Journal of Substance Abuse Treatment 40 (2011) 150 164

Regular article

Predictors of addiction treatment providers' beliefs in the disease and

choice models of addiction
Christopher Russell, (M.Sc.), John B. Davies, (Ph.D., F.B.Ps.S.), Simon C. Hunter, (Ph.D.)
School of Psychological Sciences and Health, University of Strathclyde, Glasgow, G1 1QE Scotland, UK

Received 8 January 2010; received in revised form 16 September 2010; accepted 22 September 2010

Abstract

Addiction treatment providers working in the United States (n = 219) and the United Kingdom (n = 372) were surveyed about their beliefs
in the disease and choice models of addiction, as assessed by the 18-item Addiction Belief Scale of J. Schaler (1992). Factor analysis of item
scores revealed a three-factor structure, labeled addiction is a disease, addiction is a choice, and addiction is a way of coping with life,
and factor scores were analyzed in separate hierarchical multiple regression analyses. Controlling for demographic and addiction history
variables, treatment providers working in the United States more strongly believe addiction is a disease, whereas U.K.-based providers more
strongly believe that addiction is a choice and a way of coping with life. Beliefs that addiction is a disease were stronger among those who
provide for-profit treatment, have stronger spiritual beliefs, have had a past addiction problem, are older, are members of a group of addiction
professionals, and have been treating addiction longer. Conversely, those who viewed addiction as a choice were more likely to provide
public/not-for-profit treatment, be younger, not belong to a group of addiction professionals, and have weaker spiritual beliefs. Additionally,
treatment providers who have had a personal addiction problem in the past were significantly more likely to believe addiction is a disease the
longer they attend a 12-stepbased group and if they are presently abstinent. 2011 Elsevier Inc. All rights reserved.
Keywords: Addiction; Treatment providers; Beliefs; Disease; Choice

1. Introduction which undermines their values and best intentions (White,

The question what is addiction? has long polarized the
medical, social science, legal, and spiritual communities into
those who view addiction as a disease (Benowitz, 2008;
Jellinek, 1960; Ketcham, Asbury, Schulstad & Ciaramicoli,
2000; Kalivas & Volkow, 2005; Koob & Nestler, 1997;
Leshner, 1997; Lyvers, 1998; Maltzman, 1994; Vaillant,
1990) and those who view addiction as a cognizant choice
(Fingarette, 1988a, 1988b; Heyman, 2009; Merry, 1966;
Szasz, 1972; Playfair, 1991; Room, 1983; Schaler, 2000).
Many professional and lay conceptions of addiction can be
traced back to this dichotomy in causationdrug-addicted
individuals are either responsible/moral agents who perpe-
trate acts of mayhem on themselvesor victims of a disorder
2001). Regardless of the scientific credibility of the disease
and choice (or free will) models, research has shown that
clients of addiction services tend to adopt the addiction
ideology of their treatment service (Koski-Jannes, 2004).
Therefore, the extent to which addiction treatment providers
believe their clients' addictive behaviors are diseased or
chosen should be expected to have a strong bearing on how
clients will attribute the causes of their problems, seek to
resolve these problems, and believe in their capacity to
achieve a desired change. Extending research by Schaler
(1992), we examined addiction treatment providers' beliefs
about addiction and investigated the factors explaining
variance in beliefs, with a specific interest in the importance
of country in which treatment is provided.

1.1. Dichotomous and trichotomous thinking about addiction

Corresponding author. School of Psychological Sciences and Health,
University of Strathclyde, 40 George Street, Glasgow, G1 1QE Scotland, UK. The disease and choice models of addiction are not the
E-mail address: christopher.russell@strath.ac.uk (C. Russell). only perspectives of addiction in existence; they are only the

