in my life I believe it is 
important to than?k God for giving me the courage and the grace to act in 
this wa.y." The SBS statements were: "I believe I am blessed by God with 
many gifts I do not deserve." "I feel it is important to thanik God when I 
manage to do the right thing." 
Items 5 and 6 in Table 6 express the humility element. The original 
representative-belief statements extracted from AA literature were: "First 
of all, in order to begin solving my problems, I had to quit playing God. I 
had to realize that I was not God." "I seek through prayer and meditation 
to improve my conscious contact wit!h God as I understand Hirn, praying 
only for knowledge of His will and the power to carry that out." The SBS 
statements are: "It's only when I stop trying to play God that I can begin to 
learn what God wants for me." "I know I am able to meet life's challenges 
only with God's help." 
Items 7 and 8 in Table 6 express the tolerance element. The original 
representative-belief statements extracted from AA literature were: "I 
believe that people who have done wrong to me are perhaps spiritually 
sick. I think it is best to ask God to help me show them the same tolerance, 
pity, and patience that I should give to a sick frie?nd." "I have no desire to 
convince anyone that there is only one way by which faith can be acquired. 
All of us, whatever our race, creed, color, or beliefs, are the children of a 
living Creator, with whom we may form a simple, understandable 
relationship, as soon as we are willing enough to try." The SBS statements 
are: "I know that forgiving those who have hurt me is important for my 
spiritual health." "I believe there are many ways to know God and that my 
way is not the only way." 
116 
Subjects were asked to mark the extent to which they agreed or 
disagreed with the statements along a five-point Likert scale ranging from 
"strongly disagree," "disagree," and "uncertain," to "agree," and "strongly 
agree." The SBS was scored in the direction of high spiritual belief, i.e., the 
higher the score, the more the subject tends to engage in spiritual thinking 
along the dimensions described. The items were included in the survey in 
the order listed in Table 6. 
The SBS was examined by two scholars on Alcoholics Anonymous 
for content validity-AA historian Dr. Ernest Kurtz, affiliated with the 
University of Michigan, Ann Arbor, Michigan, (see Kurtz, 1988), and 
anthropologist Dr. Paul Antze, of York University, Toronto, (see Antze, 
1987). Their criticism, comments, and suggestions were incorporated in 
the development of the SBS inventory. 
Cronbach's alpha was calcufated for the SBS and a=.92, (standardized 
item a=.91, n=280). These statistics are listed in Table 5. 
The Multi-Dimensional Health Locus of Control Scales (MHLC) 
The third part of the instrument contained the Multidimensional 
Health Locus of Control Scales (MHLC) developed by Wallston et al. (1978) 
and was used to assess health locus-of-control orientation. Two versions 
of this scale have been used in the past, "Form A" and "Form B." The scale 
consists of three independent dimensions, the Internal Health Locus of 
Control scale (IHLC), the Powerful Others Locus of Control scale (PHLC), 
and the Chance Health Locus of Control scale (CHLC). For this study, items 
were selected from Form A and Form .B based on previously established 
alpha reliabilities (Wallston et al., 1978) for each dimension, and alpha 
reliability exhibited through a pilot study conducted by the author of this 
present study. 
117 
There are two forms of the three dimensions of the MHLC scales, 
Form A and Form B. The rationale for selecting which form was used now 
follows. The form which had a higher reliability as presented by Wallston 
et al. (1978) was selected for this study with the following exception: Form 
A of the IHLC scale in the Wallston et al. (1978) study gave a reliability of 
.77 compared to .71 for Form B. However, when Form A was used in a 
pilot version of this present study it had a low reliability (.47), so the six 
items from Form B were used in the present study. Form B of the PHLC in 
the Wallston et al. study had a reliability of .72 compared to .67 for Form A, 
so six items from Form B were used. Form A of the CHLC in the Wallston 
et al. study showed a reliability of .75 compared to .69 for Form B, so six 
items from Form A were used in the present study. Table 7 shows the 
three, scales of six items each with the locus-of-control dimension in 
brackets. 
Subjects were asked to mark the extent to which they agreed or 
disagreed with the statement along a five-point Likert scale ranging from 
"strongly disagree," "disagree," and "uncertain," to "agree," and "strongly 
agree." (The original Wallston study used a six-point Likert scale. A five-
point Likert scale was used in this present study to maintain uniformity 
throughout the survey.) Each dimension of the MHLC was scored 
independently. The Internal Health Locus of Control scale was scored in 
the, direction of "internality." The Powerful Others Health Locus of 
Control scale was scored in the direction of "powerful others" attribution. 
The Chance Health Locus of Control scale was scored in the direction of 
"chance" attribution. 
The reliability findings for the present study are presented in Table 5 
and are as follows: Cronbach's alpha was calculated for the Internal Health 
118 
Table 7. 
The Multidimensional Health Locus of Control Scales (MHLC), 
(Wallst on et al., 1978) 
11. If I become sick, I have the power to make myself well again. [IHLC] 
12. I am directly responsible for my health. [IHLC] 
13. Whatever goes wrong with my health is my own fault. (IHLC] 
14. My physical well-being depends on how well I take care of myself. 
[Il-ILC] 
IS. When I feel ill, I know it is because I have not been taking care of 
myself properly. [IHLC] 
16. I can pretty much stay healthy by taking good care of myself. [IHLC] 
P7. If I see an excellent doctor regularly, I am less likely to have health 
problems. [PHLC] 
PB. I can only maintain my health by consulting health professionals. 
[PHLC] 
P9. Other people play a big part in whether I stay healthy or become sick. 
[PHLCJ 
P10. Health professionals keep me healthy. [PHLC] 
Pl 1. The type of care I receive from other people is what is responsible for 
how well I recover from an illness. [PHLC] 
P12. Following doctor's orders to the letter is the best way for me to stay 
healthy. [PHLC] 
C13. No matter what I do, if I am going to get sick, I will get sick. [CHl.C] 
C14. Most things that affect my health happen to me by accident. [CHLCJ 
C15. Luck plays a big part in determining how soon I will recover from 
an illness. [CHLC] 
C16. My good health is largely a matter of good fortune. [CHLCJ 
C17. No matter what I do, I'm likely to get sick. [CHLC] 
C18. If it's meant to be, I will stay healthy. [CHLC] 
Note. IHLC scale a=.64, (standardized item a=.66, n=284), mean=20.76, 
(SD=3.14, n.=294); PHLC scale a=.57, (standardized item a=.58, n=284), 
mean=14.84, (SD=3.14, n=.295); CHLC scale and a=.63, (standardized item 
a=.63, n=282), mean=13.02, (SD=2.96, n:::295). 
119 
Locus of Control (IHLC) scale and a=.64, (standardized item a=.66, tt=284). 
The maximum possible score on the IHLC scale was 30. The higher the 
score, the more respondents believed their behavior alone determines 
their s tate of health or illness. 
Cronbach's alpha was calculated for the Powerful Others Health 
Locus of Control (PHLC) scale and a=.57, (standardized item a=.58, n=284). 
The maximum possible score on the PHLC scale was 30. The higher the 
score, the more the respondent believed that control over health or illness 
is external to self and lies in the hands of powerful others, e.g., medical 
doctors. 
Cronbach's alpha was calculated for the Chance Health Locus of 
Control (CHLC) scale and a=.63, (standardized item a=.63, 11=282). The 
maximum possible score on the CHLC scale was 30. The higher the score, 
the more the respondent believed that control over health or illness is a 
result of chance, fate, or luck. 
Demographic Questions 
The fourth part of the survey instrument requested demographic 
information from the respondents. Subjects were asked to indicate their 
age at last birthday; gender; race / ethnic background; marital status; 
education status (highest); religious affiliation; whether they were an 
addiction-treatment provider or not; whether they were certified as an 
alcohol or addiction counselor or not; whether they considered 
themselves to be an alcoholic or addict in recovery or not; whether they 
currently attended AA or any other 12-step program or not; how long they 
had been in AA or any other 12-step program; whether they had attended 
AA or any other 12-step program in the past or not; whether they were 
currently abstinent from alcohol and/or mood-altering drugs or not; and 
120 
Table 8. 
Demographic Characteristics of the Sarnple 
Mean (SD) n (%) 
Age (at last birthday) 
44.04 {9. 68 l 293 
"How long have you been in 
AA or any other 12-step 
program?. " 
Years in AA 5.04 6.89 224 
"If you do drink alcohol and/ 
or use mood-altering drugs, 
please enter the average 
number of drinks/ times you 
use drugs per week." 
Number of alcoholic :t 
drinks/ drugs/ week 1.82 3.21 
. 
130 ,, 
Gender 
Male 186 (63.10) 
Female 109 (36 .90} 
Race/Ethnic Background 
White 208 (94 . 90) 
Black 7 ( 2 .40) 
Hispanic 4 ( 1.00) 
American Indian/ 
Alaskan N alive 3 ( 1.00} 
Asian 1 ( 0 . 30) 
Marital Status 
Never married 41 {13.90) 
Married 187 (63.40) 
Widowed 6 ( 2.00) 
Separated/Divorced 59 (20.00) 
Educational Status (check highest) 
Some college 28 ( 9.50) 
Bachelor Degree 39 (13.20) 
Graduate Degree 218 (73.90) 
Medical Degree 6 ( 2.00} 
Other 3 ( 1. 00) 
121 
Table 8. (continued) 
n (%) 
Religious Affiliation 
Protestant 81 (27.50} 
Catholic 46 (15.60) 
Jewish 42 (14.20) 
Atheist 22 ( 7.50) 
Agnostic 30 (10.20 ) 
Other 64 (21. 70) 
Are you a Certified 
Alcohol or Addiction 
Counselor? Yes 153 (51.90) 
No 142 (48.10) 
Do you consider yoursel~ 
to be an alcoholic or addict 
in recovery? Yes 100 (33. 90 ) 
No 193 ( 65 .40 ) 
Do you currently attend 
Alcoholics Anonymous? Yes 10 1 (3 4.20} 
No 194 (65. 80 ) 
Have you attended AA or any other 
12-step programs in the past? Yes 206 (69.80) 
No 80 (31.00) 
Are you currently abstinent from 
alcohol and/ or mood-altering drugs? Yes 187 (61. 70) 
No 111 (37. 60 ) 
122 
the number of drinks/ drugs they used per week. Table 8 contains a 
summary of this demographic information on the sample. 
Addiction Recovery Without Treatment Beliefs 
The fifth part of the inventory requested the percentage of drug 
addicts respondents believed got over their addiction without any form of 
medical or 12-step type treatment. Percentage figures from O to 100 were 
listed in intervals of ten and subjects were asked to circle the appropriate 
percentage figure. The question was asked in the following way: "What 
percentage of drug addicts do you believe get over their addiction without 
any form of medical or 12-step type treatment? (Please circle one)" 
Comments J., ; 
The last item on the survey welcomed comments on the instrument :~?; 
1? ?? 
?. .. . ,'  
or the topics addressed. The item was phrased in the following way: "You .;,  .,''  
"' I 
are welcome to write any comments on this instrument or the topics 
addressed in the space below." 
Treatment-Provider Groups .,. . ,.. ..  ~ 
Each survey was coded in order to determine whether the person on .!.$ 
the various mailing lists had responded. If they had not returned the 
survey they were sent a reminder card based on the number in the upper 
right-hand corner of the survey form. The subjects were informed of this 
coding procedure and confidentiality was guaranteed. The numbers were 
cut off upon return of the survey form. 
Numbers coded from 1-167 indicated the respondent was from the 
Society of Psychologists in Addictive Behaviors (SPA B). Those numbers 
from 168-311 were from Rational Recovery Systems (RRS) and those from 
312-511 were from the National Association of Alcoholism and Addiction 
Counselors (NAADAC). 
r:-. :: 
123 
Sample Characteristics 
Tables 8 and 9 give a breakdown description of characteristics of the 
sample. Treatment-provider group membership included 98 (33.2%) from 
SPAB, 63 (64%) males and 35 (36%) females; 91 (30.8%) from RRS, 69 (76%) 
males and 22 (24%) females; and 104 (35.3%) from NAADAC, 53 (51 %) 
males and 51 (49%) females. Table 9 reflects the sample characteristics by 
treatment-provider group. A breakdown of groups by significant-group 
compositions is presented in Appendix J. 
Respondents were from the three groups, SPAB, RRS, and 
NAADAC, and these groups varied significantly by gender in terms of 
2
expected and observed frequencies, (X =12.97, df=2, p<.001). Appendix J 
lists the groups that varied significantly in terms of expected and observed 
group frequencies. 
Statistical Procedures 
In order to answer the primary research question, "what are some o.f 
the factors that explain beliefs among addiction-treatment providers about 
the etiology of drug addiction?," multiple-regression analyses were 
conducted using the Statistical Package for the Social Sciences (SPSS) 
computer program on an IBM mainframe computer at the University of 
Maryland Computer Science Center. First, Pearson's Product Moment 
Correlations were calculated to assess the strength and direction of 
correlation between all variables. Scores on the SBS were entered at step 
one s: th MH.LC scales were entered together at step two, and 
, scores 1or . e 
Seo. II h ?ni?ng demographic variables were entered at step res on a t e rema1 
three. The incremental increase in Rz was calculated for significance at 
124 
Table 9. 
Sample Characteristics by Treatment-Provider Groups,.. 
SPAB RRS NAADAC 
11 98 (33.2) 91 (30.8) 104 (35.3) 
Gender 
Male 63 (64.0) 69 (76.0) 53 (51. 0) 
Female 35 (36.0) 22 (24.0) 51 (49.0) 
Recovery Status 
In recovery 19 (19.0) 15 ( 15. 0) 65 (65.0) 
Not in rec. 79 (41. 0 l 74 (38.0) 39 (20.0) 
i? I 
AA Status .~..1R ,!,, ?  
,?t 
In AA now 20 (20.0) 8 ( 8.0) 73 (73.0) :' ',  
?.: 
Not in AA " 
...".,   
now 78 (40.0) 83 (43.0) 31 (16.0) .t ... =~; 
~. .. 
In AA past 57 (28.0) 55 (27.0) 93 (45.0) 
':,~~ .
 
. t
.?.?  
Not in AA ' ' 
past 38 (48.0) 31 (39.0) 10 (13.0) 
Abstinence Status 
Abstinent 45 (46.0) 46 (51.0) 90 (87.0) 
Not 
abstinent 52 (54.0) 44 (49.0) 14 (13.0) 
?(percentage) 
125 
each step. Scores on the ABS were used as the criterion. 
The partial contribution for each variable was calculated over and 
above all the other variables, with scores on the ABS as the criterion. All 
variables were entered together into the regression equation at step one 
with the exception of the one being investigated. The variable investigated 
was then entered at step two. The incremental contribution of this 
partialed-out variable was calculated for significance in ability to explain 
variance in the criterion. 
li 
I 
,' , 
126 
CHAPTER IV 
RESULTS 
The purpose of this study was to investigate factors that account for 
variance in beliefs among treatment providers about the etiology of drug 
addiction. This section of the study presents the findings from the 
statistical analyses performed on the data collected from the survey. Prior 
to presenting findings related to each research question, means and 
standard deviations of variables are presented. Results from the various 
scales are presented first. Descriptive data is presented second, showing the 
various correlations between variables. 
The results of the statistical procedures as they relate to the research 
!j 
questions are then presented here, along with tables to further illustrate .'".  
the findings. Scores on the ABS, SBS, and MHLC, broken down by 
demographic variables of gender, certification status, addict~in-recovery 
status, AA status, abstinence status, and professional-group affiliation are 
presented in Appendices D, E, and F. Prior to presenting findings related to 
each research question, means and standard deviations of variables are 
presented. 
A complete text of comments by respondents is presented in 
Appendix G. The comments from respondents suggest that researcher bias 
was well-protected. Respondents who believed in the disease model of 
addiction accused the investigator of bias in favor of the free-will model. 
Those critical of the disease model accused the investigator of bias in favor 
of the disease model. 
A correlation matrix for all variables is presented in Appendix H. A 
complete matrix of individual item-by-item intercorrelations for the ABS 
127 
and SBS is presented in Appendix I. Factor analyses of the SBS and ABS 
and discussion of these findings appear in Appendix K. 
Results for the ABS 
The m ean score on the ABS was 54.12, (SD=13.55, n==295). 
Statistically-significant differences in scores on the ABS by gender, 
certification status, addict-in-recovery status, AA status, abstinence status, 
and treatment-provider group membership are presented in Appendix D. 
Results for the SBS 
The mean score on the SBS wc1s 24.27, (5D==8.55, n=294). Statistically-
significant differences in scores on the SBS by gender, certification status, 
addict-in-recovery status, AA status, abstinence status, and treatment-
provider group membership are presented in Appendix E. 
Results for the MHLC Scales 
Results for the IHLC Scale 
The mean score on the IHLC scale was 20.76, (SD=3.14, n=294). 
Statistically-significant differences in scores on the IHLC scale occurred by 
treatment-provider group membership. These findings are presented in 
Appendix F. Scores by gender are also presented in Appendix F. 
Results for the PHLC Scale 
The mean score on the PHLC scale was 14.84, (SD=3.14, n=295). 
Statistically-significant differences in scores on the PHLC scale occurred by 
treatment-provider group membership. These findings are presented in 
Appendix F. Scores by gender are also presented in Appendix F. 
Results for thE> CHLC Scale 
The mean score on the CHLC scale was 13.02, (SD=2.96, n=295). 
Statistically-significant differences in scores on the PHLC scale occurred by 
128 
treatment-provider group membe,rship. These findings are presented in 
Appendix F. Scores by gender are also presented in Appendix F. 
Recovery Beliefs Without Treatment 
When asked what percentage of drug addicts respondents believed 
got over their addiction without any form of medical o:r 12-step type 
treatment, the mean percentage indicated was 25.07, (SD=-24.42, n=293t and 
ranged from zero to 100 percent. 
Findings Related to the Research Questions 
Table 10 lists all of the findings relevant to each of the research 
questions. In order to answer the research question, "do spiritual beliefs 
(SBS) of trec1tinent providers explain variance in beliefs regarding the 
etiology of addiciton among treatment providers?," the correlation (r) for 
scores with the SBS and ABS was calculated. The significance for this 
correlation was calculated as well. 
Next, all of the variables were entered into the regression equation 
at step one, with the exception of scores for the SBS variable. The 
incremental R2 and beta for this variable entered at step two were 
calculated. As Table 10 shows, SBS explains 42 percent of the variance in 
2 
ABS and gives an incremental increase in R of .03, over and above all 
others variables, a finding that is significant at p<.001 level. 
In order to answer the research question, "does the health locus-of-
control orientation of treatment providers explain variation in beliefs 
regarding the etiology of addiction?," all scores for the three dimensions of 
the MHLC scales were entered at step two in the regression equation, with 
scores for the SBS in the equation at step one. The incremental increase in 
variance explained by health locus-of-control orientation was then 
calculated. The contribution of MI-ILC scores was tested for significance. 
129 
Table 10. 
Factors Explaining Variation in Addiction Beliefs 
Do spiritual beliefs (SBS) of treatment providers explain variance in 
beliefs regarding the etiology of addiction among treatment providers? 
Incremental 
Variable r p R2+ Beta+ p+  
SBS .63 .42 <.001 .03 .28 <.001 
Does the health locus-of-control orientation (MHLC) of treatment 
providers -explain variation in beliefs regarding the etiology of addiction? 
Incremental 
Order Variable R2 R2 F df p 
Step One SBS .42 
Step Two MHLC .43 .01 4.66 22,190 <.0001 
Incrementnl p+  
Variable r p R2+ Beta+ 
PHLC .18 <.0001 .02 .14 <.01 
IHLC -.13 .02 <.00 .01 .90 
CHlC .09 .11 <.00 .07 .18 
F df 
MHLC .02 12.21 1,190 <.0001 
130 
Table 10. (continued) 
Does the age, gender, race/ethnicity1, educational status, marital 
status, religious affiliation, certification-as-treatment-provider status, 
alcoholic/ addict in recovery status, past and present experience in 12-step 
and/or other treatment programs, plus length of time in these programs, 
as well as their current drinking or drug-taking status, i.e., whether they 
are abstinent or not, and their professional-group affiliation explain 
variation in beliefs regarding the etiology of addiction? 
lncrementnl 
Order Variable R2 F df p 
Step One SBS ? 42 
Step Two MHLC .43 .01 4.66 22,190 <.0001 
Step Three Group"'2 
Gender 
Drug freq. 
AA now 
AA past 
Cert. 
Education 
Religious 
Affiliation *3 
Rec. addict. 
Marital 
Status,..4 
Age 
AA time 
(All at step 
three) . 62 . 19 13.49 19,190 <.0001 
131 
Table 10. (continued) 
Incremental 
Variable R2+ Beta+ .. r p p 
Group?2 .07 <.0001 
SPAB -.02 .7508 
NAADAC . 31 <,0001 
Gender .31 <. 0001 .02 . 15 .0042 
Drug freq. - .35 < .0001 .01 -.12 .0323 
AA now - .55 < . 0001 .01 - . 15 . 0614 
Religious? J 
Affiliation .01 
Protestant -.03 .5560 
Catholic - .04 .4330 
Jewish . 07 .1748 
Agnostic -.01 .8350 
Maritai"4 ~ 
Status .01 )'  
Married . 04 .5016 . " 'j 
Widowed . 05 .292 4 ~ 
Sep/Div. . 01 ,8476 : , 
AA past <.00 -.01 .8716 ',I  
Certification <.00 ' ) - . 06 .2392 i 
Education <.00 . 02 '' . 7809 '?;'J .",.  
Abstinence - .37 <.0001 <'..00 .01 .8498 ??,1  
Rec. addict - .40 <.0001 <.00 - . 01 .9277 :~ 
Age <-. 01 .99 <.00 .08 .1666 
.~I 
AA Time .45 < .0001 <.00 -.07 .3407 
Note: + After controlling for all other variables at Step 1 of the regression 
equation. ?series of dichotomies created when the nominal variables were 
dummy coded. 1Significance of F for race/ethnicity= .10 so this variable 
was not entered into the regression equation. 2compared to members of 
Rational Recovery Systems, F=33.81, 3df=l,190, p<.0001. Compared to those 
respondents who identified themselves as atheists, F=2.64, df=l ,190, p>.05. 
4Compared to those respondents who identified themselves as unmarried, 
F=3.27, df=l,190, p>.05. 
132 
In order to assess for the ability of MHLC scores to explain variance 
in the ABS over and above all other variables, all of the variables were 
entered into the regression equation at step one, with the exception of 
scores-for all three of the MHLC scale scores, which were then entered at 
step two. The incremental contribution for MHLC scale scores was then 
calculated in this manner. 
As Table 10 shows, SBS scores and MHLC scale scores together 
explain 43 percent of variance in the ABS. The incremental increase in R2 
is one percent after SBS scores were entered into the equation. The 
additional increment for MHLC scores is significant at the p<.0001 level. 
When controlling for all other variables, MHLC scale scores together 
explain two percent incremental increase in R2 scores, (F=12.21, df= 1,190, 
p<.0001). (The difference of one percent in ability to explain variance in 
the ABS is attributed to shared variance with other variables.) A similar 
procedure was used to assess which of the three MHLC scales was the best 
2 
predictor. PHLC gives an incremental increase in R of .02, over and above 
all others variables, a finding that is significant at the p<.0001 level. 
In order to answer the research question, "does the age of addiction-
treatment providers, as well as their gender, race/ethnicity, educational 
status, marital status, religious affiliation, certification-as-treatment-
provider status, alcoholic/ addict in recovery status, past and present 
experience in 12-step and/or other treatment programs, plus length of time 
in these programs, as well as their current drinking or drug-taking status, 
i.e., whether they are abstinent or not, and their professional-group 
affiliation explain variation in beliefs regarding the etiology of addiction?," 
all of the demographic variables were entered into the regression equation 
at step three of the regression equation, with scores for SBS and scores for 
133 
the MHLC scales in the equation at steps one and two. All of the variables 
together explain 62 percent of the variance in ABS scores. The 
demographic variables explain 19 percent of the variance in addiction 
beliefs over and above SBS and MHLC scale scores. This incremental 
ability in R2 for the demographic variables to explain scores in the ABS is 
significant at the p<.0001 level, (f=13.49, d/=23). 
In order to explore the ability of each demographic variable to 
explain variance in the ABS over and above all other variables, each 
demographic variable was entered into the regression equation at step two 
with all other variables entered at step one, with the exception of the 
2 
Variable being tested. The incremental R and beta for each of these 
individual demographic variables entered at step two was calculated. Table 
10 shows the incremental R2 for each of these variables, the significance of 
the increment, the beta statistic for each variable, with ABS scores as the 
criterion. Three of these demographic variable are statistically-significant 
in their ability to explain variance in the ABS: Group, gender, and drug 
frequency. 
The professional-group affiliation variable was dummy coded and 
when the status for each of the three groups was entered into the 
regression equation together explained .07 percent increase in addiction 
beliefs, over and above all the other variables entered at step one. The 
incr . , the three groups is significant at p<.0001, where 
ementa1  increase ,or 
F:::33.Sl, d/=l,l 0. The mean scores for the ABS by professional-group 
9
aft?i? . . . A pendiX D. Members of NAADAC scored highest 
1 1ation are hsted 1n P 
h . b those from SP.AB. Members of RRS scored lowest 
0 n t e ABS, followed Y 
on the ABS. 
134 
Gender contributed a two percent increase in the total R2 when 
partialed out and is positively correlated with the ABS fr=.31, p<.0001), 
(value for males=l, value for females=2), i.e., females tended to score high 
on ABS and males tended to score low. This finding is significant at the 
p=.0042 level. 
Drug frequency contributed an incremental increase in R2 of slightly 
less than one percent over and above the other variables. This increase is 
significant at the p=.03 level. Drug frequency is negatively correlated with 
addiction beliefs (r=-.35, p<.0001). This means that the amount of alcoholic 
drinks and/ or mood-altering drugs consumed per week explains variance 
in addiction beliefs. The less drugs consumed the more likely the 
treatment providers are to believe in the disease model of addiction. The 
more drugs they consume, the more likely they are to believe in the free-
will model. 
