Models of Addiction: Moral and Medical

Testing, testing, testing. Okay. Renee, can you hear me? It. Test microphone. Okay. Okay. One more test here and we'll be ready to go. So welcome to Today's presentation by allce.com. Today we're going to start discussing the models and theories of co occurring disorders. Now, when we think about co occurring disorders, it's important to remember we're talking about mental health issues as well as substance abuse issues. But we're also looking at only a really small subset of the different theories of what causes these things. And when you get into the material that I've included in the course, the text material, if you decide you want to read that, and that's not on the exam, but you'll see that there's probably 75 different theories, all of them slightly different, none of them actually fully explaining why people develop substance abuse issues and mental health issues and why certain people don't develop those issues. So we're going to look at what we've got so far, and I really want to encourage you to think about how you conceptualize the origin or the causes of addiction and mental health issues. Because as you treat a patient or as you work with a patient, you're probably going to communicate to them from a standpoint that is underpinned by your theory of addiction. So as we go through that may be a little bit more clear. Over the next hour, we're going to explore the foundation, strengths, weaknesses and recovery goals of the following theories. The moral model. We still have to cover that even though it's really not used a lot anymore. The spiritual model. The disease model. That's a biggie. The genetic model, drive model, and public health model. Now, as I've said in other classes that, you know, I've done, whether it be online classes on demand or the live webinars, I am not going to hold you accountable for the minutia. What I want you to do is get the broad stroke. So I'd rather you listen and think about it and really kind of toss and turn it around in your mind than get hung up on any statistics that you may see or anything like that. So the moral model was probably one of the first models of addiction. And we can go back to prohibition and think about that. Addiction is a choice made by individuals with low moral standards. Addicts are characterized as inherently bad people who do bad things. Now, does this really explain what's going on? No, I haven't seen where it really explains a lot about what's going on with the addict. What we do see is people who embrace this model, if people who embrace this model, I'll take my own biases out of it, really have a negative self image, they're seen as bad people, which means they make bad choices. And that also kind of means that it's kind of like telling a small child you're a bad boy, as opposed to you made a bad decision. And something that is internal, stable and global, like being a bad boy, is not changeable. So can this aid in some prevention efforts? Yeah, you know, you can use it as a scare tactic. But when we really look at some of the other theories and some of the other research about why people use, you're probably going to come to find that this doesn't really hold water. Because even if they've been provided with all the scare tactics in the world, when it comes down to it, if a person is in enough pain that they need to engage in addictive behavior, what somebody said about it 15 years ago probably isn't going to make a huge difference. So, moving on, drawbacks. It increases depression and self loathing. People start seeing themselves as bad and loathsome people and it doesn't provide any real solutions. If you're bad, how do you change that? That's like saying your room is messy. Well, what messy means to me is very different than what messy means to my daughter. And what bad means to me may be very different than what bad means to someone else. So who is it to say what is moral, what is right and what is good? The recovery goals of the moral model are to develop a stronger moral compass and through willpower, make better choices. Those choices guided by some moral compass somewhere. Which takes us to our next model, the spiritual model. Now the spiritual model kind of plays off of the moral model and says it's a disconnection from God or a higher power that causes people to turn to addiction. This disconnection leaves people feeling sort of like a fish out of water. Causes separation anxiety, loneliness, alienation, and a desperation to numb that void inside. The strengths of the spiritual model are that it does work with a 12 step philosophy which encourages turning will over to the higher power. So we can look at this from that perspective. And I'll interject my own biases, if you will, right here. When we're dealing with, or when I am dealing with a patient who has an addiction or co occurring disorder, do I believe that they need to figure out a different compass? Do I believe they need to figure out a different path to take? Yeah, you know, they're not on a path that they want to be on right now. Now, what that path looks like Is going to be different for each and every person. So I think people really need to consider good, orderly, direct, Consider the big picture, the long haul, when they're making their choices. And I believe that part of addiction recovery Is not only fixing the brain chemistry, but also fixing the thinking patterns that either helped corrupt the