0740-5472/10/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2010.09.006
 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
two chosen for scrutiny in this study. Several other
perspectives of addictionsuch as an illness, disorder,
malady, allergy, ailment, sickness, condition, habit, func-
tional attribution, and social construction among others
can be viewed as implicitly ascribing or alluding to the
respective disease/choice model assumptions about addic-
tion as a compelled versus chosen act, an involuntary versus
voluntary act, and a problem inherent to the drug versus a
problem inherent to the mind of the user. Alternatively, some
theorists refute the suggestion that addiction can be fit to a
diseasechoice dichotomy, arguing addiction to be a
complex, messy intertwining of the user's biology and
sociology that subsumes elements of the disease and choice
model without contradiction.
Consequently, a diseaseintermediatechoice trichotomy
has emerged. White's (2001) degrees of freedom perspec-
tive, for example, argues addiction as a process disease
should be discussed not in terms of complete control or
complete loss of control, but in terms of degrees of
diminishment and enhancement of volitional control. The
problem with an intermediate perspective, however, is that it
must logically presume there exists a critical, discrete point
along the freedom continuum at which drug use becomes no
longer governed by phenomenological wants but by
physiological needs. This tipping point has survived as a
core hypothesis of 19th-century disease conceptualizations
of inebrietyJoseph Parrish suggested in 1888 that a line
could be crossed where drunkenness evolves into a disease
that is no longer under the conscious control of the drinker
(cited by White, 2000)through to the modern disease
conceptthe non-addicted brain is distinctly different from
the addicted brainA metaphorical switch in the brain seems
to be thrown as a result of prolonged drug use. Initially, drug
use is voluntary, but when that switch is thrown, the
individual moves into the state of addiction characterized by
compulsive drug seeking and use (Leshner, 1997, p. 46).1
To create an intermediate perspective would therefore be
redundant for the purposes of asking whether drug seeking
and use are willed or determined. Thus, although the validity
of a trichotomous model of the governing factors in
addiction and the mechanisms of change at the boundary
of each state will continue to be debated, this study was
concerned only with treatment providers' beliefs in the
disease and choice models.
1.2. The disease and choice models
The disease and choice models of addiction emerged from
different assumptions about the origins of behavior; namely,
whether behavior is determined by physical mechanism or
willed by an emergent force that transcends direct physical
mechanism (Davies, 1997). Consequently, they hold diver-
gent but equally powerful assumptions about how people
1
Allan I. Leshner was the director of National Institute of Drug Abuse
(NIDA) at time of publication.
151
become addicted to drugs and alcohol, their capacity for
control during consumption, and their prospects for change
without medical treatment. That the different sets of
fundamental assumptions driving each model are philosoph-
ically irreconcilable also necessitates, we argue, proponents
of one model to be equally passionate critics of the other.
The disease model describes addiction/substance depen-
dency as a primary, progressive, chronic relapsing disease
that is either genetically transmitted or acquired through
excessive consumption (Leshner, 1997; Ketcham et al.,
2000). Here, initial drug use occurs voluntarily. As repeated
drug use changes neural and brain function, however, the
user progressively loses control over their initial voluntary
behavior to the point that further drug seeking and use
become acts of compulsion, not choice (Ochoa, 1994; Foulds
& Ghodse, 1995). Thus, getting drug users who are in the
early or latter stages of an addiction into treatment with
medical experts often represents their best hope for arresting
but never curing the addiction (Milam & Ketcham, 1983). In
response to criticism, however, that a large body of scientific
evidence on alcoholism and alcohol problems has contra-
dicted the view of addiction as an incurable, unitary, all-or-
nothing disorder caused solely by hereditary physical
abnormalities (Miller, 1993, p. 133), a more scientifically
defensible disease model has been sought in recent years.
Miller proposed that research, treatment, and education
about alcoholism should be based on a disease model that
describes alcohol problems on continua of severity and an
etiological model comprising interactions of drug properties,
drug user, and drug setting.
The alternative model describes addiction as a motivated
choice. Here, drug taking is at all times something
individuals do voluntarily, usually when life is going badly
or to avoid coping with problems in living (Schaler, 2000).
When these problems in living are resolved, individuals
normally find that the addiction resolves with them, while
other individuals mature out of their addiction in time (Peele,
Brodsky, & Arnold, 1991) or learn to control their
consumption (Heather & Robertson, 1989). In this way,
addiction is seen as more to do with the environments people
live in than with brain pharmacology (Alexander, Hadaway,
& Coambs, 1980; Cohen, Liebson, Faillace, & Allen, 1971;
Robins, Helzer & Davis, 1975). With regard to the issue of
control, choice proponents argue that not only do drug users
never lose control over their drug use but that the best way to
curb problem drug use is to make and implement better
decisions, which does not require them to seek medical
treatment. Choice proponents tend to allow discussion of
addiction as a metaphorical disease but refute that it is a
literal brain disease (McMurran, 1994). They note that a
large body of scientific evidence contradicts disease model
claims regarding heritability, loss of control, and effective-
ness of treatment, and they denounce the disease model's
inference of a critical discrete event discriminating addicted
and nonaddicted drug users' as myth. They argue that drug
users are always free to choose to stop and that drug users'
152 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
difficulty in effecting change should not be mistaken for a
lack of freedom to do so.
1.3. Milestones in the evolution of the disease model
Treatment providers' support for each of the competing
models may vary depending on whether treatment is
provided in the United States or not. Although the idea of
alcoholism as a disease did not originate in the United States,
the modern disease concept of alcoholism has been 200 years
in the making2, during which time the United States has
presided over the most significant events in changing public
conceptions of drunkenness and drug use from voluntary
choices to involuntary compulsions (Levine, 1978; Peele,
1989). Benjamin Rush first medicalized the problem of
drunkenness in the early 19th century, his definition of a
disease of the will becoming a central message of the
American Temperance Movement (Levine, 1978).
The term inebriety was introduced in the late 19th century
to explain the seeking and problem use of a variety of drugs
as due to a common underlying pathology. Interest turned to
the effects of drugs' effects on the host, and doctors began to
hypothesize that the inebriate's apparent loss of control and
other symptoms could be traced to rogue hereditary and/or
self-impaired biological mechanisms that mark a primary
disease of the nervous system. In particular, the work of the
Drs. Parrish (1883) and Crothers (1893)prominent leaders
of the American Association for the Cure of Inebriety
described inebriety as a disease that is curable in the sense
that other diseases are curable and as inherited or acquired
through excessive consumption. This disease concept of
inebriety began a movement to treat inebriates at specialized
institutions in medical and scientific ways similar to other
diseases (i.e., through the development of vaccines). During
this period, Dr. Norman Kerr (1888) was advocating a
comparable disease concept in England. Consequently,
disease thinking about inebriety soon spread throughout
the United States and United Kingdom.
Public thinking about the disease of drunkenness took off
in 1935 with the inception and rapid growth of Alcoholics
Anonymous (AA), a spiritual self-help fellowship made up
of self-described recovering alcohol-dependent individuals
committed to helping one another maintain sobriety (Kurtz,
1988). Although AA literature does not refer to alcoholism
as a literal disease, Kurtz (2002) states that AA and members
of AA do use medical termsillness, sickness, malady
and the disease concept to reflect their belief about the
solution to alcoholismabstinenceand to convey the
hopelessness of alcohol-dependent individuals to change
themselves. Ragge (1998), for example, traces seven
features of the modern disease concept of alcoholism (e.g.,
beliefs that an intense physical craving is responsible for
alcohol-dependent individuals' loss of control and that
2
Levine (1978) and White (2000) provide a comprehensive history of
the disease concept of alcoholism.
physiology, not psychology, determines whether one drinker
will become addicted and another will not) to the Big Book
of AA (Alcoholics Anonymous World Services, 1939), the
fellowship's core publication. Alcoholics Anonymous,
through its public relations campaigns, has been instrumen-
tal in spreading and popularizing the disease concept of
alcoholism while avoiding discourse of alcoholism as a
literal disease.
Addiction as a disease in the United States gained
momentum in the mid-1990s with significant increases in
public funding of research into the genetic and neurobio-
logical foundations of addiction (Institute of Medicine
[IOM], 1996). This research agenda, accompanied by a
public education campaign that used a basic vocabulary to
teach a basic level of understanding about brain reward
circuitry, sought to move addiction is a disease from the
status of an ideological proclamation by policy activists and
an organizing metaphor for individuals seeking to resolve
alcohol and other drug problems to a science-grounded
conclusion (White, 2007). In recent years, former and
current directors of the National Institute of Drug Abuse,
Alan Leshner (1997) and Nora Volkow, respectively, have
used high-profile, highly respected academic outlets to
summarize 20 years of evidence from neurosciences and
behavioral sciences, which they claim prove addiction is a
brain disease. Leshner, additionally, called for public policy,
education, and addiction treatment to catch up with these
scientific facts. Volkow's keynote speech to the Annual
Conference of the American Psychiatric Association in 2007
followed on from a special issue of Nature Neuroscience
(multiple authors, 2005) in which a group of renowned
neuroscientists reported the latest evidence on the neurobi-
ology of addiction. Their findings described addiction as a
fundamentally neurobiological disorder.
Finally, as a vehicle for the dissemination of this new
neuroscientific evidence base to the public, the IOM (1996)
recommended that education about addiction should explain
in basic language that drugs can alter neural or brain
function, how these changes impair the user's ability to make
choices about using drugs, and that treatment is effective.
The brain hijacking metaphorthe concept that these
drugs can capture control of brain mechanisms that control
motivations and emotionswas proposed as an effective
device to increase understanding about a common effect of
some drugs on the brain. This device has since featured
prominently in major media pieces such as a TIME Magazine
(2007) feature article entitled, How We Get Addicted and a
14-part NIDA-funded TV special by HBO Documentary
Films (2007) entitled, Addiction: Why Can't They Just Stop?
Today, the American Medical Association (Morse &
Flavin, 1992), American Psychiatric Association (2000), and
NIDA (2009) continue to define as the essence of addiction
uncontrollable, compulsive drug seeking and use. Conse-
quently, the use of the word addiction in public discourse
has come to describe the activities that people engage in
because they are physically unable to avoid doing so
 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
(Levine, 1978; Mercadante, 1996; Schaler, 2000). Although
the disease model now dominates addiction discourse
internationally, the prominent role played by the United
States' psychiatric, medical, research, media, and spiritual
communities in shaping the modern disease concept of
addictive behaviors suggests that support for the view of
addiction as a disease may be stronger within the U.S. versus
nonU.S. treatment communities.
1.4. Previous research
Investigation of these questions was motivated by Schaler
(1992), who found that treatment providers tended to believe
that addiction is a disease from which only about 25% of
people recover without medical or 12-stepbased treatment.
Treatment providers who reported stronger beliefs that
addiction is a disease were significantly more likely to be
women, members of the National Association for Alcohol-
ism and Drug Abuse Counselors (NAADAC), present or past
members of AA, certified addiction counselors/therapists,
abstinent at present, and have stronger spiritual beliefs as
defined in AA philosophy. Strength of spiritual beliefs, as
measured by the Spiritual Belief Scale (SBS; Schaler, 1992)
accounted for most variance (41%) in disease beliefs.
However, although Schaler's sample comprised treatment
providers working in the United States, Canada, and
Australia, differences across these locations were not
investigated. This precludes offering conclusions about
support for the disease model in the United States relative
to out-with the United States and the hypothesized
significance of the country of treatment as a predictor of
addiction beliefs. Data were also not collected on the profit
status of treatment provided.
Furthermore, there are a number of reasons to suspect that
addiction beliefs may have changed since 1992. These
include high staff turnover rates, new pharmacological and
psychotherapeutic treatment approaches to addiction, policy
changes regarding public funding of addiction treatment and
insurance coverage, new laboratory and field evidence on
treatment effectiveness including the much publicized
findings of Project MATCH (1997) and UK Alcohol
Treatment Trial (2005), the aforementioned U.S.-led re-
search drive to emphasize the neuronal mechanisms and
heritability of addiction, and the transmission of the basic
facts of addiction neuroscience to the public, policy makers,
and treatment providers. Thus, we examined whether a
similar factorial structure emerged from ABS scores and
whether factors found by Schaler to explain variance remain
potent 18 years on.
1.5. Current study aims
The purpose of this study was to assess (a) whether belief
in the disease model of addiction is stronger among treatment
providers who work in the United States versus out-with the
United States and (b) the variance in disease and choice
153
beliefs explained by demographic and personal and
professional addiction history variables.
2. Materials and method
2.1. Recruitment methods
Treatment providers were recruited in three ways. First,
a survey pack was sent to designated persons at each of
the 21 and 94 regional Drug and Alcohol Action Teams
(DAATs) in Scotland and England, respectively. As part of
regional National Health Service Health Boards, DAATs
are responsible for the topdown and bottomup commu-
nication of substance misuse-related data between addic-
tion treatment services and local and central government
and, therefore, have excellent access to voluntary and
statutory addiction treatment providers within their region.
Drug and Alcohol Action Teams were asked to forward
the survey pack to managers of local addiction treatment
services. In turn, managers were asked to forward the
survey to all staff who are directly involved in the
provision of addiction treatment.
Second, survey packs were sent via e-mail to 785 persons
who could be identified as chief executive officers/managers
of addiction treatment services on the Web sites of several
large associations and online databases of addiction
treatment professionals. These were NAADAC, the Associ-
ation for Addiction Professionals, Federation of Drug and
Alcohol Professionals (a U.K. branch of NAADAC),
European Federation of Therapeutic Communities, Europe-
an Association for the Treatment of Addiction, Association
of Intervention Specialists, Recover Now, Time for New
Beginnings, Sober Recovery, Addiction Treatment Center
Directory, Substance Abuse and Mental Health Services
Administration, Substance Abuse Treatment Facility Locator
(U.S. Department of Health and Human Services), and
Alcohol Focus Scotland. Treatment providers typically
provide contact information for public viewing on these
Web sites for the benefit of persons seeking help for an
addiction problem, although they are assumed to not oppose
being contacted in this way by other interested parties.
Indeed, no treatment providers objected to being contacted in
this way and many were quite happy to know they were
accessible in this way.
Third, survey packs were circulated to subscribers of the
following e-newsletter mailing lists: (1) U.K. lists: Alcohol
Misuse, Drug Misuse Research, Drug Day Programmes,
Wired In, and Therapeutic Community Open Forum; (2) U.
S./Canadian lists: Addict-L, Addiction Medicine, and
Apolnet; (3) European lists: Therapeutic Communities and
European Working Group on Drugs Oriented Research; and
(4) international lists: the Kettil Bruun Society and Gambling
Issues International. These lists cover approximately 2,500
subscribers in total. The e-survey was closed 2 months after
the final survey pack was sent out.
154 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164