None of the other variables contributed a significant amount of 
increase in R2 at p=.05. 
These findings relate to the main research question: What are some 
of the factors that explain beliefs among addiction treatment providers 
about the etiology of addiction? The findings presented in Table 10 show 
that five factors explain variance in beliefs regarding addiction: Scores on 
the Spiritual Belief Scale, health locus-of-control orientation, professional 
treatment-provider group membership, gender, and the number of 
alcoholic drinks and/ or mood-altering drugs consumed per week. The 
PHLC dimension of the MHLC scales is significant in its ability to predict 
scores on the ABS. 
Therefore, the answer to the main research question-"What are 
some of the factors that explain beliefs among addiction-treatment 
135 
providers about the etiology of drug addiction?" -is that spiritua] 
thinking, as measured by the SBS, health locus-of-control orientation, 
specifically the extent to which subjects attribute responsibility for health 
and illness to powerful others, as measured by the PHLC scale of the MHLC 
scales, their professional group-membership, i.e., whether subjects are 
members or affiliated with RRS, SPAB or NAADAC, gender, and how 
many alcoholic drinks or mood-altering drugs they consume per week are 
factors that can explain a statistically significant amount of variance in 
beliefs about addiction, as measured by the ABS. 
Some Additional Findings 
Correlation Coefficients for Spiritual Beliefs 
Since spiritual thinking as measured by the SBS explained the . 
largest amount of variance in addiction beliefs over and above all other 1? 
i 
factors, the correlations between scores on the SBS and other variables 
were of interest to this researcher. Table 11 lists the correlations for nine 
variables that were significant at the .01 level. Whether or not respondents 
were in AA now was most strongly correlated with spiritual beliefs, 
followed by the number of years they had been in AA, whether they 
considered themselves to be addicts in recovery, whether they had been in 
AA in the past, whether they were abstinent from alcohol and/or mood-
alte ? d th ? ducational status, their scores on the PHLC 
rmg rugs, e1r e 
dimension of the MHLC, and whether they were certified as 
addiction/ alcoholism counselors. The direction of these correlations is 
listed in Table 11. 
136 
Table 11. 
Correlation Coefficients for Spiritual Beliefs (SBS) 
r 
In AA now?11- -.53 
Years in AA .44 
Addict in recovery?,.. -.37 
In AA in the past? -.36 
Abstinent? -.33 
Drink/d rug frequency/ week -.28 
Educational status -.25 
PHLC .21 
Gender** ,,? .18 . 
Certified?* -.16 ",,  
?,,".  
,I 
',, . 
I, 
Note. p=.01. *l=yes, 2=no. **l=male, 2=female. 
137 
CHAPTER V 
CONCLUSIONS, DISCUSSION, AND IMPLICATIONS 
This section contains a recapitulation of the research interest, a 
summary of the methods used to investigate the research questions, 
conclusions, discussion, and recommendations based on findings. 
Recapitulation of the Research Interest 
A heated controversy exists in the addiction-research and treatment 
field regarding the extent to which addiction is a choice or a disease. Beliefs 
regarding addiction appear to vary a great deal among addiction-treatment 
providers. The purpose of this study was to investigate factors that may 
explain variation in beliefs among addiction-treatment providers 
regarding the etiology of addiction. Four research questions were 
generated to explore these factors. The primary research question asked in 
this study was the following: What are some of the factors that explain 
beliefs among addiction-treatment providers about the etiology of drug 
addiction? 
Three sub-questions followed the main research question to further 
specify these factors: (a) Do spiritual beliefs of treatment providers explain 
variance in beliefs regarding the etiology of addiction among treatment 
providers? And, (b) does the health locus-of-control orientation of 
treatment providers explain variation in beliefs regarding the etiology of 
addiction? Additionally, the research interest includes (c) whether the 
following demographic characteristics of addiction-treatment providers are 
able to account for variance in beliefs regarding addiction: Do their age, 
gender, race/ ethnicity, educational status, marital status, religious 
affiliation, certification-as-treatment-provider status, alcoholic/addict in re-
covery status, past and present experience in 12-step and/ or other 
?~. .c  
138 
treatment programs, plus length of time in these programs, as well as their 
current drinking or drug-taking status, i.e., whether they are abstinent or 
not, plus the frequency of alcoholic drinks and/ or mood-altering drugs 
consumed per week, and their professional-group affiliation explain 
variation in beliefs regarding the etiology of addiction? 
Summary of Method 
The Addiction Belief Scale (ABS) was created to assess beliefs about 
addiction along the disease model and free-will model dimensions. The 
ABS was checked for validity by two experts in the addiction field. 
Agreement on content validity was achieved. The instrument shows high 
reliability. ) 
r'  
The Spiritual Belief Scale (SBS) was created to assess beliefs about .I!, I   
spirituality. The SBS was checked for validity by two experts on spirituality 
in AA. Agreement on content validity was achieved. The instrument . 111 
l,.tl .t  
shows high reliability. ,.,. 1111 
The Multidimensional Health Locus of Control scales were used to ,, 
.I.ll ?J'  
i::?l 
assess attributions for health and ilJness. The reliability statistics for this 
instrument are fair. 
An eleven-page survey form was assembled and in.duded requests 
for demographic information. The survey form and accompanying letter 
were mailed to 511 addiction-treatment providers nation-wide. They 
included a random sample of addiction-treatment providers from the 
National Association of Alcoholism and Drug Abuse Counselors, all of the 
. f R ti. 1 Recovery Systems g.roups, and all psychologists 
Sup erv1sors o a ona 
. d . . es as treatment providers and members of the 
Wh o 1 en t1f1 ed themse1 v  
. Addictive Behaviors. 
S ociety for Psychologists m 
139 
Completed and returned surveys totaled 327 and constituted a 64 
percent return rate. Of these, .32 treatment providers indicated they were 
not addiction-treatment providers, therefore, 295 addiction-treatment 
providers established the primary sample studied. 
The results were tallied and analyzed using SPSS on an IBM-
mainframe computer at the University of Maryland in College Park. The 
statistical procedures used included multiple regression analyses to assess 
the extent to which the various factors predict variance in the criterion 
measure (ABS), over and above other variables. 
Conclusions 
The findings support the idea that five factors explain variance in 
beliefs of addiction-treatment providers regarding the etiology of addiction: 
Spiritual thinking, health locus-of-control orientation, professional-group 
affiliation, gender, and the frequency of alcoholic drinks and/or mood-
altering drugs ingested per week each explain variance in beliefs of 
addiction-treatment providers regarding the etiology of addiction. 
Spiritual Thinking and Addiction Beliefs 
The findings support the idea that the spiritual thinking explains 
beliefs regarding the etiology of addiction among treatment providers. 
Spiritual thinking? explained 42 percent of the variance in addiction beliefs. 
The incremental R2 contribution of scores on the SBS, over and above all 
other variables entered at step one of the regression equation, is significant 
at the p<.001 level. Since the simple r for SBS is positively correlated with 
the ABS, scores on the SBS increase as scores on the ABS increase. 
An increase in scores on the ABS indicates a stronger belief in the 
disease model of addiction. An increase in scores on the SBS indicates a 
stronger belief in a metaphysical power that can influence experience. 
140 
The?refore, the findings support the idea that the extent to which treatment 
providers believe that a metaphysical power can influence their personal 
experience is positively correlated with the strength of their belief in the 
disease model of addiction. The stronger the spiritual belief, the stronger 
the belief in the disease modeJ. Treatment providers who disagree with 
statements suggesting that a metaphysical power can influence personal 
experience are likely to believe in the free-will model of addiction. 
Health Locus-of-Control Orientation and Addiction Beliefs 
The findings support the idea that health locus-of-control 
orientation of treatment providers explains variation in beliefs regarding 
the etiology of addiction. Spiritual thinking and health locus-of-control 
orientation together explained 43 percent of the variance in addiction 
beliefs. The incremental contribution of MHLC scores over and above 
2 
spiritual thinking was significant at the p<.0001 level. The incremental R
contribution of scores on the PHLC dimension of the MHLC, over and 
above all other variables entered at step one of the regression equation, is 
significant at the p=.01 Ievet Since the simple r for PHLC is positively 
correlated with the ABS, scores on the PHLC increase as scores on the ABS 
increase. 
An increase in scores on the ABS indicates a stronger belief in the 
disease model of addiction. An increase in scores on the PHLC indicates a 
stronger belief in the idea that powerful others are responsible for one's 
experience of health and illness. 
Control orientation explains minimal yet H ea1 t  h Io cus-0f  -
stat? t? . . 'f' nt amount of variance in addiction beliefs over and 
1s 1stica1 1 y-s1gnr 1ca 
. . . k' and all other demographic variables. Moreover, 
a b ove spiritual thm ing, 
. . ho tend to attribute responsibility for their 
treatment providers w 
141 
experience of health and illness to powedul others are likely to believe in 
the disease model of addiction. Treatment providers who disagree with 
statements attributing responsibility for their experience of health and 
illness to powerful others tend to believe in the free-will model of 
addiction. 
Demographic Characteristics and Addiction Beliefs 
The findings support the idea that for treatment providers, their age, 
gender, race/ ethnicity, educational status, marital status, religious 
affiliation, certification-as-treatment-provider status, alcoholic/ addict in re-
covery status, past and present experience in 12-step and/ or other 
treatment programs, plus length of time in these programs, as well as their 
current drinking or drug-taking status, i.e., whether they are abstinent or 
not, plus the frequency of alcoholic drinks and/or mood-altering drugs 
consumed per week, and their professional-group affiliation together ,, 
,, 
explain variation in beliefs regarding the etiology of addiction. These 
variables together with spiritual thinking and health locus-of-control 
orientation explained 62 percent of variance in addiction beliefs. 
The demographic variables explain 19 percent of the variance in 
addiction beliefs over and above scores for spiritual thinking and health 
locus-of-control orientation. This finding is significant at the p<.0001 
level. 
The findings support the idea that three demographic characteristics 
of addiction-treatment providers are able to account for variance in beliefs 
regarding addiction: Professional-group affiliation, gender, and the 
frequency of alcoholic drinks and/ or mood-altering drugs consumed per 
week each explain variance in addiction beliefs. 
142 
Professional-Group Affiliation and Addiction Beliefs 
The findings support the idea that the professional-group affiliation 
of treatment providers explains variance in beliefs regarding addiction. 
Since there were three groups, N AADAC, SPA B, and RRS, the group 
variable was dummy-coded and entered into the regression equation as 
three dichotomous variables. These three dummy-coded variables were 
entered into the regression equation together at step two. The incremental 
R2 contribution of scores for this group variable, over and above all other 
variables entered at step one of the regression equation, is statistically 
significant at the p<.0001 level. 
The highest possible score on the ABS was 90. Therefore, a score of 
45 divided the scale in half. Scores above 45 suggested a stronger belief in 
the disease model of addiction. Scores below 45 suggested a stronger belief 
in the free-will model of addiction. 
The mean score on the ABS for members of NAADAC was 64.97, for 
I. . 
members of SPAB was 52.88, and for members of RRS was 42.89. Members .~ 1,~??  
? j 
of NAADAC tend to believe in the disease model of addiction, as do : ?1 ;I!-
members of SPA B, but to a lesser extent. Members of RRS tend to believe 
in the free-will model of addiction. 
Gender and Addiction Beliefs 
The findings support the idea that the gender status of treatment 
providers explains variance in beliefs about addiction. The incremental R2 
contribution of gender status, over and above all other variables entered at 
step one of the regression equation, is significant at the p=.0042 level. Since 
the simpler for gender is positively correlated with the ABS, and males 
were scored as "l" and females as "2," scores on the gender variable 
increase as scores on the ABS increase. 
143 
An increase in scores on the ABS indicates a stronger belief in the 
disease model of addiction. An increase in scores on the gender variable 
indicates the respondent is female. 
Therefore, the findings support the idea that gender status is 
positively related with the strength of belief in the disease model of 
addiction. Female treatment providers are likely to believe in the disease 
model of addiction. Male treatment providers are likely to believe in the 
free-will model of addiction. 
Freguency of Alcoholic Drinks and Mood-Altering Drug Use/Week and 
Addiction Beliefs 
The findings support the idea that the number of alcoholic drinks 
and/or mood-altering drugs ingested per week by treatment providers can 
explain variance in beliefs about addiction. The incremental R2 
contribution of the number of alcoholic drinks and/or mood-altering 
drugs ingested per week, over and above all other variables entered at step 
one of the regression equation, is significant at the p=.03 level. The simple 
.?~  
r is negative for drug frequency and ABS scores. .,. 
The lower the number of alcoholic drinks and/or mood-altering 
drugs ingested by treatment providers per week, the more likely these 
treatment providers are to believe in the disease model of addiction. The 
hlgher the number of alcoholic drinks and/or mood-altering drugs 
ingested by treatment providers per week, the more likely they are to 
believe in the free-will model of addiction. 
Discussion 
Discussion of the Findinis in Light of the Research Questions 
Sixty-two percent of the variance in addiction beliefs was explained 
by the variables used in this study. There is clearly a strong relationship 
144 
between several of the individual variables used to explore addiction 
beliefs, as well as a combination of these variables. The demographic 
variables independent of scores on spiritual thinking and health locus-of-
control orientation explained 18 percent of variance in addiction beliefs, 
which is a significant amount. In other words, we can ascertain with a fair 
degree of confidence what addiction-treatment providers are likely to 
believe about the etiology of addiction based on their experience with AA, 
their certification, abstinence, education, and marital status, their age, their 
religious affiliation, and the number of alcoholic drinks and/o r mood-
altering drugs they consume per week, all examined together. 
One explanation for this finding is that addiction-treatment 
providers who believe in the disease model of addiction tend to share 
certain characteristics. They tend to be abstinent or drink very little. They 
are likely to be certified as treatment providers, where they undoubtedly 
receive indoctrination in the disease model of addiction. They are likely to 
be lower educated, and have strong religious beliefs. Most importantly, 
they are likely to have had a great deal of experience with AA, compared to 
those treatment providers who believe in the free-will model. Treatment 
providers who believe in the disease model of addiction are more likely to 
be members of NAADAC and to a lesser extent SPAB. Members of RRS 
are more inclined to believe in the free-will model of addiction. 
The findings of this study supfX)rt the idea that five specific factors 
explain variance in addiction beliefs among treatment providers: Spiritual 
thinking, health locus-of-control orientation, professional-group 
aff'l? . d d the frequency of alcoholic drinks and/o r mood-
1 1at1on, gen er, an 
altering drugs ingested per week. 
145 
Three of these factors, spiritual thinking, health locus-of-control 
orientation, and gender, appear to share certain characteristics. For 
example, spiritual thinking is defined in this study as belief in a 
metaphysical power that can affect personal experience. The power could 
be anything, as long as it is metaphysical and not "self." 
One possible explanation for the relationship between spiritual 
thinking and belief in the disease model of addiction is that both involve 
the attribution of power and responsibility for experience to some alien 
factor external to self. The disease-model belief attributes responsibility for 
addiction to either the "addictive drug," or physiological differences addicts 
share as compared to normal people, or a combination of the two. Belief in 
loss-of-control theory involves the attribution of responsibility for 
addiction to factors other than self. The disease is a fixed, external power. 
Similarly, spiritual thinking appears to be an attribution of release 
from the problems associated with addiction to a metaphysical power 
external to self. This spiritual power appears to both a stable and unstable 
force in the mind of the spiritual thinker. For example, the power is 
believed to be a stable force in the universe in the sense that it is always 
present, and unstat>le in the sense that the true t>eliever never reaJly knows 
when the metaphysical force is going to affect his or her life. 
"Good" experiences seem generally attributed to the spiritual force 
and "bad" ones to the disease of addiction. In either case, the attribution 
for experience is to an external factor. 
. k sense that spiritual thinking explains belief in the 
Th us, 1t ma es 
disease model. Both systems of t>elief are external in locus-of-control 
orientation. 
146 
Concurrently, low scores on the SBS predict belief in the free-will 
model of addiction. The less the belief in an external metaphysical power 
that can affect personal experience, the more the treatment provider is 
likely to attribute responsibility for addiction to willful, or self processes. 
This appears to be, more or less, a dichotomous issue regarding 
beliefs of this nature. Self attribution and spiritual attribution are 
mutually exclusive. The same dichotomy appears to hold true for beliefs 
about addiction. One is either in the disease model or the free-will model 
camp, never both. The former attributes experience to external factors, the 
latter to internal ones. The power for experience, be it the power of the 
addiction as a disease, the power of self to control the addiction, or the 
power of a metaphysical force to release the individual from the "grip" of 
the addiction is either external or internal. 
In this context, we may be in a better position to understand how 
health locus-of-control orientation explains beliefs about addiction. The 
PHLC dimension of the MHLC scales is similar to spiritual-thinking 
processes. The difference is that instead of attributing responsibi1ty for 
"health" to a metaphysical power, it is attributed to powerful others, such 
as doctors. Powerful others attribution is an external locus-of-control 
orientation. It is similar to attributing responsibility for the addiction to 
the disease and release from the addiction to the metaphysical power. 
. '- hysi?cal Power, and doctors are all believed in as 
D1sease, melap 
exte . f Po...., , er?  Low scores on the PHLC dimension predict rna1  sources o 
bel. f ? h- f . model of addiction. This is consistent with low 1e m t e ree-w1 11 
sc . . th' king The less treatment providers attribute 
ores on sp1ntua1  m ? 
re 'b'l. c t-h ?r health and illness to powerful others, i.e., doctors, 
spons1 1 1y ,or e1 
147 
the more likely they are to believe that .addiction is a w:i.Uhtl self proeiess. 
The findings are conceptually consistent. 
What is especially curious is 1the r,olte of gende.r hil explaining 
variance in beliefs regarding addiction. Why .mii:ght worn,en be more 
inclined to believe in the disease model of ,addiction~ whereas men ar,.e 
more inclined to believe in the free-wiU model? Perhaps it ii:s lhe,cause the 
sense of personal empowerment in the wudd is much Iress for women. 
than it is for men, as many feminist writers hav(e ,asserted, Women have 
been psychologically oppressed, the resu[it of living .in a patriarchal :society. 
Women may have been forced to attdb1rnte good and bad experience 
to an alien power-a male dominated socio-political environment. 
Perhaps this is the equivalent of a metaphysiaai force. Sex1m:al 
discrimination may have lowered foeUimgs of ,seilf-effkacy for women in 
relation to their own personal problems .and e~pedence witlh addkt:ion, as 
well as their beliefs about the ability of others to manage their ow,n ilives in 
the face of addiction. They may project this 5eail.Se of disempowerment and 
alienation onto others and say that ?"Urey" can't CO"li 'i\k.oi tiheir addkHon. 
Women may be more inclined to use drugs t,o ,cope wi'th !life experience, 
and resort to treatment programs that rei111.force thii:s ge:neralized sense of 
disempowerment thorough disease and spiritual attributions. This i:s one 
of the reasons that Kirkpatrick (1986) founded Wo:m.en for Sob,riety. They 
have been taught to attribute experience to external factors because they 
have been coerced into doing so, i.ie.,  women lhrie in a ma[e-domina;ted 
society. 
In any event, there seems to be thi.s theme of alienated pow.er that 
runs through these three factors, spiritual th.inking, powerful others health 
locus-of-control orientation, and being a wrnn.a:m in. society today. These 
148 
three factors explain variance in addiction beliefs. The more inclined 
treatment providers appear to attribute power for their experience to 
factors outside of themselves, the more inclined they appear to believe in 
the disease model of addiction. The less inclined they appear to attribute 
power for their experience to factors outside of themselves, the more 
inclined they appear to believe in the free-will model of addiction. 
That professional-group affiliation explains variance in addiction 
appears to be a plausible and consistent finding. Members of NAADAC 
believe quite strongly in the disease model of addiction, as evidenced by 
their mean scores on the ABS. They also score highest on spiritual beliefs. 
RRS was founded in opposition to the spiritual character of AA. Members 
of RRS are explicitly secular in their beliefs. They also seem to hold strong 
beliefs regarding personal power and self-efficacy. Their literature shows 
that they tend to favor abstinence approaches over controlled-drinking 
ones. 
,:.,  
However, the emphasis in RRS is explicitly on self-empowerment ii 
?t 
and rejection of spiritual force. Therefore, it makes sense that whether ?I ?' 
treatment providers are in NAADAC or RRS will tell us something about 
their addiction beliefs. Members of NAADAC are likely to believe in the 
disease model of addiction and members of RRS are likely to believe in the 
free-will model. 
of sPAB fall somewhere in the middle because 
P erh  aps memh ers 
?orx?st in their orientation to addiction. They may not 
the y are more beha v1 
. th 'dea of a disease or spiritual force as being 
b e li eve strongI y  m e 1 
. . yet at the same time, do not believe that 
responsible for a dd1ct1on, ' 
. . . . . l as free-will modelists believe it to be. 
a dd1ction 1s as vo1 1tiona 
. . . ponsibility to environmental factors, i.e., 
Be hav1onsts attribute res 
149 
stimulus and reinforcement. Learned behaviors, such as addiction, are the 
result of environmental shaping, not self-determination. 
Fin.ally, that drug frequency ingestion explains addiction beliefs 
seems consistent with these other findings. Those treatment providers 
who are less inclined to use drugs believe more in the disease-model of 
addiction, perhaps because they believe they are incapable of controlling 
drug use responsibly, or that the power of the addiction may take over 
their lives. It is interesting that abstinence status did not explain addiction 
beliefs in this regard. 
Moreover, that increased frequency of drug ingestion predicts belief 
in the free-will model is consistent with the idea that people who are 
drinking alcohol and/ or using drugs believe they can control their usage. 
Therefore, it seems reasonable that they are more inclined to believe that 
others can do so as well, Le, the free-will model. 
The findings from this study appear to support Levine's (1978) 
assertion that religious elements associated with the temperance era are 
closely related to the disease concept of addiction. Historically, the disease 
concept of alcoholism has its roots in the temperance movement, which 
was primarily a religious crusade. This current study supports the 
association between spiritual thinking and the disease concept of addiction. 
It is interesting to note that Catholics tend to believe most strongly 
in the disease model of addiction and atheists least of all. This finding 
appears to lend further support to the relationship of spiritual thinking 
with the disease model and secular thinking with the free-will model. 
Treatment providers who are more secular in their thinking and 
appear to take greater responsibility for their experience of health and 
illness, and are male tend to believe in the free-will model of addiction. 
- =.,,.,..-_-_ _______  
150 
They are also more inclined to belong to Rational Recovery Systems, an 
organization that was founded in opposition to Alcoholics Anonymous. 
Its founders objected to the spiritual nature of AA, (Trimpey, 1989). 
Treatment providers who are more spiritual in their thinking, 
attribute greater responsibility for their experience of health and illness to 
powerful others, and are female, are more inclined to believe in the disease 
model of addiction. They are also more inclined to belong to NAADAC, 
and to a lesser extent, SPA B. 
Implications 
Implications for Theory 
The relationship of spiritual thinking to belief in the disease model 
of addiction should tend to discredit the disease model from a scientific 
point of view. The theory that addiction is a disease is not substantiated by 
scientific research contesting the loss-of-control theory. Yet, treatment 
providers persist in believing that the chemicals of alcohol and other drugs 
can interact with physiological elements to produce a non-volitional 
behavior called addiction. This is the putative "power'' of addiction and 
l:he drug. 
Since the theory is not grounded in empirical research, and is so 
dose  Iy  re ated  to sp?i n? tuaJ t1 ?
h in?k in?g , external health locus-of-contr?o l 
ori?e t t? d b . _ female a reconsideration of both the motive for 
n a ion, an emg , 
using this theory to explain addiction, as well as the consequences to doing 
motive for believing in the disease model may 
So  seems warrante d . The 
. h rsonal and existential beliefs about the self than 
h ave to do more wit pe 
anything else. 
n (1979), these personal issues and beliefs may 
To return to C a h aI a  
. . treatment organizations "tick." As Bergmakr & 
explam how the various 
151 
Oscarsson (1991) have suggested, these issues may be the "hidden" belief 
among treatment providers. 
In other words, the therapeutically active features of addiction-
treatment programs may not be the ones the practitioners themselves 
believe in. A disease called addiction doesn't actually exist, people just 
believe H does. A higher power doesn't actually heal, people just be1ieve it 
does. 
Moreover, their personal beliefs may actually weaken the 
therapeutic effect of these features. The attribution of power to an external 
agent, be it to explain addiction, i.e., the disease, cure of the addiction, i.e., a 
higher power, or excessive reliance on powerful others, i.e.~ doctors, may 
ultimately weaken self-efficacy for the client. In this sense, the 
reinforcement of low self-efficacy may likely create more of the problems 
treatment is theoretically designed to solV'e. 
The implications of the findings from this study for theory involve 
a reassessment of both the motivation for and possible consequences of, . 
t 
f 
varying beliefs about addiction. Spiritual thinking, health locus-of- J 
control, gender status. professional-group affiliation, and frequency of drug 
ingestion, all tell us something about beliefs regarding addiction. Belief in 
the disease model of addiction is explained by an external locus-of-control 
orientation that may unite these five factors. Belief in the free-will model 
of add1' c t?t on . exp1 a  -n ed by an internal locus-of contro? l orienation JS 1 ? 
Per b . f ?nfluence beliefs regarding addiction for others in 
sona1  e1 1e s may 1 
both h the free-will model appears to be more grounded in 
cases, owever, 
. . h Moreover the internal locus-of-control is more closely 
er np1nca 1 researc . ' 
. If ffiacy than external locus of control. Perhaps 
rel  a ted to higher se -e 
152 
theories regarding addiction should be re-examined with these findings in 
mind. 