brain chemistry or maintained that high level of anxiety, anger, agitation, fight or flight stuff going on. Drawbacks to the spiritual model. There is very little empirical evidence that supports this notion that simply a disconnection from God or a higher power and causes addiction and a reconnection to that higher power eliminates addiction. There is a large percentage of people for whom this is not an option. They do not believe in a higher power. So what do we do with them? Do we tell them they're wrong? My training as a clinician would be to say no, we can't tell them that their philosophical or their spiritual beliefs are wrong. They're theirs. So we need to figure out a way to work with them. Which is one of the reasons we talk about God as good, orderly direction in the recovery circles, if you will, because it helps the people who are atheists, who are agnostic, who are just not in a good way with their higher power, to hear what we're saying without being put off by a message of spirituality. And, you know, so bringing them in to the recovery mindset is my goal. Honesty works for everybody. It doesn't matter if you have a higher power or not. Honesty works. Hope again. Hope that things will get better. Hope that if you do the next right thing, good things will happen. It works. Faith in yourself, Faith in the process, Faith in other people. At this point, we're not even talking necessarily about a higher power. Now, if people have one, great. But you can see how the principles of the 12 steps can be applied In a secular sort of situation. Recovery goals of the spiritual model consist of establishing or re establishing a connection with God or a higher power. Through this connection, Finding a roadmap for life which brings peace and contentment. That sounds wonderful. It does. But for those people who cannot or will not embrace this notion of God or a higher power, we have to find something else. The other caveat I'd throw in there is there are people who are atheist and agnostic and, you know, whatever else, who have had addictions, who have found recovery. So how do we explain that if recovery is only found through reconnection with a higher power? Now we're on to our medical model. This is the one that we talk about most, and this is the one that probably gets some of the most bad press, if you will. And there are pieces of it that are very accurate. But like every other model out there, it fails to explain with any statistical certainty who develops addiction and who does not develop addiction. So bear that in mind. The disease model says addiction is a consequence of physiological changes that addictions may cause. The disease model of mental health says that the mental health issues can be a consequence of problems in the brain chemistry. So putting that out there in addiction, these physiological alterations can cause cravings to take more drugs. We know from other presentations and the research that the physiological alterations, the brain adapting to overstimulation from drugs, it does cause changes in the brain, and those changes do cause cravings to occur. So this is very much true. When we look at mental health, we also see that differences in brain chemistry and brain circuitry and just the brain itself can also predispose someone to depression, anxiety, ptsd. We know that there are changes in the brain that take place when someone has post traumatic stress disorder. The disease model says users cannot be held accountable for their addictions and are, quote, powerless over them. It says that it's these biochemical changes, it's this organ dysfunction that causes the addiction. And that comes from the ACM website. So I put the web, the web address down there if you want to go look at it. So a different, slightly different way to look at the disease model is one that's very basic. It says there has to be an organ. Well, in this case, the organ is the brain. There has to be a defect in that organ. Brain changes that are caused either before the addiction starts, causing mental health issues that lead someone to self medicate, or brain changes that cause that happen during the addiction because of overstimulation. So there are brain changes or brain defects which cause symptoms. And these symptoms can be cravings, they can be withdrawal, they can be tolerance. The physiological symptoms lead to behavioral actions, lead to emotions, lead to a lot of other things. So the disease model says if we address that defect in that organ, then the symptoms will go away. Well, that sounds great. But since we don't know exactly what problems in the brain cause addiction, we know that there's not a gene now. But since we don't know exactly which pathways do what half the time. Well, maybe not half the time. A lot of times we don't know exactly what neuropathway certain medications are working on. We just know, hey, it seems to work cool. Always makes me feel good when I'm talking to a patient about the medications they're on, but there's no way to reliably identify a defect or a cluster of defects that we can say. If this is present in a PET scan, we know this person is going to develop an addiction. So we're going to watch a little bit of a video. It's a Grand Rounds lecture given by Martin Nicholas in October of 2010. We're only going to watch part of it. But he talks about the disease model in a way that I found very interesting. Oops. And it's not going to open on the right slide.