2.2. Sample characteristics Table 1

Demographic and professional characteristics of addiction treatment
providers by country: count (percentage within country)
The survey received 854 responses. Of these, 164 were
excluded because the Addiction Belief Scale (ABS) was Variable United States United Kingdom Total
incomplete (n = 160) or because respondents were not N 219 372 591
providers of addiction treatment/were no longer actively Age, M (SD) 47.61 (10.60) 44.03 (10.68) 45.35 (10.78)
Sex
treating clients (n = 14). We had initially planned to compare
Male 95 (43.4) 145 (39.0) 240 (40.6)
the strength of disease beliefs in the United States versus Female 124 (56.6) 227 (61.0) 351 (59.4)
several countries. However, the majority of survey responses Profit status
came from treatment providers working in the United Private/for-profit 70 (32.0) 118 (31.7) 188 (31.8)
Kingdom (n = 372) and the United States (n = 219), with Public/not-for-profit 149 (68.0) 254 (68.3) 403 (68.2)
Years as treatment provider
the remaining 99 respondents representing 21 other
01 13 (5.9) 28 (7.6) 41 (7.0)
countries. Thus, comparing disease beliefs in the United 25 53 (24.2) 99 (26.8) 152 (25.8)
States with those in several countries was not possible and 610 50 (22.8) 104 (28.1) 154 (26.1)
creating a U.S.-versus-not-U.S. variable was considered 1115 36 (16.4) 59 (15.9) 95 (16.1)
misleading, given that 79% of the not U.S. respondents 1620 23 (10.5) 41 (11.2) 64 (10.9)
21+ 44 (20.1) 39 (10.5) 83 (14.1)
came from the United Kingdom. Purely due to the
Certified
geographical distribution of our sample, it was decided to Yes 115 (52.8) 111 (30.2) 226 (38.6)
exclude the 99 non-U.K. and non-U.S. respondents so as to No 103 (47.2) 256 (69.8) 359 (61.4)
compare the strength of disease beliefs of treatment Professional group member
providers working in the United States versus the United Yes 99 (45.4) 74 (20.3) 153 (31.4)
No 119 (54.6) 290 (79.7) 332 (68.6)
Kingdom. This left a final sample of 591. Due to the
Problems treated
opportunistic sampling method, it was impossible to Alcohol 191 (87.2) 320 (86.0) 511 (86.5)
calculate a survey return rate. Professional characteristics Illicit drugs 185 (84.5) 327 (87.9) 512 (86.6)
of the sample by country are summarized in Table 1. Prescription drugs 172 (78.5) 271 (72.8) 443 (75.0)
Nicotine/tobacco 84 (39.2) 64 (17.2) 148 (25.0)
Gambling 82 (37.4) 63 (16.9) 145 (24.5)
2.3. Materials
Video gaming 27 (12.3) 18 (4.8) 45 (7.6)
Sex/Pornography 39 (17.8) 26 (7.0) 65 (11.0)
Treatment providers were invited by e-mail to complete Food 34 (15.5) 29 (7.8) 63 (10.7)
an e-survey of their addiction beliefs. This e-mail gave a Shopping 28 (12.8) 19 (5.1) 47 (8.0)
brief explanation of the study, confirmed that local ethical Internet use 30 (13.7) 19 (5.1) 49 (8.3)
Treatment methods used
approval had been granted, assured respondents of confi-
Psychotherapeutic a 190 (88.0) 326 (91.6) 516 (90.2)
dentiality, and gave contact information for the primary and Pharmacotheraputic b 135 (62.5) 210 (59.0) 335 (60.3)
secondary authors. The survey comprised three parts: the 12-Step , c 99 (45.8) 125 (35.1) 224 (39.2)
ABS, the SBS, and questions about their personal and Note: Country Variable differences were tested using the 2 statistic for
professional addiction history. Other information collected categorical variables and an independent groups t test on the one
included age (in years) and sex. continuous variable (age).
a
Psychotherapeutic methods included reported use of at least one of
2.3.1. The Addiction Belief Scale cognitivebehavioral therapy, individual and group counseling, person
center therapy, motivational interviewing, biopsychoscoial models, stress
The 18 items of this scale comprise statements about
management, art therapy, equine therapy, family systems approach, couples
addiction as described in the disease (nine items) and choice therapy, occupational therapy, rational emotive therapy, emotion-focused
(nine items) models regarding etiology, the need for therapy, mindfulness, meditation, psychodynamic therapy, Jungian therapy,
treatment, and addicted individuals' capacity for self-control, Rogerian therapy, narrative therapy, systems theory, motivational enhance-
insofar as these assumptions can be dichotomized. An ment therapy, anger management therapy, nations healing, trauma therapy,
grief and loss therapy, acupuncture, gestalt therapy, humanistic therapy,
example of a statement that reflects the disease model is
stages of change approach, Bowinian approach, shiatsu, and yoga.
Physiology, not psychology, determines whether one b
Pharmacotherapeutic methods included reported use of substitute
drinker will become addicted to alcohol and another will prescribing to support maintenance, detoxification, reduction, or abstinence
not (item 11). An example of an item reflecting the choice (at least one of methadone, buprenorphine [Subutex], lofexidine,
model is People can stop relying on drugs or alcohol as they naltrexone, chlordiazepoxide, disulfiram, acamprosate, baclofen, thiamine,
benzodiazepine, disulfiram [Antabuse], acamprosate [Campral], diazepam,
develop new ways to deal with life (item 6). Respondents
and vitamin B).
rate on a five-point Likert scale the extent to which they c
12-Step methods included reported use of 12-Step Model, 12-Step
agree with each statement (1 = strongly disagree to 5 = Facilitation, Minnesota Model, and AA/NA model.
strongly agree) and the nine choice model items are reverse p b .05.
p b .01.
scored. The highest possible score is 90 (minimum = 18),
p b .001.
with a conceptual median of 54. A score higher or lower than
54 on the ABS indicates a belief in the disease or choice
 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
model of addiction, respectively. Schaler (1995) reported
strong internal consistency for the ABS ( = .91,
standardized item, = .91, n = 266) and a three-factor
structure described as power ( = .91, n = 274),
dichotomous thinking ( = .83, n = 285), and addiction
as a way of coping with life ( = .47, n = 286). High
construct validity was evidenced by a strong negative
correlation (r = .67, p = .01) between respondents' ABS
scores and their beliefs about the percentage of individuals
able to recover from an addiction without any form of
medical or 12-steptype treatment, that is, the stronger their
belief in addiction as a disease (higher ABS score), the lower
the percentage of individuals they believed are able to
recover without treatment. The full ABS and factorial
analysis can be found in the work of Schaler (1995).
Despite reporting a three-factor structure, Schaler initially
scored ABS items in accordance with a single factor, bipolar
in nature, with endorsement of the disease model at one end
and endorsement of the choice model at the other end. As
such, the nine items designed to represent beliefs in the
choice model were reverse scored. To determine whether this
scoring system was appropriate for current data, a factor
analysis of current ABS data was conducted to check
whether addiction beliefs loaded on a single disease
choice factor (and so choice items can be reverse scored and
ABS total scores used as a dependent measure of belief in the
disease model) or whether addiction beliefs conform to a
multifactorial structure. Results of this analysis are reported
in Section 3.2.
2.3.2. The Spiritual Belief Scale
The eight items of this scale measure spiritual thinking as
defined in the philosophy of AA as belief in a metaphysical
power that can influence personal experience. Items were
adapted from how spirituality is discussed in the Big Book of
AA to form statements about God and spiritual health.
Items reflect the four spiritual characteristics of AA
release, gratitude, humility, and toleranceidentified by
Kurtz (1988). Respondents rate on a five-point Likert scale
the extent to which they agree with each statement (1 =
strongly disagree to 5 = strongly agree). Higher scores
indicate stronger spiritual beliefs. The highest possible score
is 40 (minimum = 8). Schaler (1996) reported strong internal
consistency for the SBS ( = .92, standardized item, = .91,
n = 280) and a two-factor structure described as release
gratitudehumility (six items, = .95, n = 281) and
tolerance (two items, = .53, n = 290). The full SBS and
factorial analysis can be found in the work of Schaler (1996).
2.3.3. Addiction history questions
Questions regarding respondents' professional addiction
history were whether they are an addiction treatment
provider, job title, the country and state/county in which
they provide treatment; the profit status of their treatment