The disease and drugs don' t actually cause the addict to become 
addicted and the "higher power" doesn' t actually heal addicts of their 
disease. These are metaphorical phenomena, not literal ones. As such, it 
appears they have no place in a scientific theory. 
Implications for Practice 
Addiction-treatment providers who believe in the disease model of 
addiction undoubtedly integrate spiritual thinking in their clinical practice. 
Moreover, they appear to be committed to an external locus of control 
orientation. These findings should be of concern to those who study and 
implement treatment policy, those who study the effects of different 
treatment programs on self-efficacy, and those interested in women's 
studies regarding empowerment. 
Medical health insurance companies, state-supported addiction-
treatment programs, and courts should be cognizant of several facts that )'  
t 
are evident from this study: (a) Spiritual philosophy is not medicine. It is f 
strongly associated with medicine, however, in the minds of addiction-
treatment providers. Undoubtedly, spiritual thinking plays a major role in 
treatment practice based on the disease model of addiction. (b) Some 
addiction-treatment providers believe in the free-will model of addiction, a 
belief that is diametrically opposed to the disease model. (c) Treatment 
providers who subscribe to the free-will model tend not to be spiritual 
thinkers advancing a spiritual philosophy, and are more likely to be 
secular in their thin.king, which is related to their addiction beliefsJ and 
undoubted!y  their treatment practices. 
153 
Medical health insurance companies should be cognizant of these 
facts because it may be ill?advised to support treatment programs that are 
based in spiritual and moral management techniques, instead of medically-
based ones. Moreover, higher premium rates are passed on to subscribers 
who may not want to support the establishment of a particular spiritual 
philosophy in drug addicts, in order to pay for disease-model treatment. 
Public-support treatment programs based on the disease model of 
addiction, as well coerced-treatment practices conducted by the courts, may 
be in violation of the First Amendment of the U.S. Constitution, (Luff, 
1989). Disease-model based treatment programs involved with the state 
may constitute the state's entanglement with religion, the establishment of 
a state religion based on AA spiritual philosophy, and prohibit the free-
exercise of a citizen's religion or spiritual philosophy of choice, which 
includes atheism and/or agnosticism. 
From a strictly psychological point of view, disease model 
approaches to addiction would appear to lower feelings of self-efficacy and 
reinforce an external locus of control orientation, (Schaler, 1992), as 
evidenced by the theme of self.deception and alienation of power. Thus, 
these be creating more of the problems they are attempting 
. programs may 
to solv e, 1. .e., d.1 sempo wering individuals in the name of empowering 
them. 
sed on these findings might inquire as to the 
A f urther stud  y ba
. f d. model versus free-will model treatment 
reI a  hve effects o 1sease-
? gs of self-efficacy. Moreover, research has 
programs on general fee Jm 
. el ted to health-care practices, utilization of health? 
s h own that gender 1s r a 
. eking?health care assistance, etc., (Verbrugge, 
care services, reasons for se 
rath et al., 1990; R. Royak-Schaler, personal 
1985; Travis, 1988; McG
154 
communication, 1992). The relationship between gender, self-efficacy, 
addiction beliefs, spiritual beliefs, and health-care outcomes may prove to 
be an interesting course of study. 
Implications for Further Research 
Several directions may be pursued in light of the findings from this 
study. First of all, the ABS appears to be a reliable instrument for assessing 
addiction beliefs. It should have wide applicability in any study that seeks 
to assess contemporary beliefs regarding addiction. 
The ABS could be used as either an independent or dependent 
measure. Moreover, the ABS could be shortened based on the most 
representative items as revealed through a factor analysis of the 
instrument, (Appendix K). 
Secondly, the SBS also appears to be a reliable instrument for 
assessing spiritual thinking. It should have wide applicability in any study 
that seeks to assess contemporary beliefs regarding a metaphysical power 
that can influence personal experience. The SBS could be used as either an 
independent or dependent measure. 
The SBS could be shortened based on the most representative items 
as revealed in the factor analysis, (Appendix K). For example, 54, "I feel it 
is important to thank God when I manage to do the right thing," and S8, "I 
believe there are many ways to know God and that my way is not the only 
way," may be as effective in measuring spiritual beliefs as the whole scale, 
(Appendix K, Table 12). 
A refined study of the relationship between spiritual thinking and 
beliefs about addiction could investigate the item by item correlation of the 
SBS and the ABS, to further specify which beliefs seems to go together and 
which do not. One approach to further study might involve factors t?hat 
155 
explain each of the three dimensions on the ABS. The SBS could be used 
as a dependent measure to investigate factors that might explain spiritual 
beliefs. 
Refined measures assessing levels of self-efficacy could be explored 
in terms of their relationship to spiritual and addiction beliefs. A possible 
relationship between addiction beliefs and tolerance for ambiguity could be 
explored using the ABS and the SBS. The possibilities for further research 
appear diverse and potentially fruitful. Both measures could be used as 
either independent or dependent measures to explore multitudinous 
relationships. 
156 
APPENDIX A 
ABS SURVEY INSTRUMENT 
addiction belief study 
. Please do not write your name anywhere on this instrument. The 
mstrument will take about 8 minutes to complete. Your responses will 
be held in the strictest confidence. Answer each request for information as 
honestly and accurately as you can. The number in the upper-right corner 
of this page will be cut off and discarded on return of the instrument. 
Please return the instrument as soon as possible. A pre-addressed, 
postage-paid return envelope is provided. 
If you would like to receive the results of this study, send a request on a 
separate postcard along with your name and address to: ABS Results, 
1001 Spring Street, Suite 104, Silver Spring, Maryland, 20910-4022. 
Thank you very much for participating in this study. 
Directions: Circle the appropriate response based on the degree to which 
you agree or disagree with it. This is a measure of your beliefs. There are 
no right or wrong answers. 
1. Most addicts don't know they have a problem and must be forced to 
recognize they are addicts. 
Unttrtain Strongly ~tt 
Slrongly disagree 
2. Addicts cannot control themselves when they drink or take drugs. 
Uncertaln S1r0ngly agree 
Slrongly di11gree 
3. The only solution to drug addiction and/ or alcoholism is treatment. 
U11Certaln Agree Strongly agJ'tt 
Slrongly disagrte 
ercome addiction is by relying on your own 
4. Th e b est way to  Ov
willpower. 
Ut'lcertaln Agree 
Slrongly disagree 
. . . ll r-nothing disease: A person cannot be a 
5. Add1ct1on 1s an a ~o . . . ddict with a mild drrnkmg or drug problem. 
temporary drug a 
Uru:ffllin Agrtt Strongly ag,-tt 
Strongly diygree 
157 
6. People can stop relying on drugs or alcohol as they develop new 
ways to deal with life. 
Slrongly disagree Disagru Unce11ain Agree Strongly agree 
7. Addiction has more to do with the environments people live in, 
than the drugs they are addicted to. 
Slrongly disagree Disagree Unceitain Strongly agree! 
8. People often outgrow drug and alcohol addiction. 
Slrongly disagree Uncertain Agree Strongly agree 
9. The most important step in overcoming an addiction is to 
acknowledge that you are powerless and can't control it. 
Strongly disagree Disagree Un.certain Agree Strongly agree 
10. Abstinence is the only way to control alcoholism/drug addiction. 
Strongly disagree Uncertain Strongly agree 
11. Physiology, not psychology, determines whether one drinker will 
become addicted to alcohol and another will not. 
Duagrec Unce.rtain Agree Strongly agree Strongly disagree 
12. Alcoholics and drug addicts can learn to moderate their drinking 
or cut down on their drug use. 
Uncertiin 
Strongly disagree 
13. People become addicted to drugs/alcohol when life is going badly 
for them. 
UnceJ1ain Agre.e Scrongly agree 
Strongly disagree Di.sagree 
14. The fact that alcoholism runs in families means that it is a genetic 
disease. 
Uncertain Agree S&ongly agrN? 
Strongly dis.Jgrcc 
158 
15. You have to rely on yourself to overcome an addiction such as 
alcoholism. 
Strongly disagree UnctJfain Agree 
16. Drug addicts and alcoholics can find their own ways out of 
addiction, without outside help, given the opportunity. 
S1rongly disagrtt Uncertain Agree Strongly agrtt 
17. People who are drug addicted can never outgrow addiction and are 
always in danger of relapsing. 
Strongly disagree Unc:a1ain Agree 
18. Drug addiction is a way of life people rely on to cope with the world. 
Strongly disagrtt Uncertain 
19. If I become sick, I have the power to make myself well again. 
Strongly diYp UnceNi.n 
Agree Strongly ollgl'l'l' 
20. No matter what I do, if I am going to get sick, I will get sick. 
Uncertain Agree Strongly ?Utt 
Strongly disagrtt 
21. If r see an excellent doctor regularly, I am less likely to have health 
problems. 
Disagree l.Jn(erUin Strongly agree Strongly disagree 
22. Most things that affect my health happen to me by accident. 
Agree 
Di.1agltt 
23. can o y mam. t ai?n my heal th by consulting health professionals? I nl  
Uncertain Agree Slrongly ~ 
Strongly disa8J'CC 
. ti Ponsible for my health. 
24. I am d1rec y res 
Untt111in Strongly o11g1ec 
., 
159 
25. Other people play a big part in whether I stay healthy or become 
sick. 
Strongly dis.I~ Unce.Nin Agree Strongly agree 
26. Whatever goes wrong with my health is my own fault. 
Strongly disagree Disagree Uncertain A.g,ee Strongly agree 
27. Luck plays a big part in determining how soon I will recover from 
an illness. 
Strongly disagrtt Disagree Uncert.lin Strongly agree 
28. Health professionals keep me healthy. 
Strongly diugree Disag,tt Uncert.lU'I Agree Strongly agree 
29. My good health is largely a matter of good fortune. 
Strongly disagree Disagree Unceruin 
30. My physical well-being depends on how well I take care of myself. 
Disagree Unceitllm Strongly Strongly agrec di$1~ 
31. When I feel ill, r know it is because I have not been taking care of 
myself properly. 
Agree Strongly agree 
Strongly disagree 
32. The type of care I receive from other people is what is responsible 
for how well I recover from an illness. 
Unu114in AgrH SCroClglyape 
Strongly disagree Disagtt 
33. N o matter w h a t 1 do , I'm likely to get sick. 
[)is.agree Uncert,in Agree Strongly agree Strongly di.sager 
34. If it's meant to be, I will stay healthy. 
(Jncrl14in Agree 
Di8ili,'ee Strongly agree 
Strongly disagrtt 
tay healthy by taking good care of myself. 
35. I can pretty m uc h S
UnCfttlin Ag,-ee Strongly ag-ree 
Strongly disagree 
, 
160 
36. Following doctor's orders to the letter is the best way for me to stay 
healthy. 
Stmngly diugee Disagree Uncertain Agree Stmnglyagrtt 
37. I feel that in many ways turning my life over to God has actually 
set me free. 
Stmngly diugn,e Diug,ee Uncertain Stmngly agrtt 
38. I know that all the best things in my life have come to me through 
God. 
Uncertain 
39. I believe I am blessed by God with many gifts I do not deserve. 
Agree 
Strongly Unurtaln Strongly agm diugree 
40. I feel it is important to thank God when I manage to do the right 
thing. 
Disagree Uncertain Agree Strongly agree Strongly disag,ee 
41. It's only when I stop trying to play God that I can begin to learn 
what God wants for me. 
Disagree Uncertain 
Agree Strongly agrtt 
Strongly disagree 
42. r know I am able to meet life's challenges only with God's help. 
Unc~in Stronglyagrtt 
Smlngly disagree 
43. I know that forgiving those who have hurt me is important for my 
spiritual health. 
Uncertalll Ag,ee Strongly agree 
Strongly disagJC"e 
. many ways to know God and that my way is not 
44. I beheve there are 
the only way. 
Ag,ee Strongly agree 
Strongly disagree 
46. Gender: ____M ale 
45. Age (at last birthday):~--- ___F emale 
161 
47. Race or ethnic background: 
___W hite, not of Hispanic origin 
___B lack/A frican American, not of Hispanic origin 
____H ispanic 
___. American Indian/ Alaskan Native 
---'A sian 
---?P acific Islander 
48. Marital status: 49. Educational status (check highest): 
___. Never married --~Not high school graduate 
_ _ -'Married __H igh school graduate 
___W idowed __S ome college 
_ _ _ .Separated/Divorced __B achelor's degree 
__G raduate degree 
____M edical degree 
__O ther (please specify)_ 
50. Religious affiliation: 
Protestant Muslim 
Catholic Atheist 
Jewish Agnostic 
Other (please specify) 
.d ? 
51. Are you an addiction treatment provi er? Yes No 
52. A re you a C ert 1. f i1 e d Alcohol or Addiction 
Yes 
Counselor? No 
53. Do you consider yourself to be 
Yes No 
an alcoholic or a ddi'c  t 1?n  recovery? 
d A}coholics 
54. Do you currently atten 
_ ther 12-step program?_ _Y es ___. No 
Anonymous or any 0 
162 
55. How Jong have you been in AA or 
any other 12~step program? _______y ears 
56. Have you attended AA or any other 
12-step programs in the past? __Y es ___.N o 
57. Are you currently abstinent from alcohol 
and/o r mood-altering drugs? __Y es __. ..,No 
58. If you do drink alcohol and/o r use mood-altering drugs, please 
enter the average number of drinks/times you use drugs per week: 
___ Bottles/ cans of beer/week ___M arijuana use/week 
___G lasses of wine/week __T ranquilizers use/week 
___.M ixed drinks or shots of liquor/ __S timulants use/ week 
week Other (specify) ___ _ 
59. What percentage of drug addicts do you believe get over their 
addiction without any form of medical or 12-step type treatment? 
(Please cirde one) 
0 5 IO 15 20 25 30 35 40 45 SO 
55 60 65 70 75 80 85 90 95 100 
60. You are welcome to write any comments on this instrument or 
the topics addressed in the space below. 
163 
APPENDIX B 
LETTER ACCOMpA NYING SURVEY INSTRUMENT 
AIB3S 
addiction belief study 
May 18, 1992 
Dear Colleague: 
1.a~ a doctoral candidate doing research in the area of social policy and 
addiction at the Department of Human Development, University of 
Mar~land, and am asking for your help. As an addiction treatment 
provider I suspect you know more about drug addiction than most people 
in the research field. 
You_r name has been selected from a sample of members of several 
professional treatment organizations nationwide. In order to improve the 
quality of addiction treatment the enclosed instrument was devised to 
assess the beliefs and characte;istics of care providers. 
Please take a few minutes to complete the enclosed inventory and 
return it to_me as soon as possible. For your convenience, a pre-addressed, 
postage-paid re~urn envelope is provided. . 
The handwritten number in the upper-right corner on the first page of 
the instrument is used to identify participants who have not returned the 
instrument. They will be sent a reminder card. Once recorded, the 
number will be removed to protect the identity of thos~ who ha.ve 
returned the instrument. Your responses will be held m the strictest 
confidence. 
Thank you very much for your time, cooper~tion, and help. If you have 
any questions or concerns please feel free to wnte or call me. 
Sincerely yours, 
Jeffrey A. Schaler 
Principal Investigator 
1001 Spring Street, Suite 104 
Silver Spring, Maryland 20910-4022 
Telephone: (301) 585-5664 
164 
APPENDIXC 
REMINDER POSTCARD 
addiction belief study 
June 1, 1992 
Dear Colleague: 
The results from the Addiction Belief Study are pouring in from across 
the country and I stilJ haven' t heard from you yet! Won't you please take a 
few moments to complete the inventory I sent on May 18th and return it 
as soon as possible in the self-addressed stamped envelope I provided? 
Your input is important in order to account for the many conflicting 
perspectives on addiction among treatment providers. 
If you've already completed the survey and sent it back - thanks very 
much! 
Sincerely, 
Jeffrey A. Schaler 
Principal Investigator 
165 
APPENDIXD 
MEAN SCORES FOR THE ADDICTION BELIEF SCALE1 
Mean SD n p 
ABS 54.12 13.55 295 
Gender2 <.001 
Males 50.91 13.69 186 
Females 59.60 11. 43 109 
Professional Group <.001 
NAADAC 64.97 08.81 104 
SPAB 52.88 10.95 98 
RRS 42.89 10,71 91 
Religious affiliation <.001 
Protestant 57. 94 12.91 81 
Catholic 58.70 11. 51 46 
Jewish 54.98 10.04 42 
Atheist 38.64 10.39 22 
Agnostic 45.73 12.48 30 
Other 54.63 13.76 64 
Certified?2 < . 001 
Yes 57.44 13.10 153 
No 50,54 13.15 142 
In recovery?2 <.001 
Yes 61.71 11.87 100 
No 50.36 12.70 193 
In AA now?2 <.001 
Yes 64.43 09.37 101 
No 48.75 12.23 194 
166 
MEAN SCORES FOR THE ADDICTION BELIEF SCALE 
(Appendix D continued) 
Mean SD n p 
In AA in the past?2 <,001 
Yes 56.47 13.61 206 
No 48.08 11. 57 80 
Abstinent?2 <.001 
Yes 58.00 12.90 182 
No 47.74 12.02 111 
Note. 1Highest possible score is 90. 2Two-tailed, separate variance 
estimate. 
167 
APPENDIX E 
MEAN SCORES FOR THE SPIRITUAL BELIEF SCALE (SBS)1 
Mean SD n p 
SBS 24.27 8.55 294 
Gender2 .002 
Males 23.11 8.84 185 
Females 26.24 7.67 109 
Professional Group <.001 
SPAB 23.93 7.07 97 
RRS 17.75 7.23 91 
NAADAC 30.37 6.32 104 
Religious affiliation <.001 
Catholic 29.02 6.83 46 
Protestant 28.91 6.63 81 
Jewish 21. 93 6.34 42 
Agnostic 17.60 4.99 30 
Atheist 11.27 2.62 22 
Other 24.64 8.49 64 
Certified?2 .007 
Yes 25.55 8.81 153 
No 22.89 8.05 141 
In recovery? <.001 
Yes 28.70 7.21 100 
No 22.04 8.31 192 
In AA now?2 <.001 
Yes 30.48 5.82 101 
No 21. 03 7.94 193 
In AA in the past?2 <.001 
Yes 26.15 8.33 206 
No 19.25 7.01 79 
Abstinent?2 <.001 
Yes 26.49 8.42 181 
No 20.65 7.55 111 
1
Note. Highest possible score is 248. Two-tailed sep. variance estimate. 
168 
APPENDIXF 
MEAN SCORES FOR THE MHLC SCALES 
SD p Mean 
3.15 292 
IHLC Scale 20 , 76 .44 
Gender1 
2.93 185 
Male 20,88 109 
Female 20.57 
3 .47 
. 03 
Professional Group 
20 ,79 2.92 
97 
SPAB 91 
21.37 3.42 
RRS 
3.02 104 
NAADAC 20.20 
14,84 3.15 
293 
PHLC Scale .14 
Gender1 186 
15.04 3,27 
Male 2.89 109 14.51 
Female .01 
Professional Group 98 
15.32 3.07 
SPAB J.42 91 14,10 
RRS 2. 87 104 
NAADAC 15.03 
293 
13.02 2.96 
CHLCScale .65 
Gender1 J,13 186 
13,08 
Male 2.65 109 
12.93 
Female .48 
Professional Group 3.10 98 
1J.09 
SPAB 3 .08 91 12.75 
RRS 2.73 104 
J.3 . 18 
NAADAC 
1
. 'bl core on each dimension is 30. Two-tailed, 
Note. Highest Poss1 e s 
separate variance estirnate. 
169 
APPENDIXG 
COMMENTS BY SUBJECTS (sic) 
002 (Case IO): #6: People can stop relying on drugs or alcohol as they 
develop new ways to deal with life - "after becoming abstinent." "Other" 
under educational status means registered nurse and certified in chemical 
dependency. Objection to ,,I do not deserve" on item #39. Suggestion= ur 
feel we all deserve good things in our life. We are not undeserving." 
003: I'm puzzled by so many questions relating to "God." These are 
personal beliefs and really an invasion on my personal rights. I felt the 
questions we.re an invasion of my belief system. I answered only because I 
value research and my identity will not be known. 
006: As I completed the questionnaire I was struck by the design of 
the instrument as inadequate to respond to the stated agenda. The biased 
nature of the questions re. health care providers + the forced choice 
strategy nature of the questions re. the nature of addiction & recovery 
leave little room for response to the complexity of the constellation of 
problems that an addict in active disease model brings into treatment. 
Also _ emotional disorders were not mentioned or implied. Finally, only a 
rather simplistic uninformed respondent could complete this survey 
without discomfort. I hope the data will not be used to justify something 
more than Mr. Schaler's somewhat whimsical attempt to quantify 
att't d A th' . t I see no way that this instrument could be used to 1 u es. t 1s pom , 
?u ti'f . . addiction treatment of much of anything else 1 
J s y improvement in ? 
'b ted to this effort. 
?h  ope no tax dollars contrl u 
ur efforts to conduct this survey - I have thought of 
011: I applaud  yo ? ? 
. . h' myself. As someone who had a serious alcohol 
d oing research like t is 
170 
problem and got sober in AA, I appreciate the AA experience and value 
some of the paradoxical wisdom it embraces (empowerment through 
"surrender" and non-attachment? ideals in many religions). At the same 
time, as a social scientist, I know that AA and the chemical dependency 
field has embraced its own set of pseudoscientific myths - i.e. the disease 
concept (especially the notions of 1) inevitable progression 2) absolute loss 
of control 3) and the sobriety or [couldn't read handwriting} - death - jail 
dichotomy.). I know that alcoholism and substance abuse is variable in its 
course and has a multidimensional etiology. Sorry that I was kibutzing so 
much in my answers - its just that these forced-choice surveys pressure 
simplistic beliefs/ prejudices. Unfortunately there are far too many 
chemical dependency professionals who have embraced certain beliefs as 
quasi-religious dogma dressed up as "facts". Good luck! Yours truly, a 
recovering, science-minded ( but God embracing), skeptical, mystical, AA-
ambivalent, post-modem friend of Bill Wilson's. ... 
013: As with any Likert scale it forces choice. I would say those who 
recover without intervention, probably were not actually addicts, but were 
abusing. Good luck! 
01 : My clinical experience over the years and knowledge of 
6
res h h d . t conclude that "addiction" is a complex, very 
earc , as 1e a me o 
ind? 'd for which simplistic models and rigid ideas about 
1v1 .uaI  phenomena 
i..arm as good to patients. Abstinence is the safest 
recovery cause as much  JI 
- . . . t' ts however, anyone in the addictions field can 
position to take with pa 1en ? ' 
. f,, ddicts" who returned to non-abusive usage. Others 
give you examples o a 
. . treatment, AA or spirituality. Much of what we 
remain abstinent without 
. g addiction is one step above superstition. 
think is necessary in trea tin 
rimary weakness: What professionals say 
Your questionnaire has one P
171 
they believe in often has little relationship to how they do treatment. 
Asking clinicians about their doubts, their everyday observations of 
behavior, and what works - if anything might yield more useful 
information. Just sitting in a rap session with a group of clinicians in the 
addictions field who are being frank with each other and not talking the 
party line, would probably give you a very different impression from the 
one this survey will yield. 
017: The "God" questions did not cover the wide range of 
spirituality different people have - only the stereotypical infantile Judeo-
Christian babble. You could have added more general questions about 
spirituality. 
023: You seem to be assessing belief in the disease model of 
alcohol/d rug addiction. I am an addiction researcher and the research does 
n_ot support such a mode! Nor does the research show 12-step programs to 
be any more effective than numerous other forms of treatment. 
024: A. In general, my responses to Qs 1-18 reflect my strong belief 
that addicts can overcome their problem on their own. Some do it 
completely on their own. Others, require outside help and information, 
but essentially do the work themselves. I strongly disagree with the disease 
model and the 12 Step (AA) model of addiction. I consider abstinence to 
be the best goal. The benefits of moderation/c utting down are far 
outweighed by the risks of returning to problematic usage. B. Qs 19-36. A 
, h h . sult of genetics, environment and behavior. ram 
Per son s ea1 t  is a re 
. h . can strongly influence health despite other 
convmced that be av10r 
? fl . / . vs genetic tendency toward heart disease), my 
m uences (diet exerase 
of control. 
answers reflect internal Io cu5  
172 
Qs 23 + 36 I answered these the way I did because the wording implies that 
the doctor and not I am responsible for my health. Q 53. I am not in 
recovery! I have recoveredr As I have had no alcohol/d rugs for over 8 
years, I do not consider addictio.n to be a problem for me. 56. I did attend 
AA and other programs. At first it was under coercion as a condition of 
treatment. I continued to attend as a result of intensive, fear based 
indoctrination by addiction counselors and AA members. I was told 
repeatedly that I would relapse and die if I didn't go to AA. I was aJso told 
that my dislike for AA meant I was resisting treatment. Now, I have 
nothing at all to do with any 12 Step program and am by far a happier 
person. I consider the 12 Step treatment I received to be unprofessional, 
philosophically repugnant and dehumanizing. (Hospital + halfway house 
settings) I consider the 12 Step programs (AA etc.) to be fear based, 
superstitious nonsense. 
025: There may appear to be some inconsistencies in my responses. 
I come from a theoretical base that is partly biopsych.osocial and partly 12 
step. J believe in assistance from a higher power (God) as well as self-
responsibility. It is a delicate balance that has taken myself ( & others) years 
to achieve. Good luck on your endeavor! 
027: I'm really glad to see God in some of the questions. I only wish 
I w k d f th t beli'eved in A God in treatment plans even though 
or e or some a ? 
they profess they are .... 
? . . aire is certainly not geared to professional -
028: This questionn 
th tible with your research design. Have fun. 
ough that may be contpa 
. ? those who do it this way [recover without 
031: On question 59
J.t  of life - just abstinent. treatment] have little qua 1 Y 
173 
038: I feel the problem with dysfunctional families "addicted or not" 
are such a problem it will have a major impact in the future of America. I 
don't see things getting better but, worse and I fear a great disintegration of 
not only America but, a stable, health and happy people. I know this is 
bleak but, a reversal in the hearts of men and women must come to make 
changes. 