There are three pillars, what passes for a disease concept in most of the alcoholism treatment and that most of us carry. Number one, that alcoholism is, among other things, a spiritual disease which can only be cured by a spiritual enlightenment involving surrender to a higher power. Number two, that individuals become alcoholic because of their moral shortcomings or their character flaws or other serious defects of personality. And number three, that alcoholics cannot help it because of their genetic constitution. In other words, if you look at an alcoholic patient through this lens, what you're looking at is an arrogant sinner who's deeply damaged in their psychological and moral structure and is genetically programmed for disaster. That's what this theory says. It's a spiritual disease, so you're an arrogance center. It's a character flaw, so you're just a really rotten person. And number three is genetic. You can't help it, you're programmed for it. Not one of these, not one of these pillars of the so called disease concept that most people are working with has stood the test of the last 50, 60 years of scientific research. Spiritual disease. Well, countless laboratory animals have been teaching us that the development of alcoholism and other addictive diseases has much more to do with pharmacology than it does with theology. You can take a rat and millions of rats and mice and other mammals are routinely turned into addicts in laboratories, maybe even right here in Victoria, that turned into addicts simply by saturating their bloodstreams with a non lethal but high dose of alcohol or other addictive drugs for a relatively short period of time. At the beginning of the process, the animal ignores alcohol, shows no interest in it, prefers the natural foods that are available. After two weeks of saturation with the bloodstream, the animals completely turn around, ignores its natural foods, goes for the alcohol or other addictive drug, and if deprived of that, will press a lever thousands of times, tens of thousands of times, will ignore hot, cold, electric shock, water, sex, any other drug in order to get more of the addictive substance, They've turned into addicts and laboratory experimenters do this routinely because the animals are such a good model of human addiction. Well, that's true. And if that's true, then what possible relevance could the concept of spiritual disease have to the development of the addiction? Spiritual disease is not a meaningful concept when applied for rats and mice, is it? Or fruit flies or nematodes, all of which can be converted into addicts by the saints of the.

So I do want to pause here and point out that he is highlighting the fact that, you know, rats and mice can have those brain changes that are brought on by the pharmacology. Now, when we talk about rats and mice, we also don't do recovery studies with them. We know that their brains can recover some when not exposed to the drugs. Where a lot of our counseling and psychotherapy comes in Is that rational mind that rats don't have. And that ability of humans to look at good, orderly direction. Yeah, we need to address the brain changes that happened. We do need to fix that organ, if you will. But in the process, we also need to look at some other secondary things, if you will. Stinking thinking, inappropriate social environments, dangerous behaviors, those sorts of things. We need to address all of those. So I don't want to throw the baby out with the bathwater, if you will. I think it's important to understand that both mental health and substance abuse do have a biological basis. There are brain changes that happen. So it's not just a moral thing, it's not just a choice thing, but it's also not just a brain thing.

What these experiments teach is that the roots of addiction Lie in the direction of pharmacology and not in the direction of phenomenology. Number two personality defects. In the last 50 years, we have developed excellent tools, excellent instruments for measuring personal personality traits, Such as the Minnesota multiphasic personality inventory and a number of others. It is now possible to determine what people's personality traits are. And then to see whether certain personality traits predispose someone to become an addict. To test theories such as whether maternal deprivation or authoritarian fatherhood or any of these other things that are thought to predispose people actually do. These studies over the past 50 years have come up consistently blank, negative. Every personality type, every personality defect or positive trait Is about equally likely to become alcoholic or addicted if they start using addictive substances. There simply is no scientific truth to the concept of moral weaknesses, Ethical defects, character defects, Personality traits, and so forth as being involved in the etiology of alcoholism.

And again, I do want to point out, because this flies in the face of so much of what we typically learn in 12 step programs and addiction classes in college. Personality defects, stinking thinking, cognitive defects, exposure to traumas, all that stuff. They haven't found a causative link for addiction. Do we know that there's a high correlation? Yes, but we have not found a causative link.