facility, number of years experience as an addiction
treatment provider, whether they are a member of any
155
professional group of addiction treatment providers, whether
they are a certified counselor or therapist for treating an
addiction, and which types of addiction problems they treat.
Regarding personal addiction history, respondents were
asked if they have personally had a problem with an
addiction in the past. If yes was indicated, they were then
asked several follow-up questions: whether they have ever
attended a treatment agency in the past; whether they have
attended in the past or presently do attend AA, Narcotics
Anonymous (NA), or any other 12-stepbased program;
number of years in total they have been a member of a 12-
stepbased program; and whether they are abstinent at
present. Respondents who indicated no to the past
addiction problem question did not answer these five
follow-up questions. Finally, an empty text box at the end
of the survey allowed respondents to comment on the survey.
3. Results
3.1. Power analysis
Power analyses were performed to determine whether the
planned multiple regression analysis would be sufficiently
powered to detect meaningful effects (f2 for multiple
regression, see Cohen, 1988) given a sample of 591. The
analysis showed that when N = 591 and = .05 and with 10
predictors, power = 1.00. Thus, it was concluded that the
present analysis was sufficiently powered.
3.2. Factor analysis of the ABS
Separate factor analyses were conducted to compare the
ABS factor structures for the U.K.- (n = 372) and U.S.-based
(n = 219) samples. Despite the ABS's apparent bipolar
content on a single dimension of addiction beliefs, extremely
similar four-factor solutions were found for each country.
Within the U.K. sample, five disease items (1 [.73], 2 [.75], 3
[.76], 5 [.61], and 10 [.57]) loaded on factor 1; four disease
items (9 [.53], 11 [.57], 14 [.68], and 17 [.49]) and one choice
item (12 [.66]) loaded on factor 1; six choice items (4 [.66],
7 [.60], 8 [.50], 13 [.54], 15 [.61], and 16 [.48]) loaded on
factor 3; and two choice items (6 [.70], 18 [.62]) loaded on
factor 4. The only differences in the composition of the four
factors extracted from U.S.-based scores were that item 12
switched from being negatively correlated with disease items
in factor 2 to strongly positively correlated with the choice
items in factor 3 and items 13 and 15 switched from factor 3
(all choice items) to factor 4 (all choice items).
Given these extremely similar factor solutions found in
separate analyses, all ABS scores (N = 591) were factor
analyzed using varimax rotation with Kaiser normalization.
Three factors were extracted, which we labeled addiction is
a disease, addiction is a choice, and addiction is a way of
coping with life, respectively. These factors together
explained 50.13% of common variance. Factor 1 had an
156 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
eigenvalue of 6.08 and explained 33.80% of variance. Ten
items loaded on this factor, nine of which were designed to
represent the disease model of addiction3 (items 1 [.67; 2
[.74], 3 [.66], 5 [.70], 9 [.72], 10 [.68], 14 [.65], and 17 [.66])
and one item designed to represent the choice model of
addiction (12: Alcoholics can learn to moderate their
drinking or cut down on their drug use), which was strongly
negatively correlated (.55). Disagreement with item 12
implied the belief that alcohol-dependent individual are
unable to learn to moderate drinking/drug use, which is
consistent with the disease perspective. The item with the
strongest correlation value reads, Addicts cannot control
themselves when they drink or take drugs.
Factor 2 had an eigenvalue of 1.83 and explained 10.19%.
Six of the remaining eight items designed to represent the
choice model loaded on this factor (items 4 [.58], 7 [.72],
8 [.50], 13 [.54], 15 [.62], and 16 [.54]). The item with the
strongest correlation value reads, Addiction has more to do
with the environments people live in than the drugs they are
addicted to.
Factor 3 had an eigenvalue of 1.11 and explained 6.14%
of variance. The two remaining choice model items (6 [.65]
and 18 [.69]) loaded on this factor. The item with the
strongest correlation reads, Drug addiction is a way of life
people rely on to cope with the world. However, the
overall pattern mirrored that revealed by the factor analysis
of the entire sample: Items designed to represent the disease
and choice models correlated positively with their own kind
and correlated negatively with items representing the
alternative model.
Therefore, scores were summed for each of the three
factors extracted by the main factor analysis (addiction is a
disease, addiction is a choice, and addiction is a way of
coping with life) and used as criterion variables in
subsequent regression analyses. These factors had maximum
scores of 50, 30, and 10, respectively, with higher scores
reflecting stronger beliefs in each factor. Each factor had
good to very good internal consistency and correlated
strongly with each other, as shown in Table 2.
3.3. Hierarchical multiple regression models
To investigate the variables that explain variance in
addiction treatment providers' beliefs about addiction, three
separate hierarchical multiple linear regression analyses were
conducted, each in three steps, with score on factor 1
(addiction is a disease), factor 2 (addiction is a choice),
and factor 3 (addiction is a way of coping with life) of the
ABS used, respectively, as the criterion variables. To control
for their effects, eight variables were entered at step one of
each regression equation: sex (0 = male, 1 = female), age,
number of years as an addiction treatment provider,
certification as an addiction treatment provider (0 = no, 1
3
Correlation values in brackets.
Table 2
Correlation matrix and internal consistency values () for ABS subscales
and ABS total score
Factor 1 a Factor 2 b Factor 3 c ABS total d
Factor 1 .43 .21 .76
Factor 2 .36 .22
Factor 3 . .24
ABS
a
Cronbach's = .79, 10 items, N = 591 (addiction is a disease).
b
Cronbach's = .71, 6 items, N = 591 (addiction is a choice).
c
Cronbach's = .54, 2 items, N = 591 (addiction is a way of coping
with life).
d
Cronbach's = .67, 18 items, N = 591.
p b .001.
= yes), member of a group of addiction treatment profes-
sionals (0 = no, 1 = yes), had a personal addiction problem in
the past (0 = no, 1 = yes), the profit status of treatment
provision (0 = public/not-for-profit, 1 = private/for-profit),
and SBS score. The country in which treatment is provided
(0 = United Kingdom, 1 = United States) was added at step 2.
Finally, to assess any moderation of an effect of profit status
on ABS score by country, an interaction term for profit status
and country was regressed on ABS score at step 3. Data
satisfied assumptions of linearity, multicollinearity, and
homoscedasticity of residuals. Mean scores and standard
deviations for the three ABS factors are presented in Table 3.
3.4. Variables explaining variance in treatment providers'
beliefs that addiction is a disease
The final regression model accounted for 35.6% of
variance in treatment providers' beliefs in the disease model
of addiction (see Table 4). Step 1 produced a significant
model, F(8, 565) = 26.47, p b .001, and accounted for 27.3%
of variance in factor 1 scores. Six of the eight variables made
significant contributions.
Score on the SBS and age were both positively associated
( = .40, p b .001, and = .15, p b .001, respectively) with
ABS score. These indicate that belief in the disease model
strengthens with level of spiritual thinking and with age.
Providing private/for-profit treatment was positively associ-
ated ( = .10, p b .01) with factor 1 score. Those who
provide addiction treatment for-profit more strongly believe
(M = 28.96, SD = 6.53) that addiction is a disease than those
who provide public/not-for-profit treatment (M = 26.39, SD
= 6.15). Being a member of a professional group of addiction
treatment providers was positively associated ( = .11, p b
.01) with factor 1 score. Professional group members more
strongly believe (M = 29.61, SD = 6.09) that addiction is a
disease than nonmembers (M = 26.27, SD = 6.17). Number
of years of experience as a treatment provider was positively
associated with factor 1 score ( = .13, p b .01), with disease
beliefs strongest (M = 27.60, SD = 7.39) among those who
have provided addiction treatment for the longest (21+
years). Finally, having had a personal problem with
addiction in the past was positively associated ( = .10,
 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164 157