044: Alcoholics and addicts need help medically, AA, special 
treatment and god in there life. This is my opinion only. T.hank you. 
045: Many of my answers were "uncertain" because the question 
gave me no option. I'm sure I'll get "sick," e.g. a cold or aUergy reaction, no 
matter what I do and since most people in my family die of cancer my 
chances for that, regardless of what I do appear good? nonetheless there are 
probably many things I can do to help myself out, e.g., not smoke - so the 
situation is not as cut and dried as the questions imply. 
049: J have a real problem with the A.A. philosophy of power; 
particularly in regards to women who are survivors of any form of abuse. 
054: Thank you for what appears to be very useful and informative 
re?search. As an advisor to RR and an advocate of alternative treatments 
for people with emotional and substance related problems, I am very 
concerned about what Stanton Peele, Stan J. Katz, Albert Ellis and others 
have noted about the out?of-control state of addiction treatment and the 
delet ? f ?c d coercive met.hods of the 12-step/f aith healers. 
erious e 1ects an 
Thank God for skeptical and inquiring minds who can say no to 
. h bl' d temperance hysteria now plaguing our country. 
abs ol  utism and t e m ? 
?. . . . nnaire is geared, it seems, toward 12-step models of 
061 This questio 
? t considering alternatives, such as 'Rational 
Intervention. How abou 
Recovery'? 
174 
064: I have no problem with individuals having and maintaining 
religious beliefs or affiliations only with its dogmatism interfering with the 
individual self reliance and individuality and behavior. 
068: I don't feel the questionnaire was well constructed, many 
ambiguous questions/statements. 
092: Several study questions vague, ex. 3 & 8; addiction/use/abuse 
used interchangeable but not so; Questions presume that person with 
drinking and using problems are alcoholics and addicts. See R.E.T. and 
expanded concept as possible narrative for study review of literature. Good 
luck. 
093: As always I hate the forced choice aspect of these questions. The 
world is not an either/or place but rather a both/and reality. Dualistic 
thought is a half-truth, and research psychology is guilty of promoting a lot 
of half-truths. 
095: This questionnaire is heavily 12 step oriented and does not take 
into account other successful programs such as Rational Recovery, SOS 
and individual therapy. I would like to have seen more questions that 
allowed for individuality etc. instead of "pigeon-holing." 
097: Dear Jeffrey: The ABS sounds as if it was prepared by a 
person(s) who believe in the disease model, 12 step approaches to 
treatment and a limited view of the field of "additions". The work of 
Peele, Washton, Ellis, Trimpey, Marlatt, Miller, Hester must be considered 
and included in this instrument, the flavor of which implies or assumes 
that the respondent(s) are in recovery, actively dependent or abusive. 
Th , . f om no use experimental, use, abuse, dependence, ere s a contmuum r ' 
pathological intoxication. 
- I 
175 
098: On questions 19-36 I had difficulty choosing the answers. A 
person can engage in exercise, refrain from tobacco and alcohol use and etc 
and this generally will result in improved health. However, many health 
problems come from things beyond one's control such as genetic 
influences and random events in ones life. Also, a person can be 
physically fit and still not be healthy, e.g., Jim Fixx. Seeing a doctor on a 
regular basis improves the odds for staying healthy but it is no guarantee of 
good health. Re: the God questions: I believe we Jive in a natural 
I universe. I see no evidence of a supernatural realm beyond ours. 
I 099: Your question phraseology has a built in bias - an assumptive 
bias (e.g. "Do you still beat your wife?"), making it easy to read into the 
question for those of us who use the non-12 step model. "Addict" and 
"alcoholic" are lay terms and not part of DSM-III terminology. We use 
''dependence" or "abuse." Addict::::drug dependent person. "Alco11olic" is 
virtually meaningless. The person is either alcohol dependent, abusive or 
non-problematic. I have tried to avoid reading into the question. My 
point is - you may not know whether I am responding to your intended 
question, or to the built in bias. As an example: "Most people who are 
dependent upon drugs don't know they have a problem; and must be 
forced to recognize they have a problem" (then I would agree). Confusing? 
Well,  ?t get s  . when dealing with all the non-proven dribble in this 1 worse ? 
field A f d student at U of M, and graduate, I wish you well. 
. s a ormer gra 
lOl: I believe that the distinction between drugs, alcohol, nicotine, 
caff ? d h n fatty sweets is false and pernicious; as is the idea 
exne an per aps eve 
th t nd alone as the best way of maintaining sobriety, 
at 1 2 step programs s a 
G 0 d thing as well. and perhaps the whole 
176 
107: Please bear in mind that AA and the other spiritual approaches 
are offensive to some clients. 
110: Some of the questions are not good questions for me because I 
do believe in the reality of addiction, i.e., there is no such thing as going 
back to drinking if a person has crossed the line between abuse and 
addiction. I do not believe addicts of any kind are "diseased" or genetically 
predisposed. While I believe addiction is overcome by making rational 
decisions which keep the person abstinent I think it is an 
oversimplification to suggest its simply HwilJpower." And finally, within 
the objective world of real illness, we much acknowledge that genetics 
plays a real role in what illnesses ultimately "get'' us; I believe that using 
"disease" and "illness" as a metaphor for social deviance is making us all a 
little crazy. 
112: AA is not the only treatment of choice although its value as a 
group support is unquestioned. AA may be the first step but character, 
temperament luck, economics are variables that have to be mapped to 
1 
I affect a treatment plan. 
116: I think the locus of control paradigm is too black and white to 
be applied to a clinical perspective on addictions. 
1 lB: My daughter is a reco"Vered opiate addict. she is almost 37 years 
old a d f. ed with Rational Recovery. I attended many NA, 
n ? ma 11 y recover 
AA . . h d went to AJ-Anon as a "co-dependent." 12 step 
? meetings with er an 
n f b t I never said that to my daughter because there 
ever elt right for me, u ? 
. favor of whatever works. For me, and 
was no alternative. I am in 
. b d hter a cognitive approach was more appropriate. 
su sequently for my aug 
eel dichotomy between the humanistic (i.e., the 
121: I feel it is a fl aw 
?ritual approach (I.e., power came from a higher 
power is in me) and the 5P1 
177 
power). Both approaches can work i.e. an addicted person should take 
responsibility for own health/recovery, but appealing to deity is one way to 
do this. I like lots of the ideas as suggested by Stanton Peele (my basic 
assumption rests on social learning theory) but the blatant humanism 
seems naive. He should read The Arrogance of Humanism by (illegible). 
One does not need to destroy a system of recovery that is beautiful to 
hundreds of thousands in order to make his own (basically sound) points. 
126: Sounds like Seligman's attribution theory to me. It might 
make an interesting study to see if different attribution styles render a 
patient more or less amenable to different styles of treatment. e.g. AA and 
other 12 step patients might do better with a style of attribution that puts 
responsibility outside themselves, like onto God or genetic endowment. 
Dynamic approaches might be more syntonic to people who believe 
themselves to be responsible for the ills and good fortune that comes this 
way. Good luck. 
139: It's hard to answer these questions because they are very 
categorical. There isn't any question that asks about the. interaction 
between the physiological and environmental components of health or 
addiction. Thus, I disagreed with most of the questions because the 
wording is so absolute. 
144: Sometimes you asked for "absolute" answers to questions such 
as #3. The only solution which is never true. In other words there is 
never an "only" solution to any human problem. How do I know? (20+ 
years experience in the field! Best of luck. 
147: This is exactly one of those kind of "instruments,, I find most 
annoying. It has the feel of being the wet stone on which an axe is ground. 
The creators biases and opinions restrict a real exchange of information. 
178 
Addiction is a human condition and therefore has few absolutes. This is 
especially true a one practices therapy in a more global way and over time 
with clients. Your instrument could be improved by asking therapists 
their beliefs rather than creating a forced choice questionnaire based on a 
narrow perception of addiction treatment. 
148: I believe chemical dependency is a complex biological 
psychological social and spiritual disorder brought on by a multiplicity of 
factors unique to the individual, that there is no single aetiological (sic) 
pathway nor universal outcome, and no a priori set of conditions which 
are necessary nor sufficient for the emergence of the disorder. Since my 
thinking is nondeterministic and nonreductionist, I found responding to 
dichotomies confusing because I can agree with the potentiality of 
presumptively mutually exclusive alternatives. Good luck in your study. I 
would indeed like a copy of your results and will send you a postcard. 
Thank you for the opportunity to be a part of your study. 
150: Slanted re 12-step programs~There are others such as Rational 
Recovery which do not in any way deal with 'higher power' whatever that 
is. 
153: What is annoying is the dogmatic, rigid use of never, always, 
best, only adjectives in your statements. Nothing is 100%! So I have to 
disagree even though the statement may well be 95% correct. Only a rigid, 
pompass ass would agree with most of the statements, so what will that tell 
you. For example, I could agree with #1 if you said "many'' instead of 
"most" and you eliminated the bit about force. It is more accurate to say 
they have to get badly hurt before they come to be aware they are hooked. 
154: This instrument is too simplistic to capture my beliefs. 
179 
158: Jeff Schaler's work is commendable. The medical-model of 
addiction treatment exists to exploit "patients" for their insurance 
coverage. The best predictor of diagnosis of "addict" among self-referred 
people at treatment centers is whether the person has health insurance 
that covers addiction treatment. 
163: I found the response options vague, unclear + unrepresentative 
of my opinion. Also terms need to be defined. does drug addiction include 
drug abuse or is it a separate phenomena? What is "health"? Does it 
include broken bones, colds, flus, congenital heart problems, cancer? 
167: My views on recovery have changed. In the past, I believed 
that AA was the "only" way. As I have progressed through my own 
recovery process I have come to value personal empowerment as a means 
to a healthier existence. I'm uncertain if personal empowerment is the 
paradox of Step One or was the ability to initiate recovery innate. For the 
past several years I have struggled with the confines of a 12-step model. I 
question if group norms, pressure, etc. do not have more to do with 
maintenance than one might think (or question if they are part of such a 
group). My experience has been that it is necessary to conform to the group 
to be received by the group. I did this for probably 5 years. But now I 
question things. So, where does someone like me fit? I'm certain of what 
a sponsor would say or group members when I choose not to regularly 
attend meetings. When I recently did attend I was encouraged to come 
back so I could "get my ass kicked." Now, why would anyone (I) want to do 
that? My recovering friends maintain I might drink if I don't do recovery 
like them. So if I did relapse, it would logically follow that that happened 
because I didn't attend meetings. Why do they relapse then when they do 
attend? Something is working quite well for me considering it has been 9 
180 
years since I have found it necessary to use alcohol. My life feels fairly 
manageable and as stable as anyone else's. I might also add, that I feel 
much more at peace with myself since I no longer feel "shamed" about 
never doing enough or as prescribed by the Steps, endlessly striving to do 
more for my recover. Ugh - maybe they're right, I am headed for relapse. 
And that very question illustrates the level of my earlier indoctrination 
into AA. The bottom line is, I believe there are many roads to living a 
healthier life. I also believe that if you don't choose to do that you are 
never going to get there! I won't go bas far as saying an addict can safely 
use but I don't know that for sure. I am curious about your research. What 
are you trying to understand? I would welcome a response to this if that is 
feasible for you. Good luck! (#409). 
172: Too Long!!! 
175: (1) Assumed religious (God) references were offensive and 
should have been in a separate section of form for only those interested in 
that area to answer. (2) #55 is poorly worded. 
176: Questions were much too confining for anyone adhering to a 
multivariate or biopsychosodal model of addiction. 
185: As a treatment provider, I use many individualized treatment 
methods. The questions were hard to answer because I had to generalize. 
While some people respond to 12-step/A A - it does not fit everyone. 
A person who is spiritually oriented will generally respond to AA. 
One who is not spiritually oriented will often be resistant to the "loss of 
control/higher power'' concepts - with that person I generally use more of 
a "rational recovery" model, turning his need for control into a positive 
force in treatment. Most of my "uncertain" responses were due to the fact 
181 
that the statements would or would not apply - depending on the 
individual. 
210: You may want to consider inclusion of life experience with 
alcoholics/ drug abusers as a question in this survey. Many 
clinicians/nurses/and physicians are Adult Children of Alcoholics and /or 
are members of SA (Sexaholics Anon.) GA (Gamblers Anon.), WA 
(Workaholics Anon.) etc. and are therefore practicing 12 step practice 
within their work. 
212: Due to the system you offered for answering these questions, 
some of the answers I gave appear to be definite opinions, however, if 
there was room for explanations, my reasoning would be more dear. 
213: These are rather simplistic statements, which make them 
difficult to endorse or refute. When you correlate the different domains 
related to beliefs about addiction, disease and a higher power, I'm not sure 
you'll be able to understand why you got what you got. But good luck! 
217: Interesting questionnaire. Strongly suggest you look at 
diagnostic criteria issues in discussing your results. How, exactly, are you 
defining te?rms such as "addiction," "alcoholism," etc. My responses on 
many items would differ depending on such definitions. For example, I do 
see people "outgrowing" adolescent/early adult alcohol/ drug abuse (DSM-
111-R criteria), but do not see people "outgrowing" physical dependence on 
alcohol or other physically-addicting chemicals. 
220: 12 steps ain't the only way to go! 
222: I found many of the questions very ambiguous and impossible 
for me to answer accurately and realistically. Also, as I note on the 
questionnaire, I do not relate to some of the terminology used, e.g., 
Alcoholism, in my opinion refers to the Philosophy of AA - a philosophy I 
182 
Eersonally find to be irrational for the most part. Although I am aware 
that many find 12 steps - helpful to a professional I refer clients when it 
seems appropriate for them. "Alcoholic" - is another word coined by AA -
An adjective used as a noun. In my opinion individual people can and do 
abuse and become dependent on Alcohol & other drugs, including nicotine 
and Prescription Drugs. It has not been scientifically proven that Substance 
Abuse is a disease. Personally I believe there is a "Genetic" Connection 
plus other factors. Stating Alcohol & Drug Abuse for example leaves 
manx people confused e.g. Many people do not realize Alcohol & Nicotine 
are Actually Druis. in fact the# l Nicotine & #2 Alcohol J2.r.u& problems 
in this Country. Nicotine is responsible for more Illness & Death than All 
other Drugs combined e.g. 5000,000 Deaths per year due to Nicotine related 
causes. Akohol 100,000 deaths per year. Cocaine 8,000 deaths per year. 
Personally I can relate to RRS. Are you familiar with Rational Recovery 
Systems? If not I've enclosed some information for you. Finally, I'd just 
like to say tha t as a professional counselor I am ethically obligated to be 
aware of available treatment programs and other resources to the best of 
my ability and to provide each client with information that seems to be the 
rnost appropriate for them. Therefore I refer clients to AA RRS (Rational 
Recovery Systems) SOS (Secular Organization for Sobriety), Women for 
Sobriety etc. I look forward to reviewing the results of your study. 
Of our questions suggests to me that your 224 : The  struct  ure Y
hyp th . . h' l'ke "Therapist beliefs about themselves are 
o es1s 1s somet mg l 
high! .th h ?r beliefs about clients, and about what 
? Y correlated w1 t e1 
c ? t,, J think this is true, although I hope there 
0 nstitutes effective treatmen ? 
a ,, way" is not the only (or best) way. Questions 
re those who know that my 
t,el'efs would be helpful, esp. differing beliefs 
a b out working with others 1 
183 
than one's own. (Beliefs about beliefs?) Best wishes and hopes for a 
fruitful study! 
225: Re: those questions using the word "God" - I understand "God" 
to mean a power higher than myself. Therefore, my understanding of God 
does not come through, nor has been defined through, a religious 
affiliation. 
226: #51 and #52: I used to work in addictions which seems to be an 
important piece of info not addressed. Although not certified, I received a 
master's in rehab in the addictions. The only thing that kept me from 
being certified was leaving the field too soon to meet the employment 
criteria. #49 - Shouldn't the degree & major be included? The specialty 
area (Rehab, med, social work, psychology) I would think would affect 
answers. #48 - Living with someone. 
228: Comments per items - item #11. Most addicts do know they 
have a problem, but deny it. 2. Some addicts can control their use, but 
most cannot. There are several stages of addiction. Control is maintained 
in the early "honeymoon" stage. 3. Some addicts quit on own without 
treatment, especially in the early stages of addiction. 4. Internal 
motivation and willpower is very important to recovery, but it is often not 
sufficient by itself. #15. Yes you have to rely on yourself ... and on others. 
I wish you had qualified your statements with words such as "most" 
(addicts.). Your sentences imply that all addicts are the same. I was 
tempted to disagree with all of the statements because I could always think 
of an exception. However, I imagine you did intend to describe most 
addicts, or addiction in general and I answered with this in mind. 
230: I'm curious as to all the health questions. Are you conducting a 
study from a medical perspective? My health - emotional, spiritual, and 
184 
physical are all in God's plan. I believe I can take care of myself and if I get 
sick; by following suggestions of professionals, I will get better. I don't 
believe that I planned to grow up to become an addict with the disease or 
dis-ease of addiction. Accepting that I have a disease - addiction or medical 
enables me to do whatever is necessary to become well. 
233: Many of my responses would be different if the questionnaire 
indicated alcohol abuse vs. alcohol dependence. The words 
addict/addiction mean alcohol/drug dependence for me, hence my 
answers. Also, I support the disease concept of addiction, but view 
addiction as a complex disorder involving psychological aspects as well. 
good luck with study! 
234: Phrases like addict + alcoholic are folk/ common language 
phrases. As we (society, or part of it) are trying to "put the person first" (i.e. 
"persons w / disabilities" not "the disabled") the phrase "people dependent 
on alcohol/ drugs" is more appropriate, accurate, less stigmatized etc. - it 
describes the person, not label him/her. -Also, the DSM-111-R diagnoses on 
the basis of behavior therefore "alcohol dependence" not "alcoholism." 
Furthermore, "isms" are philosophies + ways of thought (Marxism, 
Catholicism, Romanticism, stoicism. .. ) Medical conditions (not necessarily 
diseases) are not "isms" even rheumatism is a folk expression for 
rheumatoid arthritis). These?, obviously, were hard to answer w /in the 
confines of a likert-scale because beliefs (for me) are more complex than a 
one sentence construct. Additional background/explanations help "fill 
out:' the belief. 
244: It is obvious from the slant of the questionnaire that you are 
addicted to AA and the 12 step program. It is not God that makes a person 
drink it is not God who will stop it. In my psychiatric psychotherapeutic 
185 
work l f m d i? t i? mportant to enhance and empower the feeling of self 
control of th e m?  ct1? v1? du al.  We are m?  the fm? al analysis responsible to and 
for ourselves. The Devil made me do it is not a valid excuse. 
246: Get with what is going on - Check into Rational Recovery, 
Women for Sobriety, SOS, etc.!! Your "research" reflects too strong a 
personal bias!!! 
250: The questions were black + white, making them difficult to 
answer, many were only partly true or partly false, since other factors are 
also important. 
251: Dear Jeffrey, I have problems with the instrument as there is, to 
my way of thinking, a built in bias. The questions are too black and white. 
Right from Ql ... Some addicts MAY benefit from forced education in 
relation to their condition. I was uncomfortable answering most of the 
questions as the result of my answers creates a picture of my opinion that is 
incorrect. Because each individual is different in many ways, one would 
use different approaches to help them. Because of the layout of the 
instrument and the wording used answers become inaccurate. A summary 
will result in a weighted indication (in my opinion). I have chose to make 
those questions that r felt did not give me room to answer accurately; I 
hope I haven't spoilt my contribution. Thank you for the opportunity to 
participate, I wish you well .... 
252: I. Trying to respond to your addiction belief study. Understand 
your position as a researcher, and the systemic requirements of a study. 
Still, have great difficulty as a respcndent. 2. I see early addictive behavior 
as Willful, deliberate behavior on the part of the individual. Once physical 
add' . . ( 'thdrawal risk, etc.) then the behavior is less 
- 1ction has set m w1 
deliberate though still controllable by the addict. 3. I have seen addicts go 
186 
15 months without drugs (as measured by frequent urine testing), only to 
use again within 30 minutes of release. I consider such use a deliberate 
choice, involving drug seeking etc. 4. Understand your research need for 
absolutes, but I don't practice that way; item 9 on your questionnaire; it 
depends on the person. For someone with strong dependency needs who 
is going to remain dependent that may be true. For a person who will heal 
by asserting themselves and taking responsibility for their behavior, that is 
not true. 5. Item 14; analogy; I inherited a genetic predisposition to 
diabetes. However, my need for insulin depends almost 1:1 on my 
food/ exercise balance. Question, if I don' t need insulin am I diabetic? If 
someone doesn't drink/shoot up, and doesn't need to, are they 
addicted????? How much is genetic? How much is internal? How much 
is situational? 6. Item 15: Ultimately, whether you rely on Jesus, good 'ole 
doc Bobby, voodoo, or whatever, it is your hand that lifts the substance off 
the table. 7. I have seen addicts who turned themselves around. Others 
have been able to maintain only with chemical antagonistic help. My 
belief is that whatever works is right. When we know more about people 
and addiction we may be more effective, but right now we are deep in 
highly computerized ignorance, publishing statistically accurate tables of 
garbage. 
257: Enclosed is a pamphlet about Rational Recovery. Hope you 
enjoy! Good luck with your study. I bet if you do it again in. 10 years, you'll 
see a big difference - I hope! 
259: The 12-step approach is a cult supported by testimonials only. 
The ''Disease Theory" is a marketing device. I'm familiar with "Rational 
Recovery'' - is based on science and research. 
187 
261: I cannot complete the questionnaire. Questions are way too 
over simplified & do not leave room for the many, many factors that can 
contribute to a health or alcohol problem. The questionnaire feels like it is 
designed to get counselors to agree or disagree with dogmatic statements -
12 step programs can be approached as a dogma but do not have to be. 
263: The last question is ambiguous. Do you mean 'What 
percentage of drug addicts who get over their addiction do so without 
medical or 12-step treatment?" (That's how I interpreted it.) Or do you 
mean "of all those addicted to drugs what percentage get over their 
addiction without ... etc.?" Obviously a great number never get over their 
addiction by any means. 
264: This was a very difficult survey to respond to. The questions 
were very black & white with words such as: only, cannot, best, worst, etc. 
I believe in the line between abusers & addicts and that addicts do need 
some type of help outside of themselves, whether that be 12 step programs 
( which isn't for everyone, therapy, etc.). I also believe that alcoholism is 
an illness (disease) but can involve psychological characteristics as well that 
must be treated. I believe I have issues with food and have attended OA in 
the past, but have chosen to attend therapy instead as I found it more 
applicable to me at this time. I believe the addictions field is going through 
yet another change. We started out believing addictions were solely caused 
by mental problems and lack of personal willpower. Then we swung to the 
opposite extreme of believing that it was only a disease & could be helped 
only by admitting powerlessness & attending 12-step meetings. We now 
seem to be heading toward the medium perspective which takes 
individual differences &: different therapeutic approaches into account. I 
188 
am supportive of anything that works for an individual, given that it is 
not a harmful substitute. 
265: Bad questions! Uninformed person wrote this questionnaire. 
Lowest level AA thinking? 
268: It seemed to me that the five choices of answers/responses to 
the questions often did not offer satisfactory choices. Example - #11 - It is 
clear to anyone in the field that both likely play a role in addiction. In #59 
when you use the phrase "get over their addiction," do you mean stop 
using or being in recovery? These are 2 different states, and the answer is 
dependent on whichever one you mean. 
271: Very thought provoking question/statements! I believe there 
are no easy, all encompassing answers and will pass on your questions to 
my clients. Thank you! 
275: Questions are too va&ue for meaningful answers. 
277: Many of the questions were ambiguous and difficult to answer 
because of the way they were worded. 
278: Strong lecturer of Rational Recovery groups. People who are 
addicts or alcoholics, can help themselves the best. Treatment can only be 
a guide to recovery. 
279: Q59: Depends on which definition of addiction you use and 
what you mean by get over. 
280: I work with Native Americans for last 2 1/2 years (influenced 
some answers). 
281: Some of the questions are difficult to answer, due to the 
differences in the stages of the addictive diseases. Alcohol is a drug! While 
doing your doctoral keep this in mind. I don't feel that this is stressed 
enough! 
189 
283: As with any multiple choice questionnaire tends to reflect an 
assumed answer. For example - question #59 above - I would estimate that 
people can become abstinent without a 12 step program, but, the % is 
probably less than 1 %. This would be closer to 0% than 5%. I conclusion, I 
do not feel that this survey accurately reflects my opinions related to this 
topic, because, the wording is very vague or contradictory in 50% of the 
questions. 
284: I would welcome a survey that requires a less rigid mindset to 
answer. Considering all the evidence, I'd say the votes aren't in on many 
theories. My observation over the past 12 years tells me that there is a 
genetic predisposition, that there is no cure for alcoholism, that heavy 
drinking isn't always but usually addiction, that often predisposing 
conditions are trauma in childhood (including neglect). Above all that we 
need to remain open minded re: what works for people. I personally 
believe 12 steps are powerfully effective - but not the end all and be all. 
That therapy is often indicated, and that everyone's requirements are 
d ifferent and the reasons for that are still a mystery. Diet, exercise, therapy, 
group therapy, psychodrama, individual therapy, twelve steps AA, 
abstinence, love + support, spiritual counsel, expression - dance, art, 
singing, sports, writing, meaningful work, relationship, community, 
intellectual stimulation. 
285: In your survey, you are talking about addiction and getting into 
areas such as religion and spirituality. I am not against religion and 
spirituality, but I don't believe it is necessary in treating addiction: If 
addiction is a disease (and basically its called a disease because the medical 
profession wants reimbursement) why is it treated with a "spiritual or 
religious" program? The 12 steps say "having had a spiritual awakening" -
190 
this is para  d OX.I ca l be cause 1. ? I have a disease, I can't get rid of it, I will 
always have it. The 12 step model is not consistent with the disease 
concept. In your survey you didn't separate physical addiction versus 
emotional addiction. I don't believe you can use the word addiction to 
cover everything: After all, Hthe program" says its physical, mental, 
spiritual. 