If you will read the current issue of Scientific American and you'll see bursting to the surface of a semi popular magazine like that, a dispute that has been raging in the field of genetics for the last five years or so. As you know, a little over 12 years ago or so, we first succeeded in sequencing the human genome. And we now have tools unlike any that we've ever had before for looking in the human genome to see where the genes are that might cause certain diseases. And so this research has been done for a broad range of diseases, including of course, alcoholism and autism and cancer and heart diseases and many others. And the expectations and promises made at the beginning of the genetic research, modern genetic research, was that we would soon locate the specific genes or gene variations or alleles that caused these specific diseases. If you will read the the current summaries of what's not what's happened with genetic research, you will see a tremendous earthquake through the science because what's been found in so many cases of major diseases is, in a word, nothing. The better we see into the genome, the more clearly we understand what's really happening, the fewer genetic routes we find of the major diseases. And that's the case as well with alcoholism. The idea that there was that there is a gene, an alcoholism gene, has now been debunked. It is no longer the case that there is an alcoholism gene. We now can look in the genome. There is no such gene. There may be a number of genes that predispose people to alcoholism when in combination, but no one yet knows whether that's 8 Genesis or 100 genes or 800 genes that make up the pattern. And also we now know that there's not one single pattern, but there may be many different patterns. And we also know that each of these patterns is profoundly influenced by the interaction of the organism with the environment. The old idea of the DNA as a mainstream or as a computer program that determines the person's life and behavior has been completely exploded. If you leave, as I say, if you'll read the Scientific American article, which summarizes much, much professional literature prior to that time, you'll See that the field of genetics research is in a huge crisis because of the fact that now that we can really see what's going on, we see that it's not going on, that our old preconceptions about many of these diseases are simply not true. But it's a great, great turning, it's a great exciting moment to be in today's research because we now know the level of ignorance. But in any event, I'm going to stick to my subject, which is that the idea that there is an alcoholism gene and that the alcoholic is determined by his gene to become an alcoholic is just a myth. It's vaporware. It did not bear out. Bottom line. The religious, psycho, moralistic geneticist stock that the legacy disease concept conveys to us is without a scientific foundation. It is not a true, genuine and evidence based model of addictive disease. Given the pejorative content that's inherent in this model, namely that the alcoholic client is an arrogant sinner with terrible character flaws in genetically programmed. It isn't a surprise, is it, that physicians and other health care providers who have never taken an addiction medicine course to learn differently, would have this furniture in their minds and that they would look at the alcoholic patient as someone that's not very pleasant to deal with, as someone that really ought to be somewhere else, get out of here, go to AA and don't bother me. That's too often the feeling you get. And the reason for it is that medical professionals haven't been supplied with a valid, empirically supported model of addictive disease. Now, as a result of the shaky to say it in the most kind way, as a result of the shaky foundations of the legacy disease concept, the disease concept has many opponents, not only popular opponents, but also scientific opponents. There was a book a few years ago by Herbert Fingert attacking the whole disease concept and saying it was just all bunk, that there was nothing to the disease concept of alcoholism at all. And there are many purveyors of many disciples of them today. If you follow the popular literature, you will see any number of websites that tell you that the idea of alcoholism is disease is just jump. And the Supreme Court of the United States, when confronted with the disease concept, when asked to test its validity in particular cases, has thrown it out with scathing and sarcastic remarks that the disease concept is amorphous, ill defined means meaningless, empty of content, and certainly not anything that the court could base its decisions on. So you have an opposition to the disease concept that would throw it out in its entirety. And the result of that would be, you know, that if you discard the disease concept, what you're saying is that a physician should have nothing to do with, shouldn't even come to physicians offices to be sure, secondary symptoms of it like the liver diseases and so forth, that remains for the doctors. But alcoholism per se as a primary disease is not for the doctors. It's not disease. Get it out of here. And that means that the jurisdiction over the alcoholic goes away from the medical profession and goes toward the clergy. The sinner, yes, alcoholics, the sinner. So it goes to the clergy and the faith based organizations and it goes to the courts, the judges, and it goes to the prisons where they punish or try to reform or they warehouse. At least in the US they warehouse and store the alcoholic until the money runs out. So the decision over whether alcoholism is a disease or not is not just a scientific decision. It is in some ways above all a jurisdictional decision, an economic decision, and a social decision of great importance.