Table 3
Mean scores and standard deviations for the three factors of the ABS
Variable n Disease Choice Way of coping with life
Sex
Male 269 27.63 (6.72) 16.83 (3.63) 6.76 (1.47)
Female 322 26.86 (6.07) 17.05 (3.45) 7.17 (1.49)
Country
United Kingdom 372 24.97 (5.77) 17.96 (3.22) 7.40 (1.35)
United States 219 31.02 (5.53) 15.24 (3.39) 6.28 (1.48)
Profit status
Private/for-profit 188 28.97 (6.53) 15.85 (3.46) 6.55 (1.75)
Public/not-for-profit 403 26.39 (6.15) 17.47 (3.45) 7.19 (1.31)
United States Profit Status
Private/for-profit 70 33.96 (4.54) 13.13 (2.55) 5.41 (1.35)
Public/not-for-profit 149 29.64 (5.43) 16.23 (3.28) 6.68 (1.36)
United Kingdom Profit Status
Private/for-profit 118 26.02 (5.68) 17.46 (2.88) 7.22 (1.62)
Public/not-for-profit 254 24.49 (5.75) 18.19 (3.35) 7.48 (1.20)
Years treating addiction problems
01 41 27.15 (6.35) 16.83 (3.60) 7.17 (1.58)
25 152 27.32 (6.35) 17.17 (3.76) 7.21 (1.56)
610 154 27.19 (6.34) 17.64 (3.11) 7.12 (1.34)
1115 95 27.20 (5.83) 16.29 (3.09) 6.81 (1.45)
1620 64 27.42 (6.25) 16.39 (3.44) 6.53 (1.74)
21+ 83 27.60 (7.39) 16.47 (4.14) 6.76 (1.32)
Member of professional group
Yes 173 29.61 (6.09) 15.70 (3.23) 6.59 (1.49)
No 409 26.27 (6.17) 17.46 (3.50) 7.16 (1.47)
Past addiction problem
Yes 199 29.15 (6.39) 16.06 (3.79) 6.76 (1.63)
No 392 26.27 (6.17) 17.40 (3.31) 7.09 (1.41)
Attended treatment in the past a
Yes 135 29.69 (6.45) 15.70 (3.71) 6.70 (1.65)
No 64 28.02 (6.17) 16.81 (3.87) 6.91 (1.59)
Attended 12-step group in the past a
Yes 145 30.17 (6.29) 15.37 (3.69) 6.61 (1.68)
No 54 26.41 (5.89) 17.93 (3.45) 7.17 (1.44)
Attend 12-step group at present a
Yes 94 31.60 (5.57) 14.40 (3.44) 6.46 (1.75)
No 105 26.96 (6.31) 17.54 (3.48) 7.04 (1.47)
Years as member of 12-step group a
0 10 24.40 (4.86) 17.30 (3.13) 7.50 (1.08)
01 63 25.70 (5.91) 18.40 (3.31) 7.21 (1.45)
25 10 24.40 (6.93) 18.00 (3.89) 6.90 (2.18)
610 17 30.88 (5.94) 14.88 (4.23) 7.12 (1.76)
1115 20 30.70 (5.55) 16.35 (3.94) 6.95 (1.54)
1620 23 32.13 (4.70) 14.39 (2.39) 6.48 (1.28)
2125 13 32.00 (5.40) 14.77 (2.20) 6.15 (1.68)
25+ 42 32.83 (5.07) 13.38 (2.96) 6.00 (1.75)
Abstinent at present a
Yes 145 29.90 (6.32) 15.61 (3.69) 6.69 (1.64)
No 53 23.78 (3.74) 19.39 (2.81) 7.35 (1.50)
Note: The highest possible scores for factor 1 = 50, factor 2 = 30, and factor 3 = 10. Higher scores on each factor reflect stronger addiction beliefs.
a
Question answered only by the 199 respondents who indicated they have had a personal addiction problem in the past.
p b .05.
p b .01.
p b .001.

p b .05) with factor 1 score. Those who have had a personal
addiction problem more strongly believe (M = 29.15, SD =
6.39) that addiction is a disease than those who have not had
an addiction problem (M = 26.23, SD = 6.16).
Step 2 in the model accounted for a significant increase
of 8.0% explained variance in factor 1 scores, Fchange(1,
564) = 68.55, p b .001. After partialing out variance
explained by variables in step 1, providing addiction
treatment in the United States was positively associated (
= .32, p b .001) with factor 1 score. Providers of addiction
treatment in the United States more strongly believe (M =
31.02, SD = 5.53) in the disease model of addiction than
158 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164