290: Difficult to strongly agree or disagree as every individual is 
different. 
292: Sounds like locus of control and the 12 Step AA dependency fad 
w?t th the self-help support group trend. 
Comments From Non-Addiction Treatment Providers 
The following comments are from respondents who indicated they 
are not addiction treatment providers: 
001: This instrument has given you a great deal of information 
about me. I hope it will be heJpful and I trust anonymity will be respected. 
Personal viewpoint: Health care providers can help to give needed rest to 
the body of an alcoholic or addict, direction to the mind and spirit but 
beyond that it is very much an individual's responsibility to seek Jong term 
help via 12-step programs. The sole purpose of a treatment center is to 
direct the individual to a 12-step program that they can identify with - AA 
is !lQ! the place to direct a person with only narcotics problems. If alcohol 
is not the problem (symptom) AA is not the solution. 
002: There are certain health related questions and God related 
questions which I felt inherent in the actual question was a bias, therefore, 
I refra m? ed from answeri.n g. I'm reluctant to commit to this survey not 
kno ? d ~h,,.y: you are doing the survey ... in relation to 
wing who you are an 
such volatile & perhaps delicate issues. 
191 
003: Comment on #11 & #14: My field of expertise is genetic factors in 
substance abuse and the neuro-physiological factors underlying substance 
abuse. Could have answered #11 the other way because the question forces 
a choice in a situation which is not either/o r. I would be most interested 
in your results - another area of interest of mine is e?valuation of AA. AA 
meetings are frequently dominated by a small group of rigid, authoritarian 
"gurus" whose thinking process closely resembles born-again 
fundamentalists. They believe Bill W. is their messiah and the Big Book 
their bible and these "inspired words" are not to be questioned. Also - I 
teach pharmacology courses in a program to certify alcohol/ drug 
counselors. Most are already active in the field. If you want a larger 
sample - who like most counselors are not members of professional groups 
- let me know. 
004: #4 - Term "will power" not medical or scientific term. I would 
substitute "ability to change your thinking." #7 - Depends more on one 
paradigm of life. 10. - But why take a chance? 13. - Also when things go 
well! 15. - Prefer "alcohol dependency" over "alcoholism." 19. - Mostly. 
26. - Or genetic make up. 43. It's stupid to harbor resentment; better to 
deal with hurt for emotional, mental and physical health. 44. - Don't 
understand statement. Don't understand goal of questions. Will we 
receive your conclusions? Believe prognosis for alcohol dependents 
recovery very high. 
008: I'm a vocational rehab counselor. Most of the questions on my 
health are strongly flawed in view of my very extensive medical history. 
I've had genitourinary problems since age 22 months. So, no, I'm not 
responsible for my body rejecting a transplanted kidney, but yes, I'm 
responsible for how I react to that and what I do about it. I am also 
192 
responsible for taking care of myself and doing the best I can by exercising 
and trying to stay fit & health. From a professional point of view I abhor 
AA. 
009: I work in AOD prevention, not treatment. 
010: 12-step is not for everyone - secular humanists, atheists and 
agnostics have an especially difficult time, especially in rural areas where 
they are often abused by being told they are in "denial" because they don't 
"buy" the "party line" hook, line and sinker. Also, feminists have a 
majorly hard time accepting 12 step when it has been traditionally 
dominated by males and m asculine higher power language is used in most 
settings. Saying the "Lord's Prayer" at the end of meetings pretty well 
establishes 12 step as a Christian Based philosophy. 
012: Don't send another ... [item 11} Come on, give me a break, black 
and white thinking went out ages ago] This survey is worthy of a high 
school diploma certainly not a Ph.D. [item 36: deify the MD pray to the 
great pharmacist in the sky] Show this to your supervisor, go out get a 
drink, pray and go out and live with a few alcoholics for a couple of 
months than get a life ... the poorest example of research I have ever seen 
... surely NAADAC would not approve this ... LBJ stamp, how appropos 
[return stamp was Hubert Humphrey]. 
013: It would have been helpful to include your definition of 
addiction. 
015: I think it's unconscionable that addiction treatment is almost 
completely dominated by 12-step treatment, which is lacking in statistics 
vis a vis how well it really works. It's high time that people be given a 
choice of treatments, which should include non-secular treatments such as 
Rational Recovery, which makes a concerted effort to be accountable and to 
193 
be scientifically rigorous to the extent that it is able to be, given the 
embryonic stage of its existence. The widespread notion that 12-step is the 
only way is extraordinarily destructive. A concerted effort must be made to 
turn that idea around. 
024: Answered regarding abuse + dependence. Not extreme forms 
of dependence. 
027: #19 - I have the power to choose to receive assistance from 
individuals with appropriate skills and to assist myself in addition to what 
I do for myself directly. #32 - The type of care can either impede or expedite 
recovery from illness and what I may do for myself. Interesting 
survey. ...G ood luck! 
028: As an experimental psychologist, I realize that many of the 
questions are forced-choice. But those questions that do not separate types 
of alcoholics, i.e. genetic vs. psychological, confuse the issue. They would 
be answered oppositely depending on whether they are referring to a 
genetic (primary) or psychological (secondary) alcoholic. The survey is 
written as though all drug-dependency is the same. 
030: I am still in graduate school, so I am still forming my ideas 
about addiction and the process of recovery. I will be specializing in 
drug/ETOH treatment during my internship beginning in December. 
Also, the questions about my own health were somewhat confusing for 
me. I have had cancer, which I do not believe was caused from something 
l did/ did not do. I feel my mental attitude, however, was partially 
responsible for my recovery. On the other hand, I believe that minor 
illnesses such as colds, flu, etc. can be exacerbated by stress+ mental state 
which contribute to one's ability to ward off or recover from illness. 
194 
031: I am a coordinator for a Rational Recovery group. I stopped 
using alcohol about two years ago but do not consider myself "in recovery" 
or "alcoholic." I am a person who at one time abused alcohol + found it 
was easier to stop than moderate. Your survey seems focused on AA and 
its principles. If this is its intent, fine. It if means to be broader the number 
of questions you address about God and AA are biasing your results. I am 
the creator of a text on drugs and alcohol and consider myself a 
psychopharmacologist. I have no objection to ... nor to your contacting me. 
032: Choice is the heart of a healthy lifestyle. Deterministic theories 
and theologies are no excuse or adequate explanation for addictive 
behavior. Recovery is hard work and that is up to the individual to make 
responsible choices. Recommended self-help program for chemically 
dependent people - Rational Recovery. 
APPENDIX H 
CORRELATION COEFFICIENT :\iATRlX 
SBS Il-ILC PHLC CHLC Age? Gender Ed. Cert. 
ABS .63** -.13" .18? .09 -. oo .31 ?? -.26** - .26?* 
SBS 1.00 - .06 .211'* .04 -.06 .18"* - . .25** -.16** 
Recovered Addict .10 -.04 -.01 - .13* -.01 ? 42 ** .28** 
AANow .OS -.05 .03 - .09 -.10 .34** .25** 
AA Time - .09 .07 -.03 ? 3.2 *,.. . 09 -.37** - .32** 
AA Past .04 -.03 . 04 -.05 - .14* .18** .25*" 
Abstinence .07 .04 .00 -. 09 -.10 .29** .27** 
Drug Freq. .09 .02 .05 ? 04. -.15* .16** .16** 
IHLC 1.00 -.02 -.31** .06 - .OS . 03 .02 
PHLC 1.00 ? .29 * * -.08 -.08 -. 01 .10 
CHLC LOO -.15* -.03 - . 0.2 -.03 
A~ 1.00 - .10 .03 -.13* 
Gender 1.00 -.05 - .04 
Education 1.00 .31** 
...... 
\0 
U1 
APPENDIX H (Continued) 
Recovered Addict AA Now AA Time AA Past Abstinence Drug Frequency 
ABS -.40** -.55** .45*-tr -.28** -.37** -.35** 
SBS -.37** - . SJ** .44** -.36** -.33** -.28** 
Recovered Addict 1.00 . 67** . 64 ... * . 33 * * .51** .35** 
AA Now 1.00 -.68 11 * .36** .49** .34** 
AA Time 1.00 -.34** .45** -.30** 
AA Past 1.00 . 3 5** .29** 
Abstinence 1.00 .58** 
Note. ?p=.05, ??p=.01, two-tailed, N=295. 
...... 
\Cl 
?' 
APPENDIX I 
INTERCORRELATION OF ABS ITEMS (A) BY SBS ITEMS (S) COEFFICIENTS 
S1 S2 S3 S4 S5 S6 S7 S8 
Al .25** .26** .22** .27** .28** .30** . 23 * * .11 
A2 .42** .39** .32** .41** .45** .43** .31** .17 ** 
A3 .20** .18** .15** .22** .29** .27** .20** .14* 
A4 .44** .42** .35** .42** .48** .46** .30** .22** 
AS .40** .39** . 23,,.,,. .43** .41** . 43 * * .30** .20** 
A6 .16** .10 .1s-- .06 .08 .12* - . 03 -.05 
A7 .28** .25** .17** .24** .28** .25** .13* .15** 
AB .46** .39** . 33,,.,,. .39** .48** . 45 ** . 21 1"* . 13 ? 
A9 . 63 ** .54** .42** .58** .61** .58** . 40 * * .25** 
A10 . 43 ** .43** .28** .42** .48** . 4 7 ** .30** .20** 
All .40** .34** . 29** .34** .36** .37** .25** . 17** 
A12 .47** .42** .28** .42** .43** .46** .26** . 13* 
A13 .18** .19** .12 .19** .16** .14* .07 .06 
A14 .45** . 43 ** .33** .41** .43** . 43** .27** .14 * 
AlS .48** .44** .32** .46** .48** . 47 ... . 33 ** .16** 
A16 .47** .40** . 36** .43** .50** .46** . 3 4 * ? .17** 
A17 . 47** .43** . 31 ** .47** .44** .48** .34** .20** 
A18 .16** .13* .16** .17 ** .13 * .19** .02 .06 
Note. ?p=.05, ,.,.,,=.01, (two-tailed, N=295) 
.... 
\0 
~ 
APPENDIX] 
SIGNIFICANT GROUP COMPOSITIONS: CHI-SQUARE ANALYSIS OF EXPECTED VS OBSERVED FREQUENCIES 
AA Recovery Certif. AA Gender Abstin. 
past status1 status now status 
Group ** ** 
** ** ** ** 
26.74 58.61 49.39 93.90 12.97 41.22 
(2) 2 ( 2) {2 ) (2) (2) { 2) 
Marital * ** ** 10.60 19.00 34.00 * * 19.68 
status ( 3) ( 3) ( 3) ( 3) 
Ed. ** 20.05 ** ** 73.17 ** ** 32.68 76.44 18.41 
status { 4) (4) {4) ( 4) ( 4) 
Rel. ** ** ft 23.98 23.28 29.62 ** 15.07 
affil. (5) ( 5) ( 5) {5 ) 
AA past 30.31 ** 
*,. 
17.09 36.08 ** 5, 57 * 
(1) ( 1) ( 1) ( 1) 
Abst. ** 74.67 20.90 ** 71.04 ** 
status (1) (1) {1) 
AA now 133.26 ?? 18.72 ** 
( 1) ( 1) 
Cert. ** 22.24 
status (1) 
Gender * 5.57 
(1) 
Note. 1Consider themselves to be alcoholics or addicts in recovery. 2(df). * p=.02, ** p=.002 \-,C) 00 
199 
APPENDIXK 
FACTOR ANALYSES 
Results for the Factor Analyses of the SBS and the .ABS 
Results for the Factor Analysis of the SBS 
Factor analyses were conducted to investigate underlying conceptual 
dimensions on the SBS (Table 12) and the ABS (Table 13) because they are 
new, the SBS scale was able to explain variance in the ABS in a statistically-
significant way, and the researcher was interested in whether the two 
dimensions of the ABS grouped separately in terms of their correlations 
with one another. 
As Table 12 shows, two factors were extracted from the SBS utilizing 
varimax rotation - Kaiser normalization. The first factor had an 
Eigenvalue of 5.17, with 64.7 percent of variance. The first six items on the 
SBS, items Sl-56, were highly correlated with factor one and grouped 
together representing the three spiritual dimensions of release, gratitude, 
and humility, the highest correlation being with item S4 at .91. This item 
reads: I feel it is important to thank God when I manage to do the right 
thing. It was designed to express the gratitude element of spirituality. 
Factor 2 had an Eigenvalue of 1.08, with 13.4 percent of the variance. 
Items S7 and S8 correlated highest here, both designed to represent the 
tolerance dimension of spirituality, S8 with the highest correlation at .91. 
Results for the Factor Analysis of the A BS 
As Table 13 shows, three factors were extracted from the ABS 
utilizing varimax rotation - Kaiser normalization. The first factor had an 
Eigenvalue of 7.22, with 40.1 percent of variance. The items with the 
highest correlations for this factor were Al (.52), A2 (.64), A3 (.59), AS (.51), 
I 
Table 12. 
Factor Analysis of Scores on the Spiritual Belief Scale: Varimax Rotation 
Ii 
"' 
u 
Factor 1 Factor 2 l 
Eigenvalue 5.17 1.08 
Percent of Explained Variance 64.70 13.40 
Cumulative Percent of Explained Variance 64.70 78.10 
lS11 1 feel that in many ways turning my life over to God has 
actu.aUy set me free. l"Release1 .85 .24 
lS21 I know that all the best things in my life have come to me 
through God. lReleasel .89 .26 
lS31 l believe I am blessed by God with many gifts 1 do not 
deserve. lGratitude1 .80 -.04 
[S4] I feel it is important to thank God when I manage to do 
the right thing. [Gratitude] .9 1 .21 \\ 
lS51 It's only when 1 stop trying to play God that I can begin to 
learn what God wants for m.e. {Humilty] .82 .37 
lS61 I know I am able to meet life's challenges only with God's 
help. {Hwnilty] .89 .25 
[S7] I know that forgiving those who have hurt me is important 
for my spiritual health. {Tolerance] .41 . 67 
[S8] I believe there are many ways to know God and that my way 
is not the only way. {Tolerance] .03 .91 
N 
0 
a 
Table 13. 
Factor Anal,xsis of Scores on the Addiction Belief Scale: Varimax Rotation 
Factor 1 Factor 2 Factor 3 
Eigenvalue 7.22 1. 59 1.04 
Percent of Explained Variance 40.10 18.80 5.80 
Cumulative Percent of Explained Variance 40.10 49.00 54.80 
[Al] Most addicts don't know they have a problem and must 
be forced to recognize they are addicts. [Disease model] .52 .11 .07 
[A2] Addicts cannot control themselves when they drink or 
take drugs. [Disease model] . 64 .24 . 13 
[A3] The only solution to drug addiction and/or alcoholism 
is treatment. {Disease model] .59 .34 -.30 
[A5] Addiction is an all-or-nothing disease: A person cannot 
be a temporary drug addict with a mild drinking or drug 
problem. [Disease modelJ .51 .56 . 14 
[A9] The most important step in overcoming an addiction is to 
acknowledge that you are powerless and can't control it. 
[Disease model] . 71 .45 .09 
N 
0- 
Table 13. (continued) 
Factor 1 Factor 2 Factor 3 
[AlOJ Abstinence is the only way to control alcoholism/drug 
addiction. [Disease model] .61 .57 -.03 
[All] Physiology, not psychology, determines whether one drinker will 
become addicted to alcohol and another will not. (Disease model] .04 .80 .27 
[A14] The fact that alcoholism runs in families means that it is 
a genetic disease. [Disease model] .29 .71 .10 
[A17] People who are drug addicted can never outgrow addiction 
and are always in danger of relapsing. [Disease model] . 62 .47 .10 
[A4] The best way to overcome addiction is by relying on your 
own willpower. [Free-will model} .69 .04 .22 
[A6] People can stop relying on drugs or alcohol as they develop 
new ways to deal with life. [Free-will model] .02 .05 .65 
[A7] Addiction has more to do with the environments people live 
in, than the d.rugs they are addicted to. [Free-will model] .22 .40 .44 
[AB] People often outgrow drug and alcohol addiction. (Free-will model] .52 .46 .26 
[A12J Alcoholics and drug addicts can learn to moderate 
their drinking or cut down on their drug use. [Free-will model] .56 .54 .10 
N 
0 
Iv 
j 
II 
Table 13. (continued) 
Factor 1 Factor 2 Factor 3 
[A13J People become addicted to drugs/ alcohol when life is 
going badly for them. [Free-will model] . 19 .14 . 61 
[AlS] You have to rely on yourself to overcome an addiction 
such as alcoholism. [Free-will model] .70 -.00 .37 
[A16] Drug addicts and alcoholics can find their own ways out of 
addiction, without outside help, given the opportunity. 
[Free-will modelJ . 69 .33 .04 
[A18J Drug addiction is a way of life people rely on to cope with 
the world. [Free-will model] . 05 .11 . 68 
tv 
0 
CJJ 
204 
A9 (.71), AlO (.61), A17 (.62), which were all designed to represent the 
disease-model dimension, and A4 (.69), AB (.52), A12 (56), A 15 (.70) and Al6 
(.69), all designed to represent the free-will dimension. Item A9, with the 
highest correlation of .71, read: The most important step in overcoming an 
addiction is to acknowledge that you are powerless and can't control it. 
The second factor had a.n Eigenvalue of 1.59, with 18.8 percent of 
variance. The item with the highest correlation on this factor was Al 1 
with a correlation of .80. This item reads: Physiology, not psychology, 
determines whether one drinker will become addicted to alcohol and 
another will not. Items All, AS (.56), AlO (.57), A14 (.71) were all designed 
to represent the disease-model dimension. Item A12 was the only other 
item in factor two that had a correlation above .SO with .53. It was designed 
to represent the free-will dimension. 
The third factor had an Eigenvalue of 1.04, with 5.8 percent of 
variance. Three items grouped together with high correlations on this 
factor, all designed to represent the free-will perspective, with A18 the 
highest at .68. A18 reads: Drug addiction is a way of life people rely on to 
cope with the world. The other two items were A6 (.65) and Al3 (.61). 
Discussion of Factor Analysis of the SBS and the ABS 
Discussion of Factor Analysis of the SBS 
The factor analysis of scores on the SBS shows that the three 
dimensions of spirituality characterized by release, gratitude, and humility, 
are not as distinct as originally thought to be: The three dimensions are 
positively correlated with one another. The tolerance dimension separated 
from the other three and is more distinct. 
The item with the highest loading on Factor One, 54, #I feel it is 
important to thank God when I manage to do the right thing," is most 
205 
representative of the three dimensions. The statement contains elements 
of release and humility, in addition to gratitude. For example, "doing the 
right thing," can be interpreted as a release from doing the wrong things. 
"Thanking God" for something the individual does that is considered 
good, is a form of humility. So, from a logical point of view, it makes 
sense that the three dimensions group together on this statement. 
The item with the highest loading on Factor Two, 58, "I believe 
there are many ways to know God and that my way is not the only way," is 
most representative of the tolerance dimension. In the reliability analysis 
of the SBS, this was the item that, if deleted, raised the alpha level from .94 
to .96. The item also has the highest mean, 4.30 (SD=.10, n=280), compared 
to the seven other items which have an average mean of 2.91). 
This final statement, item S8, is one that may be difficult to disagree 
with. The purpose of the SBS is to measure spiritual thinking, as defined 
by belief in a metaphysical entity that can influence experience. People 
who assert they do not believe in God may well be inclined to agree with 
this statement. People who assert they believe in God may well be inclined 
to disagree with the statement. 
For example, a self-described atheist or agnostic may believe that 
diverse paths to knowing God are equally legitimate in being illegitimate, 
i.e., they are all false because either God does not exist1 or can' t be known. 
Yet, when a person agrees with the statement, he or she is expressing a 
belief in God, in that God is something that exists, something that can be 
known in diverse ways. To be intellectually consistent, the true atheist 
and/ or agnostic should theoreticaUy disagree with this statement. If God 
does not exist, or we cannot know that God exists, then one way of 
knowing God, or diverse ways of knowing God, are equally false. 
206 
On the other hand, many people believe their way of knowing God 
is the only way. Therefore, they may disagree with the statement and yet 
still believe in God and engage in spiritual thinking. For example, the 
survey was given to a woman who described herself as an ex-nun and 
currently a born-again Christian. She said she disagreed with the 
statement because she believes that Jesus is the only way a person can 
know God. 
A final point is worth mentioning: Note that item 53 on Factor 
Two, which reads "I believe I am blessed by God with many gifts I do not 
deserve," is the only item to be negatively correlated with the others. 
Many treatment providers objected to the "I do not deserve" part of this 
statement. This item had the lowest mean, 2.29 (SD==l.23, n==280), 
compared to the other seven items. It is the most distant item from 
tolerance in the sense that the more treatment providers believe there are 
many ways to know God, and that their way is not the only way, they 
believe they are deserving of the gifts they feel God has blessed them with. 
Certainly this final belief is not indicative of humility. 
These points aside, the SBS appears to do a good job of assessing 
spiritual thinking, the release, gratitude and humility dimensions are not 
as distinct in the minds of addiction-treatment providers as was originally 
believed to be, and the three of them together are quite distinct from the 
tolerance dimension of spiritual thinking. 
Discussion of Factor Analysis of the ABS 
The ABS seems to do a good job of measuring beliefs about addiction 
in terms of representing two sides of the disease v. free-will controversy, as 
evidenced by the high alpha reliability. The ABS also appears to measure 
three distinct dimensions: A power dimension; a dichotomous-thinking 
207 
dimension; and a way-of-coping-with-life dimension. These three 
dimensions appear to be pivotal issues in the disease-model debate. 
The dichotomous-thinking dimension constituting Factor Two 
lends support to the notion set forth by Alexander & Rollins (1984) that AA 
is a cult characterized by Lifton (1961). The notion of addiction as a "way of 
life," or, way of coping with life, as extracted in the third factor appears to 
support assertions by Fingarette (1988) that heavy drinking is a "central 
activity" in life, as well as Alexander's (1990b) adaptive model of addiction. 
The power dimension of Factor One seems confirmed in the discussion 
above regarding the common thread that runs through spiritual thinking, 
health locus-of-control orientation, and gender status. 
That treatment providers hold contradictory points of view 
regarding the disease and willful nature of addiction supports Caetano's 
(1987) findings that conceptions about alcoholism are "not entirely 
consistent in the public's mind: the disease concept may be contradicted 
and supported at the same time," (Caetano, 1987, p. 158). 
The fact that treatment providers appear to hold contradictory beliefs 
regarding addiction, e.g., disease model and free-will model items load 
together on the same Factor, is worthy of comment and does not 
necessarily detract from the content and construct validity of this measure: 
The underlying dimensions of beliefs regarding power and powerlessness, 
dichotomous thinking, and drug addiction as a way of coping with life, 
appear to be key issues in the controversy. 
Five free-will beliefs loaded high on Factor One (power): A4, AB, 
A12, AlS, and A16 with seven disease-model beliefs. Factor Two 
(dichotomous thinking) loaded items that were disease-model beliefs with 
the exception of Al2. Factor Three (way of life) loaded only free-will items. 
208 
Since Factor Three loaded only free-will items it appears there is no 
contradiction here and further commentary is not warranted. 
Factor Two included one item expressing the free-will model, A12, 
and it had the lowest correlation of the items that loaded highest on this 
Factor, .53. The underlying dimension fo.r Factor Two is explained as 
dichotomous thinking. Of the other four items, AS, AlO, Al 1, and A14, 
A12 seems most at odds with Al0, for here we have the diametrically-
opposed viewpoints on the controlled-drinking/drug-taking controversy-
yet the two are positively correlated with one another. How can this be? 
In other words, addiction-treatment providers who believe that 
abstinence is the only way to control alcoholism/drug addiction also 
believe that alcoholics and drug addicts can learn to moderate their 
drinking or cut down on their drug use. Perhaps one way of explaining 
this apparent contradiction in beliefs is that the people who hold them also 
believe that addicts can moderate their addiction, they won't moderate it, 
and therefore the best solution is abstinence. They may believe that addicts 
have the power to control their drug ingestion behavior, they just won't do 
it. The.refore, the best approach to helping drug addicts is the abstinence 
approach, which is really more of a utilitarian perspective on addiction 
treatment than a logical one. 
In terms of the apparent contradiction of simultaneously held 
beliefs, i.e., those of the disease-model perspective and the free-will model, 
for Factor One (power), seven of the items that loaded on Factor One are 
disease-model items and five are free-will model. All are highly correlated 
with one another in a positive way. An analysis of this apparent 
contradiction will now proceed i tern by item. 
209 
Item A4, "The best way to overcome addiction is by relying on your 
own willpower," appears to strongly contradict A3, "The only solution to 
drug addiction and/ or alcoholism is treatment," and A9, ''The most 
important step in overcoming an addiction is to acknowledge that you are 
powerless and can't control it." The assumption here is that those who 
hold a strong belief in the disease model of addiction couldn't possibly 
agree with idea that willpower is the best way of overcoming addiction. In 
fact, those who disagree with the disease model may disagree with the 
belief that willpower is the best way. For the statement may suggest to 
them that people who are drug addicted don't need help or support from 
others and the idea that they can rely solely on their own willpower may 
seem to be an unreasonable expectation that could lead to further addiction 
and trouble, i.e., problems in living. That a drug addict should rely on 
others for help in solving his or her problem does not necessarily mean to 
these addiction-treatment providers that addiction is a djsease devoid of 
volition components. In this sense the holding of these two beliefs is not 
inconsistent. 
Yet, from a strictly logical point of view, abstinence and seeking help 
from others are still willful acts, and a person exercises willpower in 
seeking to fulfill these acts. Therefore, a contradiction, strictly speaking 
does seem to be present i-n the minds of those who hold these two beliefs. 
