A common question that arises when talking about addiction is why? Why do people use? Why do some people become addicted while others don’t? Why can’t people who are addicted just stop?

These questions are understandable especially when individuals dealing with addiction have suffered catastrophic consequences as a result of their use. Yet the answers to these queries are complex, and there isn’t a one-size-fits-all answer. In this chapter we will look to answer these common inquiries to gain a better understanding of addiction.

Nature or nurture? Yes!

Is the cause of addiction related to nature or nurture? Often a combination of factors contribute to the development of an addiction. Various theories of addiction seek to explain these factors. To better understand addiction, it is important to explore these theories and look at the risk factors.

Theories of Addiction

Morals and Personal Responsibility

A widely held societal belief is that addiction is simply a lack of willpower or moral compass. After all, it’s hard to imagine why someone would continue a particular behavior despite having catastrophic consequences related to it. Many people assume that addiction is a matter of choice, and if the addicted person simply had willpower and would adhere to appropriate morals, they would be able to stop. This is not the case with addiction. Once the brain has been hijacked, the power of choice is removed even for the most righteous.

The Agent

With an agent model of addiction, the focus is on the drug, or the agent, and its powerful effects. Drugs affect the central nervous system, including the brain. The most significant area of the brain that is impacted by drugs is the nucleus accumbens, often referred to as the “pleasure center.” Because of the drugs’ ability to tantalize this pleasure center in profound ways, drugs are seen as the reason people use and become addicted. Not sure if this model of addiction is widely accepted? Simply look at “the war on drugs” which emphasizes the notion that if we simply get rid of the drugs, we’ll get rid of the drug problem and thus addiction.

Genetics

Much research has been done to determine whether or not there is a genetic component related to addiction. Just as people may be genetically predisposed to certain diseases such as cancer or diabetes, so too may be the case with addiction. Given the findings from various studies, genetics does appear to play a role in the development of addiction. However, it’s important to remember that individuals are complex beings with complex and unique experiences. Simply because a person is predisposed does not guarantee they will develop an addiction. However, they will be more at risk to develop one. More research into epigenetics, the study of the interaction between the environment and genetic make-up, is being conducted.

Learned Behavior

Social learning models of addiction focus on combinations of factors. One is that alcohol and drug use are behaviors that are influenced or learned from others (family and peers) who model that behavior. Another factor in social learning models is the importance of classical and operant conditioning. When drugs or alcohol are ingested into the body, involuntary reactions occur such as neurotransmitters being released (classical conditioning). The consequence of ingesting, often a pleasurable feeling, draws an individual back to use (operant conditioning). The expectations that person has as to what drugs or alcohol will do (the cognitive process and belief) are the final factor that comprise social learning models. Let’s be honest . . . drug and alcohol use have some benefits; otherwise, people wouldn’t use them. Of course there are negative consequences associated with using, such as hangovers, but those who are addicted overlook these disadvantages and focus on the pleasurable effects.

Sociocultural Influences

Sociocultural models take into account the societal environment in which people live and how that environment may influence use. The idea is that environments with higher levels of use, combined with easily accessible drugs and alcohol, place individuals at a higher risk for consumption. Furthermore, drugs and alcohol are often portrayed in advertising and media in positive ways. One area of particular concern is disadvantaged communities. Look in any socioeconomically deprived area, and you are likey to find an abundance of liquor stores.

Public Health

The public health model is the most comprehensive model of addiction. It takes various factors into consideration when identifying the causes of addiction. These factors are broken into three categories: the agent (the drug), the host (the individual), and the environment (those factors outside of the individual). Addiction is viewed as the result of a complex relationship between biological, psychological, and social factors (Kinney, 2014). Because of the intricacy of this model, we feel it is the most comprehensive and best for guiding treatment.

Risk and Protective Factors

Risk factors can be internal (within the individual) or external (outside the individual). No single risk factor or combination of risk factors determines whether a person will develop an addiction. Instead, having one or more risk factors increases the chances that an individual who uses alcohol or other drugs will develop an addiction.

These risk factors include (in no particular order of importance):

• Having a mental health disorder
• Lack of family involvement
• Lower socioeconomic status
• Peer pressure
• Using drugs at an early age
• Chaotic home environment
• Poor social skills
• Drug availability
• Low self-esteem
• Poor academic performance or other school related problems
• Using drugs that have a higher likelihood of physical or psychological dependence (opiates, cocaine, etc.)
• Route of administration (such as smoking or injection)

The good news is, just as there are risk factors that can contribute to developing an addiction, so too are there protective factors that can help prevent addiction. Like risk factors, protective factors can be internal or external. Also, just as having one or more risk factors does not make addiction inevitable, having one or more protective factors is not a guarantee that an addiction will not develop.