Table 4
Separate hierarchical multiple linear regression analyses using scores on three factors extracted from the ABS as criterion variables
Disease Choice Way of coping with life
Step Predictor Step 1 Step 2 Step 3 Step 1 Step 2 Step 3 Step 1 Step 2 Step 3
1 Sex .03 .02 .01 .00 .04 .03 .12 .07 .08
Age .15 .14 .13 .10 .08 .08 .12 .10 .10
Years treating addiction problems a .13 .13 .14 .02 .01 .02 .02 .02 .02
Certified .00 .02 .03 .01 .01 .02 .04 .01 .00
Professional group membership .11 .06 .05 .11 .06 .05 .05 .00 .02
Past addiction problem .09 .08 .07 .06 .06 .06 .03 .02 .03
Profit status .10 .13 .08 .14 .17 .08 .16 .19 .09
SBS .40 .28 027 .24 .13 .12 .14 .03 .01
Disease: F(8, 565) = 26.47, p b .001, R2 = .273
Choice: F(8, 565) = 12.89, p b .001, R2 = .154
Way of coping with life: F(8, 565) = 9.45, p b .001, R2 = .118
2 Country .32 .28 .30 .22 .33 .24
Disease: Fchange(1, 564) = 68.55, p b .001, R2change = .080
Choice: Fchange(1, 564) = 48.71, p b .001, R2change = .067
Way of coping with life: Fchange(1, 564) = 57.80, p b .001, R2change = .082
3 Country Profit Status .10 .18 .21
Disease: Fchange(1, 563) = 3.84, p = .051, R2change = .004
Choice: Fchange(1, 563) = 10.80, p b .001, R2change = .015
Way of coping with life: Fchange(1, 563) = 14.40, p b .001, R2change = .020
a
Ordinal scale variable.
p b .05.
p b .01.
p b .001.

those who provide addiction treatment in the United
Kingdom (M = 24.97, SD = 5.77).
Step 3 in the model yielded a nonsignificant increase of
0.4% explained variance, Fchange(1, 563) = 3.84, p N .05.
Therefore, the country of treatment did not moderate the
effect of profit status on treatment providers' beliefs that
addiction is a disease.
3.5. Variables explaining variance in treatment providers'
beliefs that addiction is a choice
The final regression model accounted for 23.6% of
variance in treatment providers' beliefs that addiction is a
motivated choice. Step 1 produced a significant model, F(8,
565) = 12.89, p b .001, and accounted for 15.4% of
variance in factor 2 score. Four of the eight variables made
significant contributions.
In complete contrast to factor 1 scores, score on the SBS
and age were both negatively associated ( = .24, p b .001,
and = .10, p b .05, respectively) with factor 2 scores.
These indicate that beliefs that addiction is a choice weaken
as strength of spiritual thinking increases and with age.
Providing private/for-profit treatment was negatively asso-
ciated ( = .14, p b .01) with factor 2 score. Those who
provide public/not-for-profit addiction treatment more
strongly believe (M = 17.47, SD = 3.45) that addiction is a
choice than those who provide private/for-profit treatment
(M = 15.70, SD = 3.46). Being a member of a professional
group of addiction treatment providers was negatively
associated ( = .11, p b .01) with factor 2 score. Treatment
providers whom are not members of a group of addiction
professionals more strongly believe (M = 17.46, SD = 3.50)
that addiction is a choice than group members (M = 15.70,
SD = 3.23).
Step 2 in the model accounted for a significant increase
of 6.7% explained variance in factor 2 score, Fchange(1, 564)
= 48.71, p b .001. After partialing out variance explained
by variables in step 1, providing addiction treatment in the
United States was negatively associated ( = .30, p b
.001) with factor 2 score. Providers of addiction treatment
in the United Kingdom more strongly believe (M = 17.96,
SD = 3.22) that addiction is a choice than those who
provide addiction treatment in the United States (M = 15.24,
SD = 3.39).
Step 3 in the model yielded a significant increase of 1.5%
explained variance in factor 3 score, Fchange(1, 563) = 10.80,
p b .001. To interrogate this interaction, simple effects
analyses were conducted (i.e., repeating the analysis with
neither the Country Profit Status interaction term nor main
effects of country), first for U.S.-based treatment providers (n
= 219) and then for U.K.-based treatment providers (n = 372).
This revealed a significant negative association between
profit status and factor 2 score among U.S.-based treatment
providers ( = .40, p b .001) after controlling for seven
variables entered at step 1, Fchange(1, 207) = 31.42, p b .001,
R2 change = .117. No significant association was found
between profit status and factor 2 score among U.K.-based
providers (see Table 5). This indicates that country of
treatment moderates the relationship between profit status
and treatment providers' beliefs that addiction is a choice,
 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164 159

Table 5
Decomposition of Country Profit Status interaction effects found for factors 2 and 3: Results from U.S.-based (and U.K.-based) treatment providers
Choice Way of coping with life
Step Predictor Step 1 Step 2 Step 1 Step 2
1 Sex .02 (.08) .04 (.08) .05 (.06) .11 (.07)
Age .19 (.05) .10 (.05) .10 (.18 ) .01 (.18 )
Years treating addiction problems a .13 (.08) .12 (.08) .10 (.03) .10 (.03)
Certified .06 (.03) .09 (.03) .10 (.06) .13 (.06)
Professional group membership .00 (.14 ) .07 (.13 ) .08 (.00) .01 (.01)
Past addiction problem .09 (.08) .07 (.07) .03 (.01) .05 (.02)
SBS .15 (.16 ) .05 (.16 ) .23 (.07) .12 (.07)
Choice, U.S.-based: F(7, 208) = 3.74, p b .001, R2 = .082
Choice, U.K.-based: F(7, 350) = 4.07, p b .001, R2 = .075
Way of coping with life, U.S.-based: F(7, 208) = 2.84, p b .01, R2 = .088
Way of coping with life, U.K.-based: F(7, 350) = 2.32, p b .05, R2 = .044
2 Profit status .40 (.07) .41 (.09)
Choice, U.S.-based: Fchange(1, 207) = 31.42, p b .001, R2change = .117
Choice, U.K.-based: Fchange(1, 349) = 1.74, p N .05, R2change = .005
Way of coping with life, U.S.-based: F(1, 207) = 32.56, p b .001, R2 = .124
Way of coping with life, U.K.-based: F(1, 349) = 2.92, p N .05, R2 = .008
a
Ordinal scale variable.
p b .05.
p b .01.
p b .001.