A8, "People often outgrow drug and alcohol addiction," is 
inconsistent with all of the other disease-model items at first glance, yet the 
contradiction with the first six items, especially Al, A2, A3, AS, A9, and 
AlO, can be resolved through the following logic: People can outgrow drug 
and alcohol addiction if they are forced to recognize they are addicts, get 
210 
treatment for their addiction, acknowledge they are powerless to their 
addiction, and engage in abstinence. A17 is the trouble item. 
How can people who believe in A171 "People who are drug addicted 
can never outgrow addiction and are always in danger of relapsing," also 
believe that "People often outgrow drug and alcohol addiction?" For one 
thing, the focus for some treatment providers on A17 may be the latter part 
of the statement - people who are drug addicted are always in danger of 
relapsing. This part of the statement is not inconsistent with A8. This may 
explain a great part of the inconsistency. 
On the other hand, people simply hold contradictory beliefs and they 
do not make logical sense. One reason for this is they may have been 
taught to believe that addicts cannot mature out of their addiction, when 
they, the treatment providers, personally believe that addicts can. They 
may have learned that addiction can never be overcome or outgrown, as 
part of the ideology of their own treatment program if they themselves are 
addicts in recovery. They may have learned to believe certain ideas about 
addiction because they were taught their own sobriety was contingent upon 
believing in these ideas. For example, believing addiction is a disease is an 
integral part of treatment for the disease. Until the patient exhibits signs of 
belief in the disease they often are not considered to be making progress. 
Despite these beliefs, the treatment provider may well observe that his or 
her patients are in fact maturing out of their addiction. 
Here is the discrepancy between what addiction treatment providers 
may have learned to believe, based on their own experience of addiction 
and sobriety, or perhaps as part of becoming certified as an addiction 
treatment counselor, or some other educational and/ or professional 
211 
certification process, and  what they may know to be true based on their 
own observations of addicts. 
Again, while 80 percent of these items are designed to represent the 
disease -mode I  on.e nta ti. on to ad d1' ch. on, an underlying theme or dimension 
is present throughout all of them: Dichotomous thinking. For example, 
in AS, "Addiction is an all-or-nothing disease: A person cannot be a 
ternporary drug addict with a mild drinking or drug problem," the 
dich.otomous, or either-or way of viewing addiction as a disease is explicit. 
Moreover, the statement expresses dichotomous thinking in its second 
half. There is no such thing as a middle ground when it comes to 
addiction. Either a person is an addict or he or she is not. If the person is 
an addict, he or she has a disease, period, there is no middle ground. 
AIO, "Abstinence is the only way to control alcoholism/drug 
addiction," expresses dichotomous thinking through the use of the word 
"only," This is a unilateral perspective on addiction and its control. On 
the one side is abstinence, on the other is addiction. Either abstinence or 
addiction is the way the statement reads. 
All,. "Physiology, not psychology, determines whether one drinker 
Will become addicted to alcohol and another will not,'' is another dear 
statement of dichotomous thinking, and is the most representative 
state,..,,.e n t f F T There is a sense of absolutism present in this ??l or actor wo. 
black or white belief. Either physiology or psychology determines addiction 
in thi" tment providers agree with the statement, the 
s case. The more trea 
Inor th . . . . black or white fashion, an either-or 
e ey view add1ct10n m a ? 
e . Again there is no middle ground. 
P rspective, dichotomously. ' 
h !ism runs in families means that it is a 
A 14, "The fact that alco 0 
. ?(ficult to understand as an expression of 
genetic disease," is perhaps di 
212 
dichotomous thinking. The statement expresses the belief that either 
alcoholism is genetically determined, and this explains why it may run in 
families; or it is a learned behavior, and this is why it runs in families. It 
is an absolute statement in this sense, that alcoholism is genetically 
determined, or that it is learned. If people see alcoholism as a combination 
of the two, they should disagree with the statement. 
And finally, A12, "Alcoholics and drug addicts can learn to moderate 
their drinking or cut down on their drug use," is a free-will modelist's 
belief, and really represents the flip side of AlO, which asserts that 
abstinence is the only way to control alcoholism/drug addiction. The 
controlled-drinking and/ or drug-taking versus abstinence controversy is 
often viewed as a mutually-exclusive issue, and much of the disease model 
of addiction controversy has centered on these two approaches. The free~ 
will modelist believes in the addict's ability to moderate his or her drug 
ingestion. The disease modelist absolutely refutes it. The disease modelist 
tends to see the controversy from an either-or perspective, i.e., moderate 
drinking or drug ingestion is not an option for the addict. It equals death. 
The free-will modelist sees controlled-drinking or drug ingestion and 
abstinence as more or less equally viable ways of dealing with addiction. 
While many of the other items that loaded high on Factor One can 
be interpreted as expressing this dichotomous-thinking dimension, they do 
not seem salient in this respect, compared to the way in which items 
loaded high on Factor Two do. 
It is interesting to note that the seven disease-model items correlate 
highly with the five free-will model items, an apparent contradiction in 
beliefs held. What do the twelve items have in common? 
213 
At first glance, the twelve items that load highest in correlation on 
Factor One all express beliefs about power. Al, "Most addicts don't know 
they have a problem and must be forced to recognize they are addicts," 
while a statement that clearly expresses a disease-model orientation to 
addiction, also communicates a belief about power. One might interpret 
this statement as saying that the, addiction problem is so powerful addicts 
don't even know they have a problem, and, being powerless in this respect, 
must rely on the power of others to force them to recognize they are 
addicts. 
A2, "Addicts cannot control themselves when they drink or take 
drugs," is again a statement expressing beliefs about power-addicts cannot 
control themselves, they do not have the power to control themselves 
when they drink or take drugs. A3, "The only solution to drug addiction 
and/or alcoholism is treatment," can be construed as a statement 
expressing beliefs about power in the sense that the power of treatment is 
the only solution to addiction, i.e., everything else is powerless. Of course 
treatment involves the power of another person or persons outside of the 
self. 
AS, ,., Addiction is an all-or?nothing disease: A person cannot be a 
temporary drug addict with a mild drinking or drug problem," expresses a 
belief about power in the sense that when a person has the addiction, 
which is either present as a disease or not present at all, there is no power 
that a person can exhibit to moderate the problem. A9, "The most 
important step in overcoming an addiction is to acknowledge that you are 
powerless and can't control it," expresses the power theme again clearly. 
A 10, "Abstinence is the only way to control alcoholism/ drug addiction," is 
another power statement in the sense that abstinence is the way to control 
114 
or have power over addiction. A17, "People who are drug addicted can 
never outgrow addiction and are always in danger of relapsing," expresses 
the power theme in the sense that addicts are at risk of the danger of 
relapse,  a powerf  ul force, one that 1. s so powerful 1. t cannot be outgrown, 
and even th e power of maturati? on cannot overcome the power of 
addiction. 
A4, 'The best way to overcome addiction is by relying on your own 
Willpower,  ,, 1. s o b v1. ous1 y a power-on.e nted  statement, only this time the 
I 
I power theme refers to the power within or of the self. AB, "People often 
I outgrow drug and alcohol addiction," refers to the power of maturation as 
a force able to overcome the power of addiction. Al2, "Alcoholics and drug 
addicts can learn to moderate their drinking or cut down on their drug 
Use," is a free-wiII model statement that expresses the power theme in the 
sense that it refers to a person's ability to exercise the power of moderate or 
controlled drinking and drug-taking as a way of dealing with the power of 
addiction. A15, "You have to rely on yourself to overcome an addiction 
such as alcoholism," refers to the power of self, not others, to overcome the 
P0 wer of addiction. And finally Al6, "Drug addicts and alcoholics can find 
their own ways out of addiction, without outside help, given the 
0 Pporturu ty n . power-oriented statement in the sense that it is similar , 1s a 
to AlS and ref  ers to th  e _pow er of self,  really self-efficacy, as contrasted with 
outside h . .h of non-self forces, e.g., others, in overcoming 
e1 p, or, t e power 
the power of addiction. 
ower self power, powerlessness, powerful 
The refore, a theme of  P ' 
oth dd'ct'on runs through these 12 items, despite the 
ers, and the power of a 1 1 
fact h d sign to express the disease-model 
t at the first seven were e 
? . h second 12 were designed to express the 
0 nentation to addiction and t e 
215 
free-will model. Power is an underlying theme or dimension for those 
items that loaded heavily on Factor One. 
216 
REFERENCF5 
Akers, R.L. (1991). Addiction: The troublesome concept. The Journal of 
Drug Issues, .iL 777-793. 
Alcoholics Anonymous World Services. (1967). As Bill sees it: The A.A 
way of life ... Selected writings of A.A.'s co-founder. New York: 
Alcoholics Anonymous World Services, Inc. 
Alcoholics Anonymous World Services. (1973). Came to believe. .. The 
spiritual adventure of A.A. as experienced by individual members. 
New York: Alcoholics Anonymous World Services. 
Alcoholics Anonymous World Services. (1976). Alcoholics Anonymous: 
The story of how many thousands of men and women have 
recovered from alcoholism, (3rd ed.). New York: Alcoholics 
Anonymous World Services, Inc. 
Alexander, B.K. (1990a). Peaceful measures: Canada's way out of the 'war 
on drugs.' Toronto: University of Toronto Press. 
Alexander, B.K. (1990b). The empirical and theoretical bases for an 
adaptive model of addiction. The Journal of Drug Issues, 2Q., 37-65. 
Alexander, B.K. & Schweighofer, A.RF. (1988). Defining "addiction." 
Canadian Psychology, 29, (2): 151-162. 
Alexander, B.K. (1987). The disease and adaptive models of addiction: A 
framework evaluation. Journal of Drug Issues.12., 47-66. 
Alexander, B., Hadaway, P., & Coambs, R. (1980). Rat park chronicle. 
British Columbia Medical Journal,~ (2): 54-56. 
Alexander, F. & Rollins, M. (1984). Alcoholics Anonymous: The unseen 
cult. California Sociologist: A Journal of Sociology and Social 
Work, Winter, 33-48. 
217 
American Medical Association. (1'9'67). Manual on akoholism of the 
American Medical Association. Chicago,: Amce:r1can Medical 
Association. 
Antaki, C., & Brewin, C. (1982). Atibributions and psychologkal change: 
Applications of attributional theories ?t,o diin1ical and education 
practice. New York: Academic Press. 
Antze, P. (1987). Symbolic action in Akoholics Anonymous. ln M. 
Douglas, (Ed.), Constructive drinking: Piernp:edives on. drink from 
anthropology (pp. 149~181). New York: Cambrid,ge University Press. 
Bailey, M.B. (1970). Attitudes toward :alcoholism before an.d afiter a 
training program for social casew,orker:s. Onar1~edy T-ournat of 
Studies on Alcohol, ;n_, 669-683. 
Bakalar, J.B. & Grinspoon, L. (1984). ,Drug control in a fr.ee society. New 
York: Cambridge University Press. 
Bales, RF. (1944). The therapeu:tk role of Akoholics Anonymous ,as seen 
by a sociologist. Quarterly Journal ,o,f Studies on .Alcohol, fr 267-278. 
Ballenger, J., Goodwin, F., Major, L., ,& Brown~ G. (1979). Ak,o!hol and 
central serotonin metabolism in man. Archives of Genera.Jl 
Psychiatry,~ 224-227. 
Bandura, A. (1986). Social foundations of thougimt & aicfbion: A social 
cognitive theory. Englewood Cliffs, N.J.: Pre:ntice-HalL 
Bandura, A. (1984). Recycling misco.nc,ep:tron:s of perceived self-efficacy. 
Cognitive Therapy and Research.~ 231~255 . 
Bandura, A. (1983). Self-efficacy deter.minant.s of an'tkipated foars and 
calamities. Journal of Persom:ality and Social Psychology,~ 464-469. 
Bandura, A. (1978). Reflections on self-efficacy,. Advancres in Behavior 
Research and Therapy, 1, 237-269. 
218 
Bandur a, A ? 0977). Self-efficacy: Toward a unifying theory of behavioral 
change. Psychological Review, M, 191-215. 
Barnett,  M ? L ? ( 1955). A. kohob.s m m.  the Cantonese of New York City: an 
anthropological study. In 0 . Diehelm (Ed.), Etiology of chronic 
filcoholism (pp. 179-227). Springfield, III.: Charles C. Thomas. 
Barrett, W. (1979). The iJlusion of technique: A search for meaning in a 
.rechnological civilization. Garden City, N.Y.: Anchor 
Press/Doubleday. 
Bates on, G. 0 971). The cybernetics of /?self": A theory of alcoholism. 
Psychiatry, M, 1-18. 
Beasley, J.D. (1988). A fatal misunderstanding: The disease theory of 
alcoholism. fournaJ of Applied Nutrition, 4Q, 1-3. 
Beauchamp, D.E. o98o). Beyond alcoholism: Alcohol and public health 
12.,oli?Y. Philadelphia, p A.: Temple University Press. 
Bennett, L.A. (1988). Alcohol in context: Anthropological perspectives. 
12rugs & Society, 2., 89-131. 
Berg, N.L. 0971). Effects of alcohol intoxication on self-concept: Studies of 
alcoholics and controls in. laboratory conditions. Quarterly Tournal 
Qf Studies on A lcohoL Jf, 442-453. 
Berger, L.s. (1991). Substance abuse as symptom. Hillsdale, N.J.: The 
Analytic Press. 
Ber&nl kr (1991). Does anybody really know what they a , A., & Oscarsson, L. 
l ted to methodology of treatment 
are doing? Some comments re a 
. . . nal of Addiction, ~ 139-142? 
service research. Br1t1sh four - . 
B . - f control among opiate addICts. 
erz1ns,  J.I. ,  & Ro ss, W. F.  (J973). Locus o 
l,,i ,rui:gca!!J...!P~sJ.:.yc!:!.hl.loo~0l 91~g,y,""'" .4Q. B4- ? 
JQurnal of Consulting: a~_n 
219 
Biernacki, P. (1986). Pathways from heroin addiction: Recovery without 
treatment. Philadelphia: Temple University Press. 
Bigelow, G., Cohen, M., Liebson, I., & Faillace, L.A. (1972). Abstinence or 
moderation? Choice by alcoholics. Behavioral Research and 
Therapy.1.Q, 209-214. 
Billings, P. (1990, May 7). [Interview in Robert Bazell, The drink link.} 
The New Republic, 13-14. 
Blakey, R. & Baker, R. (1980). An exposure approach to alcohol abuse. 
Behavioural Research & Therapy, IB, 319-325. 
Blum, K., Noble, E., Sheridan, P.J., Montgomery, A., Ritchie, T., 
Jagadeeswaran, P., Nogami, H., Briggs, A.H., & Cohn, J.B. (1990). 
Allelic association of human dopamine D2 receptor gene in 
alcoholism. Journal of the American Medical Association, 263, 2055-
2060. 
Blumberg, L.U., & Pittman, W .L. (1991). Beware the first drink!: The 
Washington Temperance Movement and Alcoholics Anonymous. 
Seattle, Wash.: Glen Abbey Books. 
Blumberg, L.U. (1978). The institutional phase of the Washingtonian 
Total Abstinence Movement: A research note. Journal of Studies 
on Alcohol,~ 1591-1606. 
Bolos, A.M., Dean, M., Lucas-Derse, S., Ramsburg, M., Brown, G.L., & 
Goldman, D. (1990). Population and pedigree studies reveal a lack 
of association between the dopamine D2 receptor gene and 
alcoholism. Journal of the American Medical Association, 2~4, 3156-
3160. 
Bowen, R.B. (1988). Raising public awareness about the extent of alcohol-
related problems: An overview. Public Health Reports. 103, 559-563. 
220 
Brisbane,  F?L ?  ( 1989). Alcoholism-From many perspectives. Social 
~asework: The foumal of Contemporary Social Work. June, 323-324. 
BroWn, D. 0991, October 2). Genetic studies yield opposite results. The 
.Washington Post, p . A3. 
Brown, H .P. & Peterson, J.H. (1991). Assessing spirituality in addiction 
treatment and follow-up: Development of the Brown-Peterson 
Recovery Progress Inventory (B-PRPI). Alcoholism Treatment 
Quarterly, 8., 21-50. 
Brundage, V. (1985). Gregory Ba teson., Alcoholics Anonymous, and 
stoicism. Psychiatry: Touma! for the Study of Interpersonal Process, 
1?, 40-51. 
Butts, S. V., & Chotlos, J. (1973). A comparison of alcoholics and non-
I alcoholics on perceived locus of controJ. Quarterly Journal of 
filudies on Alcohol,Jt 1327-1332. 
C., Bill. (1965). The growth and effectiveness of Alcoholics Anonymous in 
a southwestern city, 1945~1962. Quarterly Tournal of Studies on 
Alcohol,~ 279-284. 
Cactore t, R. & Gath, A . (1978) Inheritance of alcoholism in adoptees. 
fuitish Tournal of Psychiatzy, 132 252-258? 
Caetano R ( . ki n.1tterns and alcohol problems in a national 
, . 1989). Dnn ng r-
. I ~cohol use among; U.S. Ethnic 
sample of U.S. Hispanics. n 
11.1? ? ? 7) RockviJie, Md.: National Institute on 
~.unontJes (pp. 142-16 ? 
Alcohol Abuse and Alcoholism. 
Ca . . bout alcoholism and its treatment. 
etano, R. (1987). Public opin10ns a 
IQurnaI of Studies on Akoh2L ~ t53-l60. . 
Ca . the disease concept of akohobsm. 
halan, D. (1988). Implicat10ns of 
.Qrugs & Societ~ b 49-68. 
221 
Cahalan, D. (1979). Why does the alcoholism field act like a ship of fools? 
British Journal of Addiction, 21.., 235-238. 
Cahalan, D. (1970). Problem drinkers. San Francisco: Jossey - Bass. 
Calicchia, J.P. (1974). Narcotic addiction and perceived locus of control. 
Journal of Clinical Psychology, ;2Q, 499-504. 
Chess, S.B., Neuringer, C., & Goldstein, G. (1971). Arousal and field 
dependency in alcoholics. The Journal of General Psycholo&Y? ~ 93-
102. 
Chick, J., Rison, B., Connaughton, J., Stewart, A., & Chick, J. (1988). Advice 
versus extended treatment for alcoholism: A controlled study. 
British Journal of Addiction,~ 159-170. 
Chein, I., Gerrard, D.L., Lee, R.S., & Rosenfeld, E. (1964). The road to H: 
Narcotics, delinquency, and social policy. New York: Basic Books. 
Chotlos, J.W., & Dieter, J.B. (1959). Psychological considerations in the 
etiology of alcoholism. ln D.S. Pittman (Ed.), Alcoholism; an 
interdisciplinary approach. Springfield, Ill.: Charles C. Thomas. 
Christiansen, J.A., Reich, J.W., Obitz, F.W., & Baumann, D.J. (1980). Effect 
of information about role and outcome on alcoholics' attributional 
processes. Journal of Studies on Alcohol, 1L 922-929. 
Christopher, J. How to stay sober: Recovery without religion. Buffalo, 
N.Y.: Prometheus Books. 
Churchill, J.C., Broida, J.P., & Nicholson, N.L. (1990). Locus of control and 
self-esteem of adult children of alcoholics. Journal of Studies on 
Alcohol, ll, 373-376. 
Clifford, J.S. (1983). Self-efficacy counseling and the maintenance of 
sobriety. The Pe?rsonnel and Guidance Journal, g, 111-114. 
222 
Cloninger, C.R. (1991). D2 dopamine receptor gene is associated but not 
linked with alcoholism. Journal of the American Medical 
Association, 266, 1833-1834. 
Cloninger, C.R., Bohman, M., & Sigvardsson, S. (1981). Inheritance of 
alcohol abuse. Archives of General Psychiatry,~ 861-868. 
Clouser, R.A., & Hjelle, L.A. (1970). Relationship between locus of control 
and dogmatism. Psychological Reports, ?2., 1006. 
Cohen, D. (Ed.). (1990). Challenging the therapeutic state: Critical 
perspectives on psychiatry and the mental health system. The 
Journal of Mind and Behavior, .!1-
Cohen, F. (1962). Personality changes among members of Alcoholics 
Anonymous. Mental Hygiene, 12, 427-437. 
Cohen, M., Liebson, I., Faillace, L., & Speers, W. (1971a). Alcoholism: 
Controlled drinking and incentives for abstinence. Psychological 
Reports, ~ 575-580. 
Cohen, M., Liebson, I., Faillace, L., Allen, R. (1971b). Moderate drinking by 
chronic alcoholics: A schedule-dependent phenomenon. Journal of 
N ervous and Mental Disease, 153, 434-444. 
Collins, R.L., Lapp, W.M., Emmons., K.M., & Isaac, L.M. (1990). 
Endorsement and strength of alcohol expectancies. Journal of 
Studies on Alcohol, ~ 336-342. 
Comings, D.E., Comings, B.G., Muhleman, D., Dietz, G., Shahbahrami, B., 
Tast, D., Knell, E., Kocsis, P., Baumgarten, R., Kovacs, B.W., Levy, 
D.L., Smith, M., Borison, R.L., Evans, D.D., Klein, D.N., MacMurray, 
J., Tosk, J.M., Sverd, J., Gysin, R., & Flanagan, S. (1991). The 
dopamine D2 receptor locus as a modifying gene in neuropsychiatric 
223 
disorders. Journal of the American Medical Association, 266, 1793-
1800. 
Conger, J.J. (1956). Reinforcement theory and the dynamics of alcoholism. 
Quarterly [ou.mal of Studies on Alcohol, lZ, 296-305. 
Conneally, P.M. (1991). Association between the D2 dopamine receptor 
gene and alcoholism. Archives of General Psychiatry,~ 664-665. 
Cooper, R., Berger, L.5., & Jackson, R.N. (1985). Alcoholism-Recovery and 
responsibility. The Center Magazine, .IB, 62-64, [Letters to the Editor]. 
Cooper, D., & Fraboni, M. (1988). Toward a more valid and reliable health 
locus of control scale. Journal of Clinical Psychology.~ 536-540. 
Corner, G.W. (Ed.). (1948). The autobiography of Benjamin Rush: His 
"travels through life" together with his "Commonplace Book for 
1789-1813." Princeton: Princeton University Press. 
Costello, R.M., & Manders, K.R. (1974). Locus of control and alcoholism. 
British Journal of Addiction,~ 11-17. 
Crawford, J.R., Thomson, N.A., Gullon, F.E., & Garthwaite, P. (1989). Does 
endorsement of the disease concept of alcoholism predict 
humanitarian attitudes to alcoholics? The International Journal of 
the Addictions, M, 71-77. 
Criteria Committee, National Council on Alcoholism. (1972). Criteria for 
the diagnosis of alcoholism. Annals of Internal Medicine, '!J_, 249-
258. 
Davidson, R. (1992a). Prochaska and DiClemente' s model of change: A 
case study? British Journal of Addiction, flZ 821-822. 
Davidson, R. (1992b}. The Prochaska and DiClemente model: Reply to the 
debate. British Journal of Addiction, ffZ, 833-835. 
224 
Davies, D.L. (1962). Normal drinking in recovered alcohol addicts. 
Quarterly Journal of Studies on Alcohol, U, 94-104. 
Davis, F.W., & Yates, B.T. (1982). Self-efficacy expectancies versus outcome 
expectancies as determinants of performance deficits and depressive 
affect. Cognitive Therapy and Research, Q., 23-35. 
OiClemente, C.C. (1981). Self-efficacy and smoking cessation maintenance: 
A preliminary report. Cognitive Therapy and Research,~ 175-187. 
Distefano, Jr., M.K., Pryer, M.W., & Garrison, J.L. (1972). Internal-external 
control among alcoholics. Journal of Clinical Psychology,~ 36-37. 
Ditman, K.S., Crawford, G.G., Forgy, E.W., Moskowitz, H., & MacAndrew, 
C. (1967). A controlled experiment on the use of court probation for 
drunk arrests. American Journal of Psychiatry. 124, 160-163. 
Dolan, M.A. (1988, August 9). God, the courts, and AA. The Evening Sun 
(Baltimore), p. A6. 
Dodes, L.E. (1992). [Review of Substance abuse as symptom: A 
psychoanalytic critique of treatment approaches and the cultural 
beliefs that sustain them]. The New England Journal of Medicine, 
326, 1368-1369. 
Donovan, D.M., & Marlatt, G.A. (1980). Assessment of expectancies and 
behaviors associated with alcohol consumption: A cognitive-
behavioral approach. Journal of Studies on Alcohol, il, 1153-1185. 
Donovan, D.M., & O'Leary, M.R. (1978). The drinking-related locus of 
control scale: Reliability, factor structure and validity. Journal of 
Studies on Alcohol, 12, 759-784. 
Donovan, M.E. (1984). A sociological analysis of commitment generation 
in Alcoholics Anonymous. British Journal of Addiction, Z2., 411-418. 
225 
Eachus, P. (1990). Multidimensional health locus of control of health 
professionals. Psychological Reports, fiL 762. 
Eastman, C., & Marzillier, J.S. (1984). Theoretical and methodological 
difficulties in Ilandura's self-efficacy theory. Cognitive Therapy and 
Research,~ 213-229. 
Eckhardt, W . (1967). Alcoholic values and Alcoholics Anonymous. 
Quarterly Journal of Studies on Alcohol,~ 277-288. 
Edwards, G ., Orford, J., Egert, S., Guthrie, S., Hawker, A., Hensman, C., 
Mitcheson, M., Oppenheimer, E., & Taylor, C. (1977). Alcoholism: 
A controlled trial of "treatment" and "advice." Journal of Studies 
on Alcohol,~ 1004-1031. 
Engle, G.L. (1977). The need for a new medical model: A challenge for 
biomedicine. Science. 196. 129-135. 