These protective factors include (in no particular order of importance):

• Having a network of support
• Parental/family involvement
• Academic competence
• Having healthy coping strategies
• Sense of psychological and physical safety
• High self-esteem
• Ability to emotionally self-regulate
• Resiliency
• Social competence

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Transtheoretical Model of Change

Professionals in the field of addiction often refer to the transtheoretical model of change created by James Prochaska and Carlo DiClemente to help people who do not have an addiction understand why people continue to use and why they might relapse/lapse. While studying behavior change, Prochaska and DiClemente identified six distinct stages that people tend to move through when making behavior changes. We will discuss those in just a moment.

For now, think of your own examples of behavior change. Perhaps you’ve tried to quit smoking. Maybe you have tried to implement a healthy eating plan or an exercise routine. Other examples of behavior change include stopping cussing, listening and communicating more effectively, avoiding procrastination, being more punctual, etc., etc. The list is truly endless. Chances are you have tried to make some type of behavior change in your life. Most of us have. Chances are, you were challenged with sticking to the new behavior. Most of us do experience a return to the old behavior, even if briefly. Hats off to those who set out to make a behavior change and stick to it without ever taking a backward step. They are often exceptions to the rule. If you are one of those people, kudos to you. Now let’s look at the stages identified by Prochaska and DiClemente and see if you can relate those to your own behavior change process while we examine how it might look for the addicted individual.

The first stage they identified is what they termed precontemplation. In this stage, the individual doesn’t realize there is a problem with their behavior. They may say something along the lines of, “Problem? What problem? I don’t have a problem. I like to drink a little bit. So what? I work hard and I deserve to have a couple of drinks at the end of a long week.”

The next stage is contemplation. During this stage, the individual starts to contemplate change, realizing that perhaps something needs to be different. This stage is also marked with ambivalence: sometimes the person thinks change is necessary; at other times, the status quo feels perfectly fine.

Following contemplation is preparation, where an individual begins to take steps to prepare for change. Those with a substance use disorder may make calls to treatment centers to gather information, or make inquiries about community-based support groups. No matter what the actions, the person is taking steps in the direction of change. However, it’s important to note that an individual in this stage hasn’t fully implemented the desired behavior change.

Next up is action. Just as the name suggests, individuals in this stage are engaging in the new behavior and have taken action. They are doing it! In the case of substance use disorders, the individual has stopped using (unless a harm reduction approach is being used). They have committed to the new behavior. Prochaska and DiClemente felt it important to make a distinction between this stage and the next. They suggested the action stage lasts from a period of 0 to 6 months.

Should the new behavior continue past 6 months, the individual then enters the maintenance phase. In this stage, the individual is maintaining their new behavior. Those in recovery from addiction have an abundance of pathways for maintaining the new behavior. From community-based support groups such as Alcoholics Anonymous and SMART Recovery, to avoiding people, places, and things associated with use, to taking up new interests and hobbies . . . the list could go on ad infinitum.

One of the defining features of addiction is the tendency toward relapse, the return to the old behavior. Relapse is the last stage of change identified by Prochaska and DiClemente. Most individuals who attempt to change a behavior experience a lapse or relapse (a lapse is temporary—a bump in the road—and a relapse is a prolonged return to the old behavior). In a study conducted by Kelly et al (2019), the researchers found that the average number of times an individual attempts recovery from addiction is 5.35. If lapses and relapses are typical with any behavior change, why would we expect recovery from addiction to be any different?

It is important to recognize that a lapse or relapse isn’t a sign of complete failure. Rather, it is a time to reflect on what went wrong and what was missing from the behavior change plan. It is a time to build upon skills that were already learned and implemented as well as looking for new possibilities.

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Summary

As we can see from this chapter, there isn’t a simple answer as to one specific cause of addiction. Rather, there are many possible contributing factors. The more contributing factors (also known as risk factors) a person has, the more at risk they are of developing an addiction. The good news is there are also protective factors that can ward off risk factors and help prevent addiction from occurring. Our hope is that all who read this have a better understanding as to not only how addiction develops, but also why the simple suggestion, “Just stop!” isn’t so simple.