with only U.S.-based providers of public/not-for-profit
treatment reporting significantly stronger beliefs (M =
16.23, SD = 3.28) than private/for-profit providers (M =
13.13, SD = 2.55) that addiction is a choice.
3.6. Variables explaining variance in treatment providers'
beliefs that addiction is a way of coping with life
The final regression model accounted for 22.0% of
variance in treatment providers' beliefs that addiction is a
way of coping with life. Step 1 produced a significant model,
F(8, 565) = 9.45, p b .001, and accounted for 11.8% of
variance in factor 3 score. Four of the eight variables made
significant contributions.
Score on the SBS and age were again both negatively
associated ( = .14, p b .001, and = .12, p b .05,
respectively) with factor 3 score. These indicate that beliefs
that addiction is a way of coping with life weaken as strength
of spiritual thinking increases and with age. Providing
private/for-profit treatment was negatively associated ( =
.16, p b .001) with factor 3 score. Those who provide
public/not-for-profit addiction treatment more strongly
believe (M = 7.19, SD = 1.49) that addiction is a way of
coping with life than those who provide private/for-profit
treatment (M = 6.55, SD = 1.75). Being female was positively
associated ( = .12, p b .01) with factor 3 score. Female
treatment providers more strongly believe (M = 7.17, SD =
1.49) that addiction is a way of coping with life than male
treatment providers (M = 6.76, SD = 1.47).
Step 2 in the model accounted for a significant increase of
8.2% explained variance in factor 2 scores, Fchange(1, 564) =
57.80, p b .001. After partialing out variance explained by
variables in step 1, providing addiction treatment in the
United States was negatively associated ( = .33, p b .001)
with factor 3 score. Providers of addiction treatment in the
United Kingdom more strongly believe (M = 7.40, SD = 1.35)
that addiction is a choice than those who provide addiction
treatment in the United States (M = 6.28, SD = 1.48).
Step 3 in the model yielded a significant increase of 2.0%
explained variance in factor 3 score, Fchange(1, 563) = 14.40,
p b .001. To interrogate this interaction, simple effects
analyses were again conducted, first for U.S.-based sample
(n = 219) and then the U.K.-based sample (n = 372). This
revealed a significant positive association between profit
status and factor 3 score in the United States ( = .47, p b
.001) after controlling for seven variables entered at step 1,
Fchange(1, 207) = 32.56, p b .001, R2change = .124. Again, no
significant association was found between profit status and
factor 3 score in the U.K. sample. This indicates that country
of treatment moderates the relationship between profit status
and treatment providers' beliefs in the disease model, with
only U.S.-based treatment providers reporting significantly
stronger beliefs (M = 6.68, SD = 1.36) than private/for-profit
providers (M = 5.41, SD = 1.35) that addiction is a way of
coping with life.
3.7. Hierarchical multiple regression models applied to
data provided only by treatment providers who have
had a past addiction problem
Three separate hierarchical multiple linear regression
analyses were then conducted to investigate the variance in
addiction beliefs of treatment providers who have had a past
addiction problem (n = 199) explained by five personal
addiction history variables. Three ABS factor scores were
again used as criterion variables. To control for their effects,
160 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164

sex, age, number of years as an addiction treatment provider,
certification status as an addiction treatment provider,
membership status of a group of addiction treatment
professionals, country of treatment, profit status of treatment,
and SBS score were all entered at step 1. A further five
variables were entered at step 2 of the equation: attended
treatment in the past (0 = no, 1 = yes), attended 12-step
based group in the past (0 = no, 1 = yes), attend 12-step
based group at present (0 = no, 1 = yes), number of years in
12-stepbased group, and abstinence status at present (0 =
not abstinent, 1 = abstinent). Power analysis confirmed that
with a sample of 199, = .05, and with 13 predictor
variables, power = .89, meaning this regression model was
sufficiently powered to detect meaningful factor effects.
3.8. Variables explaining variance in addiction is a disease
beliefs of treatment providers who have had a past
addiction problem
providers who have had a personal addiction problem and
are presently abstinent more strongly believe (M = 29.90,
SD = 6.32) that addiction is a disease than those who are
not presently abstinent (M = 23.78, SD = 3.74).
3.9. Variables explaining variance in addiction is a choice
beliefs of treatment providers who have had a past
addiction problem
Controlling for the effects of the eight variables entered at
step 1, step 2 in the model accounted for a significant increase
of 5.3% explained variance in factor 1 scores, Fchange(5, 179)
= 6.13, p b .001. Only one variable made a significant
contribution. Number of years as a member of a 12-step
group was negatively associated ( = .26, p b .001) with
factor 2 score. The longer treatment providers are members
of a 12-stepbased group, the less they come to view
addiction as a choice.

Controlling for the effects of the eight variables entered
at step 1, step 2 in the model accounted for a significant
increase of 12.2% explained variance in factor 1 scores,
Fchange(5, 179) = 7.48, p b .001 (see Table 6). Two of the
five variables made significant contributions. Number of
years as a member of a 12-step group was positively
associated ( = .24, p b .001) with factor 1 score. The
longer treatment providers are members of a 12-stepbased
group, the more strongly they come to believe addiction is a
disease. Being abstinent at present was also positively
associated ( = .16, p b .05) with factor 1 score. Treatment
3.10. Variables explaining variance in addiction is a way
of coping with life beliefs of treatment providers who have
had a past addiction problem
Controlling for the effects of the eight variables entered
at step 1, step 2 in the model accounted for a nonsignificant
increase of 1.8% explained variance in factor 3 scores,
Fchange(5, 179) = 0.64, p N .05. Thus, treatment providers
who have had a personal addiction problem in the past did
not significantly vary in their beliefs about addiction as a
way of coping with life across the step 2 variables.