Engle, K.B., & Williams, T.K. (1972). Effect of an ounce of vodka on 
alcoholics' desire for alcohol. Quarterly Journal of Studies on 
Alcohol,~ 1099-1105. 
Erickson, P.G. (1990}. A public health approach to demand reduction. The 
Tournal of Drug Issues,~ 563-575. 
Erickson, P.G., Adlaf, E.M., Murray, G.F., & Smart, R.G. (1987). The steel 
drug: Cocaine in perspective. Lexington, Mass.: Lexington Books. 
Erickson, P.G., & Alexander, B.K. (1989). Cocaine and addictive liability. 
Social Pharmacology.~ (3), 249-270. 
Faillace, L.A., Flamer, RN., Imber, S.D., & Ward, RF. (1972). Giving 
alcohol to alcoholics: An evaluation. Quarterly Journal of Studies 
on Alcohol.~ 85-90. 
226 
Faulkner, W., Sandage, D.1 & Maguire, B. (1988). The disease concept of 
alcoholism: The persistence of an outmoded scientific paradigm. 
Deviant Behavior, 2., 317-332. 
Feldman, R.S. (1990). Understanding psycholosy. New York: McGraw-
Hill. 
Fillmore, K.M. (1988). Alcohol problems from a sociological perspective. 
In R.M. Rose & J. Barrett (Eds.) Alcoholism: Origins and Outcomes 
(pp. 95-110). New York: Raven Press Ltd. 
Fillmore, K.M. (1987a). Prevalence, incidence, and c.hronicity of drinking 
patterns and problems among men as a function of age: A 
longitudinal and cohort analysis. British Journal of Addiction,~ 
77. 
Fillmore, K.M. (1987b). Women's drinking across the adult life course as 
compared to men's: A longitudinal and cohort analysis. British 
Journal of Addiction,?b 80-111. 
FilJmore, K.M., & Kelso, D. (1987). Coercion into alcoholism treatment: 
Meanings for the disease concept of alcoholism. Journal of Drug 
Issues, lZ, 301-319. 
Fillmore, K.M., & Midanik, L. (1984). Chronicity of drinking problems 
among men: A longitudinal study. Journal of Studies on Alcohol, 
~ 228-236. 
Fillmore, K.M., & Sigvardsson, 5. (1988). "A meeting of the minds'' - A 
challenge to biomedical and psychosocial scientists on the ethical 
implications and social consequences of scientific findings in the 
alcohol field. British Journal of Addictions, 83 ? 609-61 I. 
Fingarette, H. (1989, Spring). A rejoinder to Madsen. The Public Interest, 
~ 118-121. 
227 
Fingarette, H. (1988). Heavy drinking: The myth of alcoholism as a 
disease. Berkeley: University of California Press. 
Fingarette, H. (1985a). Alcoholism - neither sin nor disease. The Center 
Magazine, lli, 56-63. 
Pingarette, H. (1985b). What is alcoholism? Afterword. The Center 
Magazine, lib 43-44. 
Fingarette, H. (1985c). Alcoholism and self-deception. In M.W. Martin 
(Ed.), Self-deception and self-understanding: New essays in 
philosophy and psychology (pp. 52-67). Lawrence, KS.: University 
of Kansas Press. 
Fingarette, H. (1975). Addiction and criminal responsibility. The Yale Law 
Journal,~ 413-444. 
Friedman, L., & Shapiro, 0. (Producers), & Mazur, A. (Executive Director). 
(1989). Thomas Szasz "nd the myth of mental illness [Film], 
Syracuse, N.Y.: Maxwell Graduate School of Citizenship and Public 
Affairs, Syracuse University. 
Gelernter, J., O'Malley, S., Risch, N., Kranzler, H.R., Krystal, J., Merikangas, 
K., Kennedy, J.L., & Kidd, K.K. (1991). No association between an 
allele at the D2 dopamine receptor gene (D2R2) and alcoholism. 
Journal of the American Medical Association, 266, 1801-1807. 
Gelman, D., Leonard, E.A., &: Fisher, B. (1991, July 8}. Clean and sober-And 
agnostic. Newsweek, 62-63. 
Gerhardt, U. (1989). Ideas about illness: An intellectual and political 
history of medical sociology. New York: New York University 
Press. 
Glaser, F.B. (1985). What is alcoholism? Treatment must be carefully 
matched to each individual. The Center Magazine. IB, 36-37. 
228 
Glaser, F.B. (1980). Anybody got a match? Treatment research and the 
matching hypothesis. In G. Edwards and M. Grant (Eds.) 
Alcoholism treatment in transition (pp. 178-196). Baltimore, Md.: 
University Park Press. 
Glaser, F.B., & Skinner, H.A. (1981). Matching in the real world: A 
practical approach. In E. Gottheil, A.T. Mclellan, & K.A. Druley 
Matching patient needs and treatment methods in alcoholism and 
drug abuse (pp. 295-324). Springfield, Ill.: Charles C. Thomas. 
Glassner, B., & Berg, B. (1984). Social locations and interpretations: How 
Jews define alcoholism. Journal of Studies on Alcohol,~ 16-25. 
Glassner, B., & Berg, B. (1980). How Jews avoid alcohol problems. 
American Sociological Review.~ 647-664. 
Goldfried, M.R., & Robins, C. (1982). On the facilitation of self-efficacy. 
Cognitive Therapy and Research, 2, 361-380. 
Goodwin, D.W. (1988). Is alcoholism hereditary? New York: Ballantine. 
Goodwin, D.W., Schulsinger, F., Hermansen, L., Guze, S.B., & Winokur, G. 
(1973). Alcohol problems in adoptees raised apart from alcoholic 
biological parents. Archives of General Psychiatry,~ 238-243. 
Goodwin, F.K. (1988). Alcoholism research: Delivering on the promise. 
Public Health Reports. lQJ, 569-574. 
Goodwin, F.K., Gordis, E., Hardison, D.L., & Hennigan, L.P. (1988, 
November 5). Alcoholism most certainly is a disease [Letters to the 
editor]. The Washington Post. p. A21. 
Goodyear, B. (1989). Unresolved questions about alcoholism: The debate 
(war?) goes on-Is a resolution possible? Alcoholism Treatment 
Quarterly.  .6., 1-27. 
229 
Gordis, E., Tabakoff, B., Goldman, D., & Berg, K. (1990). Finding the gene(s) 
for alcoholism. Journal of the American Medical Association, 263, 
2094-2095. 
Gorman, D.M. (1990). Is 'disease model' an appropriate term to describe 
the alcohol dependence syndrome? Alcohol and Alcoholism, 21, 
509-512. 
Gorman, D.M. (1989). Is the 'new' problem drinking concept of Heather 
and Robertson more useful in advancing our scientific knowledge 
than the 'old' disease concept? British Journal of Addiction, M:, 843-
845. 
Goss, A., & Morosko, T.E. (1970). Relation between a dimension of 
internal-external control and the MMPI with an alcoholic 
population. Journal of Consulting and Clinical Psychology,~ 189-
192. 
Gottheil, E., Corbett, L.O., Grassburger, J.C., & Cornelison, F.S. (1972). Fixed 
interval drinking decisions, l: A research and treatment model. 
Quarterly Journal of Studies on Alcohol,~ 311-324. 
Gottheil, E., Crawford, H.D., & Cornelison, F.5. (1973a). The alcoholic's 
ability to resist available alcohol. Diseases of the Nervous System, ll, 
80-84. 
Gottheil, E., Alterman, A., Skoloda, T.E., & Murphy, B.F. (1973b). 
Alcoholics' patterns of controlled drinking. American Journal of 
Psychiatry, 130, 418-422. 
Gozali, J., & Sloan, J. (1971). Control orientation as a personality dimension 
among alcoholics. Quarterly Journal of Studies on Alcohol, ll, 159-
161. 
230 
Greil, A.L. & Rudy, D.R. (1983). Conversion to the world view of 
Alcoholics Anonymous: A refinement of conversion theory. 
Qualitative Sociology, 2., 5-28. 
Grob, G.N. (Ed.) (1981). Nineteenth-century medical attitudes toward 
alcoholic addiction: Six studies, 1814-1867. New York: Arno Press. 
Gross, W.F., & Nerviano, V.J. (1972). Note on the control orientation of 
alcoholics. Psychological Reports. ~ 406. 
Gurin, P., Gurin, G., Lao, R.C., & Beattie, M. (1969). Internal-external 
control in the motivational dynamics of Negro youth. Journal of 
Social Issues, ~ 29-53. 
Gusfield, J. R. (1963). Symbolic crusade: Status politics and the American 
Temperance Movement. Urbana, Ill.: University of Illinois Press. 
Harcum, E.R. (1991). Behavioral paradigm for a psychological resolution 
of the free will issue. The Journal of Mind and Behavior, .ll, 93-114. 
Harrison, J.A., Mullen, P.D., & Green, L.W. (1992). A meta-analysis of 
studies of the H ealth Belief Model with adults. Health Education 
Research, Theory. & Practice. L 107-116. 
Hartke, R.J., & Kunce, J.T. (1982). Multidimensionality of health-related 
locus-of-control-scale items. Journal of Consulting and Clinical 
Psychology, ~ 594-595. 
Haynes, P., & Ayliffe, G. (1991). Locus of control of behaviour: is high 
extemality associated with substance misuse? British Journal of 
Addiction, ~ 1111-1117. 
Heath, A.C., Meyer, J., Eaves, L.J., & Martin, N.G. (1991a). The inheritance 
of alcohol consumption patterns in a general population twin 
sample: I. Multidimensional scaling of quantity /frequency data. 
Journal of Studies on Alcohol. g 345-351. 
231 
Heath, A.C., Meyer, J., Jardine, R. & Martin, N.G. (1991b). The inheritance 
of alcohol consumption patterns in a general population twin 
sample: II. Determinants of consumption frequency and quantity 
consumed. Journal of Studies on Alcohol.~ 345-351. 
Heather, N. (1992). Addictive disorders are essentially motivational 
problems. British Journal of Addiction.~ 828-830. 
Heather, N., & Robertson, I. (1989). Problem drinking (2nd ed.). New 
York: Oxford University Press. 
Heather, N., & Robertson, I. (1981). Controlled drinking. London: 
Methuen. 
Heather, N., Winton, M., & Rollnick, S. (1982). An empirical test of 'a 
cultural delusion of alcoholics'. Psychological Reports. ~ 379-382. 
Herd, D. (1989). The epidemiology of drinking patterns and alcohol-
related problems among U.S. Blacks. In Alcohol use among U.S. 
Ethnic Minorities (pp. 3-50). Rockville, Md.: National Institute on 
Alcohol Abuse and Alcoholism. 
Hershon, H. (1974). Alcoholism and the concept of disease. British 
Iournal of Addiction. 6-2, 123-131. 
Hill, K.J., & Larson, L.M. (1992). Attributional style in the reformulated 
learned helplessness model of depression: Cognitive processes and 
measurement implications. Cognitive Therapy and Research, 1.?., 83-
94. 
Hill, S.Y., Goodwin, D.W., Cadoret, R., Osterland, C .K., & Doner, S.M. 
(1975). Association and linkage between alcoholism and eleven 
serological markers. Journal of Studies on Alcohol, ~ 981-992. 
Horton, P.C. (1973). The mystical experience as a suicide preventive. 
American Journal of Psychiatr:x, 130, 294-296. 
232 
Institute of Medicine. (1990). Broadening the base of treatment for alcohol 
12roblem s. Washington, D.C.: National Academy Press. 
Jackson, D.N. (1967). Manual for the personality research form. Goshen, 
N.Y.: Research Psychologists Press. 
Jellinek, E.M. (1960). The disease concept of alcoholism. New Haven, 
Conn.: Hillhouse Press. 
Jellinek, E.M. (1952). The phases of alcohol addiction. Quarterly Tournal of 
Studies on Alcohol, U 673-684. 
Jellinek, E.M. (1946). Phases in the drinking history of alcoholics: Analysis 
of a survey conducted by the official organ of Alcoholics 
Anonymous. Quarterly Journal of Studies on Alcohol, Z, 1-88. 
Jessor, R. (1958). The problem of reductionism in psychology. 
Psychological Review,~ 170-178. 
Joe, V.C., Miller, P.M., & Joe, J.K. (1979). Uncontrollability and psychiatric 
symptoms. Psychological Reports, ~ 333-334. 
Jones, R.K. (1970). Sectarian characteristics of Alcoholics Anonymous. 
Sociology: The Journal of the British Sociological Association, .4., 
181-195. 
Kazdin, A.E. (1978). Conceptual and assessment issues raised by self-
efficacy theory. Advances in Behavior Research and Therapy, 1, 177-
185. 
Kegan, R. (1982). The evolving self: Problem and process in human 
development. Cambridge, MA.: Harvard University Press. 
Keller, M. (1982). On defining alcoholism: With comment on some other 
relevant words. In E.L. Gomberg, H.R. White, & J.A. Carpenter 
(Eds.), Alcohol, Science and Society Revisited (pp. 119-133). Ann 
Arbor, Ml.: The University of Michigan Press. 
233 
Keller, M. (1976). The disease concept of alcoholism revisited. Journal of 
Studies on Alcohol,~ 1694-1717. 
Keller, M. (1972). On the loss-of-control phenomenon in alcoholism. 
British Journal of Addiction, fiL 153-166. 
Kendell, R.E. (1979). Alcoholism: a medical or a political problem? 
British Medical Journal, 1, 367-371. 
Kendell, R.E. (1965). Normal drinking by former alcohol addicts. 
Quarterly Journal of Studies on Alcohol, ~ 247-257. 
Kendler, K.S., Heath, A.C., Neale, M.C., Kessler, R.C., & Eaves, L.J. (1992). 
A population-based twin study of alcoholism in women. Journal of 
the American Medical Association, 268, 1877-1882. 
Kepner, E. (1964). Application of learning theory to the etiology and 
treatment of alcoholism. Quarterly Journal of Studies on 
Alcoholism, ~ 279-291. 
Kingham, R.J. (1958). Alcoholism and reinforcement theory of learning. 
Quarterly Journal of Studies on Alcohol, 12, 320-330. 
Kirkpatrick, J. (1986). Goodbye hangovers, hello life: Self-help for women. 
New York: Ballantine. 
Kirsch, I. (1985). Self-efficacy and expectancy: Old wine with new labels. 
Journal of Personality and Social Psychology, 12, 824-830. 
Kirscht, J.P. (1972). Perceptions of control and health beliefs. Canadian 
Journal of Behavioral Science, i, 225-237. 
Kissin, B. (1983). The disease concept of alcoholism. In R.G. Smart, F.B. 
Glaser, Y. Israel, H. Kalant, RE. Popham, & W. Schmidt (Eds.), 
Research advances in alcohol and drug problems, Z (pp. 93-126). 
New York: Plenum Press. 
234 
Kj0lstad, Th. (1974). Alcoholism-an illness. British Journal of 
Addiction, 22., 133-136. 
Kia usner, s.z. (1964). Sacred and profane meanings of blood and alcohol. 
The Journal of Social Psychology, ~ 27-43. 
Kurtz, E. (1988). A.A.: The Story (A revised edition of Not-God: A history 
of Alcoholics Anonymous). New York: Harper & Row. 
Kurtz, E. & Ketcham, K. (1992). The spirituality of imperfection: Modern. 
wisdom from classic stories. New York: Bantam. 
Lau, R.R. (1982). Origins of health locus of control beliefs. Journal of 
Personality and Social Psychology, 11, 322-334. 
Lau, R.R., & Ware, J.E., Jr. (1981). Refinements in the measurement of 
health-specific locus-of-control beliefs. Medical Care, 12, 1147?1158. 
Leach, B. & Norris, J.L. (1977). Factors in the development of Alcoholics 
Anonymous (A.A,). In B. Kissin and fl. Begleiter (Eds.), Treatment 
and rehabilitation of the chronic alcoholic: The biology of 
alcoholism, volume 5 (pp. 441-543). New York: Plenum Press. 
Lender, M.E. & Karnchanapee, K.R. (1977). "Temperance Tales": 
Antiliquor fiction and American attitudes toward alcoholics in the 
late 19th and early 20th centuries. Iournal of Studies on Alcohol,~ 
1347-1370. 
Lester, D. (1989). The heritability of alcoholism: Science and social policy. 
Drugs & Society,~ 29-67. 
Levenson, H. (1973). Multidimensional locus of control in psychiatric 
patients. Journal of Consulting and Clinical Psychology, fl, 397-404. 
Levenson, H. (1974). Activism and powerful others: Distinctions within 
the concept of internal-external control. Tournal of Personality 
Assessment.~ 377-383. 
235 
Levenson, H. (1975). Multidimensional locus of control in prison 
inmates. Tournal of Applied Social Psychology, 2, 342-347. 
Levin, J.S., & Tobin, S.S. (in press). Religion and psychological well-being. 
In M.A. Kimble, S.H. McFadden, J.W. Ellor, & J.J. Seeber (Eds.), 
Religion and aging: A handbook. Minneapolis, MN.: Fortress 
Press. 
Levin, J.S., & Vanderpool, H.Y. (1991). Religious factors in physical health 
and the prevention of illness. Prevention in Human Services, 2, 41-
64. 
Levin, J.S., & Vanderpool, H.Y. (1989). Is religion therapeutically 
significant for hypertension? Social Science and Medicine,~ 69-78. 
Levin, J.S., Jenkins, C.D., & Rose, R.M. (1988). Religion, Type A behavior, 
and Health. Journal of Religion and Health,~ 267-278. 
Levin, J.S., & Schiller, P.L. (1987). Is there a religious factor in health? 
Journal of Religion and Health,~ 9-36. 
Levin, J.S., & Schiller, P.L. (1986). Religion and the multidimensional 
health locus of control scales. Psychological Reports, 2.2_., 26. 
Levine, H.G. (1984). The alcohol problem in America: From Temperance 
to alcoholism. British Journal of Addiction, 22, 109-119. 
Levine, H.G. (1978). The discovery of addiction: Changing conceptions of 
habitual drunkenness in America. Journal of Studies on Alcohol, 
~ 143-174. 
Liebe.r, C.S. (1990). Alcoholism: A disease of internal medicine. Journal of 
Studies on Alcohol, 21, 101-102. 
Lifton, R.J. (1961). Thought reform and the psychology of totalisrn: A 
study of ''brainwashing" in China. New York: Norton. 
236 
Ludenia, K., & Russell, S.F. (1983). The relationship between health locus 
of control beliefs and the MMPI with an alcoholic population. 
Journal of Clinical Psychology. ~624-627. 
Ludwig, A.M. & Wikler, A. (1974). "Craving" and relapse to drink. 
Quarterly Journal of Studies on Alcohol,~ 108-130. 
Luff, E. (1989). The First Amendment and drug alcohol treatment 
programs: To what extent may coerced treatment programs attempt 
to alter beliefs relating to ultimate concerns and self concept? In A.S. 
Trebach & K.B. Zeese (Eds.) Drug policy 1989-90: A reformer's 
catalogue (pp. 262-266). Washington, 0.C.: Drug Policy Foundation. 
MacAndrew, C., & Garfinkel, H. (1962). A consideration of changes 
attributed to intoxication as common-sense reasons for getting 
drunk. Quarterly Journal of Studies on Alcohol,~ 252-266. 
Maddux, J.E., Sherer, M., & Rogers, R.W. (1982). Self-efficacy expectancy 
and outcome expectancy: Their relationship and their effects on 
behavioral intentions. Cognitive Therapy and Research, ?_, 207-211. 
Madsen, W., Berger, D., Bremy, F.R., & Mook, D.G. 0990). Alcoholism a 
myth? Skeptical Inquirer: Tournal of the Committee for the 
Scientific Investigations of the Paranormal. .li., (Summer), 440-442. 
Madsen, W . (1989). Thin thinking about heavy drinking. The Public 
Interest,~ Spring, 112-118. 
Madsen, W. (1988). Defending the disease: From facts to Fin~arette. 
Akron, Ohio: Wilson, Brown & Co. 
Madsen, W. (1985). What is alcoholism? Therapy often has high rate of 
success. The Center Magazine, lli, 36-37. 
237 
Maisto, S.A., Connors, G.J., & Sachs, P.R. (1981). Expectation as a mediator 
in alcohol intoxication: A reference level model. Cognitive 
Therapy and Research,~ 1-18. 
Makela, K. (1991). Social and cultural preconditions of Alcoholics 
Anonymous (AA) and factors associated with the strength of AA. 
British Journal of Addiction,~ 1405-1413. 
Maltzman, I. (1991). Is alcoholism a disease? A critical review of a 
controversy. Integrative Physiological and Behavioral Science,~ 
200-210. 
Marlatt, G. A., & Gordon, J.R. (1985). Relapse prevention: Maintenance 
strategies in the treatment of addictive behaviors. New York: The 
Guilford Press. 
Marlatt, G.A. (1983). The controlled-drinking controversy: A 
commentary. American Psychologist, :IB., 1097-1110. 
Marlatt, G. A., Deming, B., & Reid, J.B. (1973). Loss-of-control drinking in 
alcoholics: An experimental analogue. Journal of Abnormal 
Psychology, fil, 233-241. 
Marshall, G.N., Collins, B.E., & Crooks, V.C. (1990). A comparison of two 
multidimensional health locus of control instruments. Journal of 
Personality Assessment, 54(1 & 2), 181-190. 
McBride, J.L. (1991). Abstinence among members of Alcoholics 
Anonymous. Alcoholism Treatment Quarterly,?., 113-121. 
McClelland, D.C. (1972). Examining the research basis for alternative 
explanations of alcoholism. In D.C. McClelland, W.N. Davis, R. 
Kalin, and E. Wanner (Eds.) The drinking man: Alcohol and 
human m otivation . (PP.? 276-315). New York: Free Press. 
238 
McClelland, D.C., Davis, W .N ., Kalin, R., & Wanner, E. (1972). The 
drinking man: Alcohol and human motivation. New York: 
Free Press. 
McGrath, E., Keita, G.P., Strickland, B.R., & Russo, N.F. (1990). 
Women and depression: Risk factors and treatment issues: 
Final report of the American Psychological Association Task 
Force on Women and Depression. Washington, D.C.: 
American Psychological Association. 
Md:;ue, M., Pickens, R.W., Svikis, D.S. (1992). Sex and age effects on 
the inheritance of alcohol problems: A twin study. Tournal of 
Abnormal Psychology, 101, 3-17. 
Mello, N.K., & Mendelson, J.H. (1972). Drinking patterns during work-
contingent and noncontingent alcohol acquisition. Psychosomatic 
Medicine, ~ 139-164. 
Merry, J. (1966). The 'loss-of-control' myth. Lancet, 1, 1257-58. 
Milam, J .R., & Ketcham, K. (1983). Under the Influence: A guide to the 
myths and realities of alcoholism. New York: Bantam. 
Miller, W.R. (1983). Controlled drinking: A history and critical review. 
Journal of Studies on Alcohol,~ 68-83. 
Miller, W.R., & Caddy, G.R. (1977). Abstinence and controlled drinking in 
the treatment of problem drinkers. Journal of Studies on Alcohol, 
~ 986-1003. 
Miller, N.S., & Gold, M.S. (1990). The disease and adaptive models of 
addiction: A re-evaluation. The Journal of Drui Issues, 20-1 29-35. 
Miller, N.S. & Mahler, J.C. (1991). Alcoholics Anonymous and the "AA" 
model for treatment. Alcoholism Treatment Quarterly, fl, 39-51. 
239 
Miller, P.M., & Mastria, M.A. (1977). Alternatives to alcohol abuse: A 
social learning model. Champaign, Ill.: Research Press. 
Mirels, H.L., & Garrett, J.B. (1971). The Protestant ethic as a personality 
variable. Journal of Consulting and Clinical Psychology,~ 40-44. 
Mitchell, J., & Stein, J. (Eds.). (1983). The Random House encyclopedia. 
New York: Random House. 
Morgenstern, J., & McCrady, B.S. (1992). Curative factors in alcohol and 
drug treatment: Behavioral and disease model perspectives. British 
Journal of Addiction, [Z, 901-912. 
Mulford, H.A., & Miller, D.E. (1964). Measuring public acceptance of the 
alcoholic as a sick person. Quarterly lo urnal of Studies on AlcohoL 
22, 314-323. 
Musto, D.F. (1991, July). Opium, cocaine, and marijuana in American 
history. Scientific American, 40-47. 
Musto, D.F. (1987). The American disease: Origins of narcotic control, 
expanded edition. New York: Oxford University Press. 
Noble, E.P., Blum, K., Ritchie, T., Montgomery, A., & Sheridan, P.J. (1991). 
Allelic association of the D2 dopamine receptor gene with receptor-
binding characteristics in alcoholism. Archives of General 
Psychiatry,~ 648-654. 
Nowicki, Jr., S., & Hopper, A.E. (1974). Locus of control correlates in an 
alcoholic population. Journal of Consulting and Clinical 
Psychology, 42., 735. 
O'Connell, T. (1991, November). Michigan historian: Spirituality at the 
heart of AA' s success. The U.S. Journal of Drug and Alcohol 
Dependence. ~ , 2. 
240 
Ojesjo, L. (1984) Risks for alcoholism by age and class among males: The 
Lundby Community Cohort, Sweden. In D.W. Goodwin, K.T. Van 
Dusen, & S. A. Mednick (Eds.), Longitudinal research in alcoholism 
(pp. 9-25). Boston: Kluwer-Nijhoff. 
O'Leary, A. (1992). Self-efficacy and health: Behavioral and stress-
physiological mediation. Cognitive Therapy and Research,~ 229-
245. 
O'Leary, M.R., Donovan, D.M., & Hague, W.H. (1974). Relationships 
between locus of control and MMPl with an alcoholic population. 
Journal of Consulting and Clinical Psychology, :H., 189-192. 
Orford, J. (1992). Davidson's dilemma. British Journal of Addiction,~ 
832-833. 
Overton, W.F., & Reese, H.W. (1973). Models of development: 
Methodological implications. In J.R. Nesselroade & H.W. Reese 
(Eds.), Life-span developmental psychology: Methodological issues 
(pp. 65-86). New York: Academic Press. 
Paredes, A., Hood, W.R., Seymour, H., & Gollob, M. (1973). Loss-of-control 
in alcoholism: An investigation of the hypothesis with 
experimental findings. Quarterly Journal of Studies on Alcohol, 34, 
1146-1161. 
Parsian, A., Todd, R.D., Devor, E.J., O'Malley, K.L., Suarez, B.K., Reich, T., 
Cloninger, C.R. (1991). Alcoholism and alleles of the human D2 
dopamine receptor locus: Studies of association and linkage. 
Archives of General Psychiatry,~ 655-663. 
Pattison, E.M., Sobell, M.B., & Sobel!, L.C. (1977). Ernergins concepts of 
alcolhol dependence. New York: Springer. 
241 
Pattison, E.M. (1976). Nonabstinent drinking goals in the treatment of 
alcoholics. In R.J. Gibbins, Y. Israel, H. Kalant, R.E. Popham, W. 
Schmidt, R.G. Smart (Eds.) Research Advances in Alcohol and Drug 
Problems Volume 3 (pp. 401-455). New York: Wiley & Sons. 
Pattison, E.M. (1966). A critique of alcoholism treatment concepts with 
special reference to abstinence. Quarterly Journal of Studies on, 
Alcohol, ll, 49-71. 
Peele, S. (1992). Alcoholism, politics, and bureaucracy: The consensus 
against controlled-drinking therapy in America. Addictive 
Behaviors, lZ, 49-62. 
Peele, S., Brodsky, A., & Arnold, M. (1991). The truth about addiction an_g 
recovery. New York: Simon & Schuster. 
Peele, S. (1990a). Behavior in a vacuum: Social-psychological theories of 
addiction that deny the social and psychological meanings of 
behavior. The Journal of Mind and Behavior, 1L 513-530. 
Peele, S. (1990b). Second thoughts about a gene for alcoholism. The 
Atlantic Monthly, 52-58. 
Peele, S. (1989). Diseasing of America: Addiction treatment out of control. 
Lexington, Mass.: Lexington Books. 
Peele, S. (1988a). Can alcoholism and other drug addiction problems be 
treated away or is the current treatment binge doing more harm 
than good? Journal of Psychoactive Drugs,~ 375-383. 
Peele, S. (1988b). The meaning of addiction: Compulsive experience and 
its interpretation. Lexington, Mass.: D.C Heath. 
Peele, S. (Ed.). (198&). Visions of addiction. Lexington, MA.: D.C. Heath. 
? 
242 
Peele, S. (1986). The implications and limitations of genetic models of 
alcoholism and other addictions. Journal of Studies on Alcohol. 1Z, 
63-74. 
Peele, S. (1981 ). Reductionism in the psychology of the eighties: Can 
biochemistry eliminate addiction, mental illness, and pain? 
American Psychologist.~ 807-818. 
Perls, F.S. (1947). Ego. hunger and aggression: A revision of Freud's 
theory and method. London: Allen & Unwin. 
Perls, F.S., Hefferline, R., & Goodman, P. (1951). Gestalt therapy: 
Excitement and growth in the human personality. New York: 
Julian Press. 
Pickens, R.W., Svikis, D.S., McGue, M., Lykken, D.T., Heston, L.L., & 
Clayton, P.J. (1991}. Heterogeneity in the inheritance of alcoholism. 
Archives of General Psychiatry,~ 19-28. 
Pomeroy, F.W. (1985). What is alcoholism? Denial of disease concept 
would be devastating. The Center Magazine, 18. 42-43. 
Prince, J.M., Glatt, M.M., Pullar-Strecker, H. (1966, June 25). The "loss of 
control" myth. The Lancet, 1423-1424, [Letters to the Editor). 
Prochaska, J.O., DiClemente, C.C., Velicer, W.F., & Rossi, J.S. (1992). 
Comments on Davidson's 'Prochaska and DiClemente's model of 
change: A case study? British Journal of Addiction,~ 825-835. 
Prochaska, J.O., & DiClemente, C.C. (1986). Toward a comprehensive 
model of change. In W.R. M,iller and N. Heather (Eds.), Treating 
Addictive Behaviors (pp. 3-27). 
Rather, B.C. (1991). Disease versus social-learning models of alcoholism in 
the prediction of alcohol problem recognition, help-seeking, and 
s tigma. Journal of Drug Education,~ 119-132. 
243 
Reznek, L. (1987). The nature of disease. New York: Routledge & Kegan 
Paul Ltd. 
Rice, O.R. (1944). The contribution of the minister to the treatment of the 
alcoholic. Quarterly Journal of Studies on Alcohol, ~ 250-256. 
Ripley, H.S. & Jackson, J.K. (1959). Therapeutic factors in Alcoholics 
Anonymous. The American Journal of Psychiatry, 11?., 44-50. 
Rippere, V. (1980). More historical dimensions of commonsense 
knowledge: Spiritual consolation for the depressed. Behavioural 
Research & Therapy, ~ 549-563. 
Ritchie, O.W. (1948). A sociohistorical survey of Alcoholics Anonymous. 
Quarterly Journal of Studies on Alcohol, 2, 119-156. 
Robins, L. N. (1978). The interaction of setting and predisposition in 
explaining novel behavior: Drug initiations before, in, and after 
Vietnam. In D.B. Kandel (Ed.), Longitudinal research on drug use: 
Empirical findings and methodological issues (pp. 179-196). New 
York: John Wiley & Sons. 
Robins, L.N., Helzer, J.E., & Davis, D. (1975). Narcotic use in Southeast 
Asia and afterward: An interview study of 898 Vietnam returnees. 
Archives of General Psychiatry,~ 955-961. 
Robinson, D. (1972). The akohologist's addiction: Some implications of 
having lost control over the disease concept of alcoholism. 
Quarterly Journal of Studies on Alcoholism, ~ 1028-1042. 
Rohsenow, D. J., & O'Leary, M.R. (1978). Locus of control research on 
alcoholic populations: A review. I. Development, scales, and 
treatment. The International Journal of the Addictions, la, 55-78. 
244 
Roizen, R. (1987). The great controlled-drinking controversy. In M. 
Galanter (Ed.), Recent developments in alcoholism. Vol. 5, (pp. 245-
279). New York: Plenum Press. 
Roizen, R., Cahalan, D., & Shanks., P. (1978}. "Spontaneous remission" 
among untreated problem drinkers. In D.B. Kandel (Ed.), 
Longitudinal research on drug use: Empirical findinis and 
methodological issues (pp. 197-221). New York: John Wiley & Sons. 
Room, R. (1989). Alcoholism and Alcoholics Anonymous in U.S. films, 
1945-1962: The party ends for the "wet generations." Journal of 
Studies on Alcohol, ~ 368-383. 
Room, R. (1988). The Movies and the Wettening of America: The media 
as amplifiers of cultural change. British Journal of Addiction,~ 11-
18. 
Room, R. (1985). What is alcoholism? Not sure "way of life" concept 
helps the situation. The Center Magazine, ~ 38-41. 
Room, R. (1983). Sociological aspects of the disease concept of alroholism. 
In R.G. Smart, F.B. Glaser, Y. Israel, H. Kalant, R.E. Popham, & W. 
Schmidt (Eds.), Research advances in alcohol and drug problems. 'Z. 
(pp. 47-91). New York: Plenum Press. 
Rosenstock, l.M., Strecher, V .J., & Becker, M.H. (1988). Social learning 
theory and the Health Belief Model. Health Education Quarterly, ti, 
175-183. 
Rotter, J.B. (1966). Generalized expectancies for internal versus external 
control of reinforcement. Psychological Monographs: General and 
Applied, fill, Whole No. 609, 1-28. 
245 
Rotter,  J? B ?  (1960) ? Some implications of a social learning the ory f or the 
prediction of goal directed behavior from testing procedures. 
Psychological Review,~ 301-316. 
Rotter, J.B. (1954). Social learning and clinical psychologx. Englewood 
Cliffs, New Jersey: Prentice-Hall. 
Rush, B. (1981). An inquiry into the effects of ardent spirits upon the 
human body and mind, with an account of the means of . 
preventing 
and of the remedies for curing them, (Eighth ed.). In G. N. Grob 
(Ed.), Nineteenth-century medical attitudes toward alcoholic 
addiction: Six studies, 1814-1867. New York: Arno. (Reprinted 
from Brookfield, Mass.: E. Merriam & Co., 1814) 
Rush, B. (1799). Observations intended to favour a supposition that the 
black Color (as it is called) of the Negroes is derived from the 
LEPROSY. Transactions of the American Philosophical Society, 1, 
289-297. 
Sadler, P.O. (1977). The "Crisis Cult" as a voluntary association: an 
interactional approach to Alcoholics Anonymous. Human 
Organization,~ 207-210. 
Sanchez-Craig, M., Annis, H.M., Bornet, A.R., & MacDonald, K.R. (19B4). 
Random assignment to abstinence and controlled drinking: 
Evaluation of a cognitive-behavioral program for problem drinkers. 
Journal of Consulting and Clinical Psychology. 2b 390-403. 
Schaler, J.A. (in press). Response to Kendler et al. Unpublished letter . 
Schaler, J.A. (1992). In Jeffrey A. Schaler, (Chair) Assessing Treatment 
Effectiveness. November 14, 1992: Sixth International Conference 
on Drug Policy Reform, Drug Policy Foundation, Loew's L'Enfant 
Plaza Hotel, Washington, D.C. 
246 
Schaler, J.A. (1991a). Locus of control and drinking control: Beliefs of 
treatment providers. [Unpublished manuscript.] 
Schaler, J.A. (1991b). Drugs and free will. Transaction Social Science and 
Modern Society,~ 42-49. 
Schaler, J.A. (1990a). Alcoholism, disease or not? Skeptical Inquirer: 
Journal of the Committee for the Scientific Investigation of Claims 
of the Paranormal, 12., (Fall), 108. 
Schaler, J.A. (1990b). Alcoholism, disease, and myth [Review of Heavy 
drinking: The myth of alcoholism as a disease]. Skeptical Inquirer: 
Journal of the Committee for the Scientific Investigation of Claims 
of the Paranormal, H, (Winter), 198-201. 
Schaler, J.A. (1989a). Alcoholism as willful misconduct. Journal of the 
American Medical Association, 261, 864-865. 
Schaler, J.A. (1989b). Truth, Traynor and McKelvey: Politics and the 
alcoholism controversy. In A.S. Trebach & K.B. Zeese (Eds.) Drug 
policy 1989-1990: A reformer's catalo~e (pp. 249-261). Wash., D.C.: 
Drug Policy Foundation. 
Schaler, J.A. (1989c). Drug use is a choice, not a disease. The Washington 
Post, June 26, Al0. 
Schaler, J.A. (1989d, December 30). Racist trends in drug policy. The 
Washington Afro-American, p. A4. 
Schaler, J.A. (1988). Alcoholism is not a disease. The Washington Post, 
October 25, A2.6. 
Schiller, P.L., & Levin, J.S. (1988). Is there a religious factor in health care 
utilization?: A review. Social Science and Medicine, ZZ, 1369-1379. 
247 
Schuckit, M.A, Goodwin, D.A., & Winokur, G. (1972). A study of 
alcoholism in half siblings. American Journal of Psychiatry, ill, 
123-127. 
Seeman, M., & Evans, J.W. (1962). Alienation and learning in a hospital 
setting. American Sociological Review,~ 772-783. 
Segal, D. (Ed.). (1987). Perspectives on person-environment interaction 
and drug-taking behavior. Drugs & Societ~ ~-
Seligman, M.E. (1975). Helplessness: On depression, development, and 
death. New York: Freeman and Co. 
Sells, S.B. (1981). Matching clients to treatments: Problems, preliminary 
results, and remaining tasks. In E. Gottheil, A.T. McLellan, & K.A. 
Druley Matching patient needs and treatment methods in 
alcoholism and drug abuse (pp. 33-50). Springfield, Ill.: Charles C. 
Thomas. 
Sessions, P.M. (1957). Ego religion and superego religion in alcoholics. 
Quarterly Journal of Studies on Alcohol, la., 121-125. 
Sexton, T.L., Ruckman, B.W., & Crehan, K. (1992). An investigation of the 
patterns of self-efficacy, outcome expectation, outcome value, and 
performance across trials. Cognitive Therapy and Research.~ 329-
348. 
Sherman, M.F., Pelletier, R.J., & Ryckman, R.M. Cl 973). Replication of the 
relationship between dogmatism and locus of control. Psychological 
Reports,~ 749-750. 
Shipley, W.C. (1940). Hartford Retreat Scale for measuring intellectual 
impairment: manual for directions and scoring ke_y. Hartford, 
Conn.: Neuro-psychiatric Institute of the Hartford Retreat. 
248 
Shoben, E.J., Jr. (1956). Views on the etiology of alcoholism. II. The 
behavioristic view. In H.D. Kruse (Ed.) Alcoholism as a medkal 
problem (pp. 47-55). New York: Hoeber-Harper. 
Siegel, R.K (1990, March 15). It's a drive as natural as food or sex. Los 
Angeles Times, p. B7. 
Siegel, R.K. (1989). Intoxication: Life in pursuit of artificial paradise. New 
York: E.P. Dutton. 
Siegel, R.K. (1984). Cocaine and the privileged class: A review of historical 
and contemporary images. Advances in Alcohol and Substance 
Abuse, i, 37-49. 
Siegler, M., Osmond, H., & Newell, S. (1968). Models of alcoholism. 
Quarterly Journal of Studies on Alcoholism,~ 571-591. 
Skolnick, J.H. (1958). Religious affiliation and drinking behavior. 
Quarterly Journal of Studies on Alcohol.~ 452-470. 
Smith, C.A., Dobbins, C., & Wallston, KA. (1991). The mediational role of 
perceived competence in adaptation to rheumatoid arthritis. 
Journal of Applied Social Psychology, ll, 1218-1247. 
Smith, M.S., & Wallston, KA. (1992). How to measure the value of 
health. Health Education Research, Theory. and Practice, Z, 129-135. 
Sobell, L.C., Sobell, M.B., & Christelman, W.C. (1972). The myth of "one 
drink." Behavioural Research and Therapy.1.Q, 119-123. 
Solomon, KE. & Annis, H.M. (1989). Development of a scale to measure 
outcome expectancy in alcoholics. Cognitive Therapy and Research, 
1J, 409-421. 
Solomon, R.L., & Corbit, J.D. (1974). An opponent-process theory of 
motivation: I. Temporal dynamics of affect. Psychological Review, 
fil., 119-145. 
? 
249 
Spotts, J.V., & Shontz, F.C. (1980). Cocaine users: A representative case 
approach . New York: Free Press. 
Stall, R. (1986). Respondent-independent reasons for change and stability 
in alcohol consumption as a concomitant of the aging process. In 
C.R. Janes, R. Stall, & S.M. Gifford (Eds.), Anthropology and 
epidemiology: Interdisciplinary approaches to the study of health 
and disease (p. 293). Boston: D. Reidel. 
Stedman, T.L. (1976). Stedman's medical dictionary illustrated. Twenty-
third edition. Baltimore, Md.: Williams & Wilkins Co. 
Stewart, D.A. (1954). The dynamics of fellowship as illustrated in 
Alcoholics Anonymous. Quarterly Journal of Studies on Alcohol, 
1?, 251-262. 
Stockwell, T. (1992). Models of change, heavenly bodies and 
weltanschauungs. British Journal of Addiction, 8.2, 830-831. 
Strassberg, D.S., & Robinson, J.S. (1974). Relationship between locus of 
control and other personality measures in drug users. Journal of 
Consulting and Clinical Psychology, ~ 744-745. 
Strecher, V.J., McEvoy DeVellis, B., Becker, M.H., Rosenstock, I.M. (1986). 
The role of self-efficacy in achieving health behavior change. Health 
Education Quarterly, U., 73-91. 
Swenson, P.R., Struckman-Johnson, D.L, Ellingstad, V.S., Clay, T.R., & 
Nichols, J.L. (1981). Results of a longitudinal evaluation of court-
mandated DWI treatment programs in Phoenix, Arizona. Journal of 
Studies on Alcohol, g 642,-653. 
Szasz, T.S. (1991). The myth of treatment. The Drug Policy Letter,~ (4) 3-
4. 
? 
250 
Szasz, T.S. (1989, October). [Interview with Andrew Meacham, associate 
editor of U.S. Journal periodicals, Thomas Szasz: The politics of 
addiction]. Focus Magazine, pp. 10-13. 
Szasz, T.S. (1987). Insanity: The idea and its consequences. New York: 
John Wiley & Sons. 
Szasz, T.S. (1985). Ceremonial chemistry: The ritual "ersecution of drugs,, 
addicts. and pushers. Holmes Beach, FL.: Learning Publications. 
Szasz, T.S. (1973). The ethics of addiction. Harper's Magazine, April, pp. 
74-79. 
Szasz, T. S. (1972, July 8). Bad habits are not diseases. Lancet. 83-84. 
Szasz, T.S. (1970). The manufacture of madness: A com"arative study of 
the Inquisition and the mental health movement. New York: 
Harper & Row. 
Szasz, T.S. (1965). The ethics of psychoanalysis: The theory and method of 
autonomous psychotherapy. New York: Basic Books. 
Tabakoff, B., & Hoffman, P. (1988). Genetics and biological markers of risk 
for alcoholism. Public Health Reports, 103, 690M698. 
Takamine, J. (1985). What is alcoholism? Disease, not stubbornness, is 
what destroys life. The Center Magazine, ll!, 41-42. 
Thompson, H.S. & Maxwell, M.A. (Ed.). (1952). An experience of a 
nonalcoholic in Alcoholics Anonymous leadership. Ouarterl~ 
Journal of Studies on Alcohol, Th 271-295. 
Thune, C.E. (1977). Alcoholism and the archetypal past: A 
phenomenological perspective on Alcoholics Anonymous. Journfil 
of Studies on Alcohol, ~ 75-88. 
Tiebout, H.M. (1961). Alcoholics Anonymous-An experiment of nature. 
Quarterly Journal of Studies on Alcohol, U, 52-68. 
? 
251 
Tiebout, H.M. (1953). Surrender versus compliance in therapy: With 
special reference to alcoholism. Quarterly Journal of Studies on 
Alcohol, 1!, 58-68. 
Travis, C.B. (1988). Women and health psychology: Biomedical issues. 
Hillsdale, N.J.: Lawrence Erlbaum Associates. 
Trice, H.M. (1959). The affiliative motive and readiness to join Alcoholics 
Anonymous. Quarterly Journal of Studies on Alcohol, 2.Q, 313-320. 
Trice, H.M. (1957). A study of the process of affiliation with Alcoholics 
Anonymous. Quarterly Journal of Studies on Alcohol, ..IB., 39-54. 
Trimpey, J. (1989). Rational recovery from alcoholism: The small book. 
3rd edition. Lotus, Ca.: Lotus Press. 
Trotter, T. (1813). An essay, medical, philosophical, a.nd chemical, on 
drunkenness. and its effects on the human body. Boston: Bradford 
& Read. 
Tuchfield, B. (1981). Spontaneous remission in alcoholics. Journal of 
Studies on Alcohol, 12, 626?41. 
Tyler, F.B., Gatz, M., & Keenan, K. (1979). A constructivist analysis of the 
Rotter 1-E scale. Journal of Personality, 1.Z 11-35. 
Vaillant, G.E. (1990, March). We should retain the disease concept of 
alcoholism. Harvard Medical School Mental Health Letter,?, 4-6. 
Vaillant, G.E. (1983). The natural history of alcoholism. Cambridge, Mass.: 
Harvard University Press. 
Vanderpool, J. A. (1969). Alcoholism and the self-concept. Quarter~ 
Journal of Studies on Alcohol, lQ, 59-77. 
Vanderpool, H.Y., & Levin, J.S. (1990). Religion and medicine: How are 
they related? Journal of Religion and Health,~ 9-20. 
ii 
252 
Vatz, RE., & Weinberg, L.S. (1990). The conceptual bind in defining the 
volitional component of alcoholism: Consequences for public policy 
and scientific research. The Journal of Mind and Behavior, 1.1.., 531-
544. 
Vatz, RE., & Weinberg, L.S. (1989, March 7). There's a new skepticism 
toward alcoholism as a disease. The Washington Post. p.WH6. 
Vatz, RE., & Weinberg, L.S. (1988). Correspondence. The New Eniland 
Journal of Medicine, 319, 179. 
Verbrugge, L.M. (1985). Gender and health: An update on hypotheses and 
evidence. Journal of Health and Social Behavior,~ 156-182. 
Verden, P., Jackson, D.N., & King, G.A. (1969). Popular conceptions of the 
etiology of alcoholism. Quarterly Journal of Studies on AicohQ}, ~ 
78-92. 
W., W. (1949). The society of Alcoholics Anonymous. The American 
Journal of Psychiatry, 106, 370-375. 
Wall, RE., Hinrichsen, G.A., & Pollack, S. (1989). Psychometric 
characteristics of the multidimensional health locus of control scales 
among psychiatric patients. Journal of Clinical Psychology,~ 94-98. 
Wallace, J. (1989a). Can Stanton Peele's opinions be taken seriously? A 
reply to Peele. Journal of Psychoactive Drug~~ 259-271. 
Wallace, J. (1989b). A biopsychosocial model of alcoholism. Social 
Casework: The Journal of Contemporary Social Work, Jun~ 325-332. 
Wallston, K .A . (1992). Hocus-pocus, the focus isn't strictly on locus: 
Rotter's Social Learning Theory modified for health. Co~nitiv~ 
Therapy and Research, 1,.Q, 183-199. 
Wallston, K.A., Smith, RA., King, J.E., Forsberg, P.R., Wallston, B.S., Nagy, 
V.T. (1983). Expectancies about control over health: Relationship to 
253 
desire for control of health care. Personality and Social Psychology 
Bulletin,~ 377-385. 
Wallston, KA., & Wallston, B.S. {1981). Health locus of control scales. In 
Herbert M. Lefcourt (Ed.) Research with the locus of control 
construct (Volume 1): Assessment methods (pp. 189-243). New 
York: Academic Press. 
Wallston, K.A., Wallston, B.S., & DeVellis, R. (1978). Development of the 
Multidimensional Health Locus of Control (MHLC) scales. Health 
Education Monographs, 2, 160-170. 
Wallston, KA., Maides, S., & Wallston, B.S. (1976). Health-related 
information seeking as a function of health related locus of control 
and health value. Tournal of Research in Personality,~ 215-222. 
Wallston, B.S., Wallston, KA., Kaplan, G.D., & Maides, S.A. (1976). 
Development and validation of the health locus of control (HLC) 
scale. Journal of Consultin~ and Clinical Psychology, H, 580-585. 
Wallston, B.S., & Wallston, K.A. (1973). Health care education programs: 
Training patient internality. Paper presented at the annual meeting 
of the American Public Health Association, San Francisco. 
Wanberg, KW., & Horn, J.L. (1970). Alcoholism symptom patterns of 
men and women: A comparative study. Quarterly Journal of 
Studies on Alcohol,~ 40-61. 
Weinberg, R., Gould, D., & Jackson, A. (1979). Expectations and 
performance: An empirical test of Bandura's self-efficacy theory. 
Journal of Sport Psycholo~y, 1320~331. 
Weisner, C.M. (1990). Coercion in alcohol treatment. In Institute of 
Medicine (Eds.) Broadening the base of treatment for alcohol 
problems (pp. 579-609). Washington, D.C.: National Academy Press. 
254 
Wheeler, L. (1990, October 11). 66% polled say addiction should be viewed 
as illness. The Washington Post, p. D7. 
Whitley, O.R. (1977). Life with Alcoholics Anonymous: The Methodist 
class meeting as a paradigm. Journal of Studies on Alcohol, 38, 831-
848. 
Wilson, B., & Jung, C.G. (1987, Summer). Spiritus contra spiritum: The 
Bill Wilson/C.G. Jung letters-the roots of the society of Alcoholics 
Anonymous. Parabola, 68-71. 
Wilson, G.T. (1978). The importance of being theoretical: A commentary 
on Bandura's "Self-efficacy: Towards a unifying theory of behavioral 
change." Advances in Behavior Research and Therapy, 1,. 217-230. 
Wolpe, J. (1978). Self-efficacy theory and psychotherapeutic change: A 
square peg for a round hole. Advances in Behavior Research and 
Therapy, 1, 231-236. 
Worell, L., & Tumilty, T.N. (1981). The measurement of locus of among 
alcoholics. In H. M. Lefcourt (Ed.), Research with the locus of 
control construct 1: Assessment methods. (pp. 321-333). New York: 
Academic Press. 
Worell, L., & Worell, J. (1972) Parent behavior form. Unpublished 
material, Department of Psychology, University of Kentucky, 
Lexington. 
Zinberg, N .E., Harding, W.M., Stelmack, S.M., & Marblestone, R.A. 0978). 
Patterns of heroin use. Annals of the New York A cademy of 
Science, '.1, 10-24. 
Zuckerman, M., & Lubin, B. (1965). Manual for the multiple affect 
adiective check list. San Diego, Calif.: Educational and Industrial 
' 
Testing Service. 
255 
FOOTNOTES 
1Kierkegaard, S. (1968). Sygdommen til D0den (W. Lorie, Trans.) [The 
sickness unto death (with) Fear and trembling]. Princeton: 
Princeton University Press, (p. 187). (Original work published 1849). 
Reprinted by permission from Princeton University Press. 
2orwell, G. (1981). Nineteen-eighty four. New York: New American 
Library, (pp. 176-178). ?1949 by Harcourt Brace Jovanovich, Inc. 
Reprinted by permission from Harcourt Brace Jovanovich, Inc. 
3stevenson, R.L. (1987). Dr. Jekyll and Mr. Hyde. New York: Penguin 
Books, (pp. 57-58). (Original work published in 1886).