Table 6
Separate hierarchical multiple linear regression analysis using scores on three factors extracted from the ABS as criterion variables: Conducted on data provided
by treatment providers who reported having had a personal problem with addiction in the past (n = 199)
Disease Choice Way of coping with life
Step Predictor Step 1 Step 2 Step 1 Step 2 Step 1 Step 2
1 Sex .00 .00 .07 .08 .09 .08
Age .12 .10 .11 .07 .08 .07
Years treating addiction problems a .07 .10 .07 .09 .02 .04
Certified .07 .07 .06 .07 .01 .01
Professional group membership .09 .06 .12 .07 .06 .05
Country .19 .14 .24 .17 .34 .31
Profit status .08 .06 .08 .06 .19 .18
SBS .48 39 .26 .12 .02 .06
Disease: F(8, 184) = 15.54, p b .001, R2 = .403
Choice: F(8, 184) = 7.57, p b .001, R2 = .248
Way of coping with life: F(8, 184) = 5.29, p b .001, R2 = .187
2 Attended treatment in the past .00 .03 .03
Attended 12-stepbased group in the past .12 .06 .06
Attend 12-stepbased group at present .08 .14 .00
Years membership of 12-stepbased group .24 .26 .14
Present abstinence status .16 .12 .04
Disease: Fchange(5, 179) = 7.48, p b .001, R2change = .122
Choice: Fchange(5, 179) = 6.13, p b .001, R2change = .110
Way of coping with life: Fchange(5, 179) = 0.64, p N .05, R2change = .018
a
Ordinal scale variable.
p b .05.
p b .01.
p b .001.
 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
4. Discussion
4.1. Key findings
Addiction treatment providers in the United States and
United Kingdom were surveyed on their beliefs about the
etiology of addiction, the need to receive treatment, and the
addicted individuals' capacity for self-control during drug
use. Seven variables were significant in explaining variance
in addiction beliefs. After controlling for the variance
accounted for by eight variables, treatment providers'
strength of beliefs in the disease model of addiction was
significantly predicted by the country in which treatment is
provided. Those who provide addiction treatment in the
United States more strongly believe that addiction is a
disease than those who provide addiction treatment in the
United Kingdom, whereas U.K.-based treatment providers
more strongly believe that addiction is a choice than U.S.-
based treatment providers. Those more likely to believe that
addiction is a disease also tend to provide for-profit
treatment, have stronger spiritual beliefs, have had a personal
problem with addiction in the past, are members of a group
of addiction professionals, have been treating addiction
problems for longer, and are older. In contrast, those who
believe addiction is a choice tend to provide public/not-for-
profit treatment, have weaker spiritual beliefs, be younger,
and not be members of a group of addiction professionals.
The country in which treatment is provided moderates the
effect of treatment profit status on providers' beliefs about
addiction as a choice and as a way of coping with life, with
those providing public/not-for-profit treatment in the United
States more strongly believing that that addiction is a choice
and a way of coping with life than U.S.-based providers of
private/for-profit treatment.
Finally, treatment providers who have had a personal
problem with addiction in the past are more likely to believe
addiction is a disease if they have attended a 12-step group
for longer and are presently abstinent. Beliefs that addiction
is a choice weaken among these treatment providers the
longer they remain members of a 12-stepbased group.
Overall, results suggest treatment providers' beliefs about
what addiction is largely fit a diseasechoice model
dichotomy, that agreement with one model predicts
disagreement with the other, and that addiction etiology
and course are understood very differently by U.S. and U.K.
treatment communities.
4.2. Conflicting beliefs in the United States versus the
United Kingdom about what addiction is
The assumed global dominance of the disease model of
addiction was not found; rather, the concept of addiction
meant very different things to the sampled U.K. and U.S.
treatment communities. The relative strength of the United
Kingdom's choice model endorsement is very surprising
given the unequivocal rejection of the idea that addicted
161
individuals are able to control themselves by influential
national health bodies such as the National Health Service
(2010): addiction is not having control over doing, taking,
or using something, to the point that it becomes harmful.
Not having control implies addiction compels action
regardless of the will of the individual. Thus, it appears
that those working at the frontline of U.K. addiction
treatment view and, therefore, likely explain addiction to
their clients in ways that contradict the disease-based
definitions and media messages of authoritative health
bodies. However, we have no evidence that treatment
providers treat clients in line with their beliefs when their
beliefs conflict with their institution's addiction ideology.
This is certainly a next step in this research.
The U.S.-based sample's tendency to favor the disease
model, however, was expected. Relative to U.K. treatment
providers, U.S. treatment providers both endorsed the view
of addiction as a disease and rejected the view of addiction as
a choice and as a way of coping with life. Disease model
beliefs appear to have persisted as the dominant view of
addiction in the United States since Schaler's (1992) initial
use of the ABS, although three methodological issues
suggest caution when comparing these studies. First,
although assumed by Schaler to be very high, Schaler does
not report the U.S.-based proportion of his sample; second,
Schaler's methodology involved mailing and requesting the
return of paper copies of his survey, whereas the current
sample were recruited and provided data online; third, the
current study did not use a repeated-measures design; it is
highly unlikely that any treatment providers provided data
for both our study and Schaler's study, and tracking down
Schaler's sample was impossible. Thus, we can only
tentatively conclude that the disease model has prevailed
as the dominant of the two models of addiction within U.S.
treatment services across the past 20 years.
That no prior research on U.K.-based treatment providers'
disease/choice model beliefs exists, however, prevents any
conclusions about whether the addiction beliefs of our U.K.
sample reflect a snapshot in an increasing, stable, or
decreasing trend of disease model support. Current findings
provide a context for assessing the stability of disease model
support over time, perhaps with developments and marked
changes to scientific and political perspectives on addiction
and a context for assessing addiction beliefs internationally.
One explanation for the discrepancy in belief systems
between the United States and United Kingdom may lay in
the sizeable difference between these country's public
funding of addiction research. In a recent national report,
Colin Blakemore, then head of the United Kingdom's
Medical Research Council (MRC) reported that, In 2003 to
2004 [the MRC] spent 2 million in total out of a 450
million budget on addiction research. The total budget of the
three NIH [U.S. National Institutes of Health] institutes that
work in this area is $2.9 billion so even if one takes a
conservative estimate of how much of that is actually
devoted to addiction research it comes out to about five
162 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
hundred times higher than in the UKin other words about
a hundred times more per head of the population (The
Science and Technology Committee, 2006). In the same
report, former chair of the Advisory Council on the Misuse
of Drugs Technical Committee, Professor David Nutt,
estimated the expenditure differential to be 1,000-fold in
favor of the United States. Future research should ask
whether there exists a significant association between this
research expenditure differential, a differential in breadths of
evidence bases regarding addiction etiology and treatment
effectiveness, and the differential in disease beliefs about
addiction reported by the current U.S. and U.K. samples of
treatment providers.
4.3. Methodological limitations
The e-survey methodology was inexpensive and allowed
faster and wider access to and response from our sample than
could have been achieved by mailing paper versions of a
survey or conducting face-to-face/telephone interviews. The
manual demands of generating a sample of 591 treatment
providers in such ways would have been impractical for this
study, although we do acknowledge that e-surveys may
induce a sampling bias, and so caution is suggested in
generalizing results to the wider U.S. and U.K. treatment
communities. For example, results may not accurately
describe the beliefs of treatment providers who declined to
participate, had difficulty in navigating the online format and
so did not complete the survey (and so, were excluded from
analyses), and those for whom electronic contact details were
unavailable/unknown and so could not be invited to
participate. Researchers who wish to make comparisons
involving current findings should also appreciate that the
dynamics of completing e-surveys versus paper-and-pencil
surveys may be different.
The larger sample of U.K.-versus-U.S.-based providers
may be partially attributed to the researchers' greater
knowledge of and access to U.K. treatment services.
Although the U.K. sample was boosted by enlisting the
help of U.K. DAATs to distribute survey packs, we made
every effort to offset this imbalance through an exhaustive
recruitment of U.S.-based treatment providers through
voluntary, statutory, and private association Web sites and
online databases. Additionally, approximately 1,750 (70%)
of the 2,500 subscribers of targeted e-newsletters are
believed to be based in the United States. Nonetheless,
recruitment would have benefited from collaboration with
researchers experienced in accessing U.S. treatment services.
4.4. Implications of treatment providers' ambivalent and
strong beliefs about addiction
Irrespective of either model's validity, current findings
indicate a potential for a diversity of addiction beliefs to exist
within treatment services, which has implications for how
effectively treatment providers work with each other and with
clients. People often enter addiction treatment because they
seek definitive answers as to why they find self-control of
drug use so elusive and to know what is wrong with them.
Ambivalence on the etiology of addiction reported by some
groups of treatment providers and the stronger committal of
the U.S. and U.K. treatment communities to the disease and
choice models, respectively, may, therefore, facilitate and
obstruct clients' change process in different ways.
On one side, treatment providers with strong beliefs in
either model are more likely to send a clear and unambiguous
message to clients about what addiction is and what it is not.
Defining the problem and giving clients clear direction as to
what they should do and expect in the short and long term
should enhance clients' perceived self-efficacy and optimism
for change. In contrast, providers who reserve judgment or
show ambivalence as to what causes addiction (which
implies endorsement of an eclectic treatment approach) may
send mixed messages to clients about the nature of their
problems and how best to deal with them. Thus, it may be
argued from a pragmatic standpoint that is it better for
treatment providers to convey a definitive perspective of
addiction to their clients, whichever that perspective may be.
On the other side, treatment providers who are strongly
committed to either model may be less flexible to change
when their beliefs are challenged by scientific evidence or
the anecdotes of other therapists and clients. In this way,
noncommitted providers should be more open to weighing
up contrasting empirical and anecdotal evidence and
adapting treatment to reflect current thinking on addiction.
The strongly disease- and choice model-committed U.S. and
U.K. treatment communities, however, may be less willing
to revise their treatment philosophy in the face of evidence
which suggests a revision should be considered. Among the
strongest disease beliefs in the current sample were reported
by treatment providers who have had a personal addiction
problem in the past but are abstinent at present; these groups
of treatment provider may be most likely to stick with the
treatment methods that have worked for clients and
themselves in the past, regardless of client differences in
symptomatology, environments, and reasons for drug use.
Finally, a common criticism of the diseasechoice debate
is that absolute truths about addiction are irrelevant so long
as people do recover. The success of treatment may
therefore depend on the degree of congruence between
treatment providers' and clients' beliefs about addiction
(Keene & Raynor, 1993). Assuming that disease-based
messages will be less effective if clients ultimately believe
that they are not diseased (and likewise for choice-based
messages), the ABS may be used to match therapists and
clients on belief compatibility at intake. If the success of
addiction treatments is shown to depend on therapists
fostering clients' clear and uncompromised addiction beliefs
of whatever kind, then we may be justified in abandoning the
search for absolute truths about addiction and instead
focusing on the importance of subjective experiences and
lay conceptualizations of addiction to the change process.
 C. Russell et al. / Journal of Substance Abuse Treatment 40 (2011) 150164
Acknowledgments
The authors are grateful to all participants who gave up
their valuable time to help with this research and to Rowdy
Yates, Douglas Cameron, Moira Plant, Martin Plant, Stanton
Peele, Ted Russell, Gemma McGill and three anonymous
reviewers for their suggestions at various stages. Dedicated
to Martin Plant.
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