Okay, so there are a couple more slides on the disease model before we, before we leave it. It is such an impactful model, it does draw such rabid response both for and against, that it's important to be well versed in it. Okay. When I was in graduate school and when I did my first practicum, I was taught the disease model and the characteristics of a disease were that it was progressive, incurable and fatal. And when I started doing research on the model of addiction and the disease model of addiction, that didn't really bear out because it's not always, not all diseases are always fatal. You know, we start thinking about some physiological diseases that aren't necessarily fatal. But let's take those three characteristics just for giggles and look at it in terms of a behavior. Nearly any behavior is progressive, incurable and fatal. Or not fatal, but progressive and incurable. Why is this? Because organisms behave in order to receive reward. We know rewards produce a dopamine rush. You see where I'm going with this? So take for example, being a salesman. When you first start out your first sale, you get an amazing rush. It's like, oh, yeah, I did it. As you keep going, you're only selling a few things a week, but you're getting that occasional rush of dopamine. It keeps you coming back, it keeps you working harder, it keeps you trying to sort of chase that high, if you will. You keep getting better. Start selling a few things per day. See, it's progressing, you're getting more dopamine surges, you're getting more money, you're Getting better at your job, you're getting better at doing what you need to do to get that dopamine rush. Eventually, you need to find bigger goals or harder targets to get the same high. You need to be the number one salesperson for the entire month or whatever the case may be. So let's say at a certain point, you're just. You're worn out, you're burned out. You've been doing this for so long, and you're just not getting the rush from it anymore. The dopamine system is exhausted. So you take a break, change careers. Ten years later, you decide you really miss it, you come back. So this is sort of the equivalent of recovery and relapse. So the person comes back, the skills that they had are still there. What they used to do is still there. What used to work is still there. When we think about the addiction, who relapses, they have these behaviors that worked to numb intolerable pain. Now, yeah, it caused a lot of intolerable pain, too, but it numbed intolerable pain. So when you look at it that way, when they're in recovery or maintenance or whatever you want to call it, and something happens that overwhelms their coping skills and nothing else is working, are they going to go back into that toolbox and find whatever works? Yeah, there's a good chance they will. So it's important to help people realize, whether you want to call it a disease or a behavior pattern or a coping skill or whatever you want to call it, if it gets bad enough and everything else has failed to work, the person with the addiction may return to the addiction to make the pain stop. That is their survival go to. So the drawbacks to the disease model is it takes responsibility away from the person. In many cases, it says, your brain, that organ, is dysfunctional. Some versions of the disease model views addicts as victims, victims to their brain dysfunction and creates a sense of learned helplessness. You're broken, you're always going to be broken. So, you know, might as well just deal with it. With the disease model, people need to develop a new way of living that protects them from these things. It's kind of like back, you know, I'm going to age myself now. Back in the day, there was a story about a boy in a bubble who had. He had no immune system or very little immune system. So they had to put him in this very sterile bubble to help him stay safe. And what the medical model basically says is, unless we can figure out how to fix your brain, you need to stay in a very controlled bubble in order to stay safe. Now, going along with the medical models is the genetics or inheritance model. And like you talked about in the video, we haven't found a gene. There is not an alcoholism gene. We do know that there are combinations of genes that are more likely to be found in people with addictions because it either makes them more reactive to the substance, or those gene sequences are responsible for pre existing mental health issues. According to asam, genetic factors account for about half of the likelihood that an individual will develop addiction. So that's the same as taking a penny and flipping it and going heads or tails. Now, I don't really want to stake somebody's life on heads or tails. We do know that it's 50 50, but we also know if somebody has a predisposition, it doesn't mean they will develop an addiction. The strengths of the medical models are that in twin studies and adoption studies, there's been some evidence that there are certain brain characteristics that may be associated with the development of addiction. The drawbacks, the exact genes and genetic causes haven't been identified. And a predisposition does not mean causation. So we can't say that just because somebody comes in. If somebody comes into your office and they've got a runny nose and watery eyes and a scratchy voice and they say they feel like crap, does that mean they have a cold? Not necessarily. They could be intoxicated on opiates. They could have any range of allergies. There's a whole bunch of things that could be going on. When we look at the presenting issues, if you will. Recovery goals of the medical models are to understand why a particular addiction is rewarding, what brain circuitry is going on in there and getting all wonky, Fixing that reward circuitry and avoiding exposure to things that could trigger the onset of the addiction. So maybe you have a really bad allergy to ragweed and you take medication in order to reduce your histamine reaction to that ragweed. That's great. You're fixing that circuitry a little bit, you know, maybe not all the way. But you also avoid exposure to ragweed because you don't want to trigger your addiction. You don't want to go, well, let's see exactly how much the medication will actually block the histamine reaction. Drive theories. Addiction involves the development of powerful drives underpinned by homeostatic mechanisms. This goes back to the broken brain. We know that the brain wants to maintain a certain level or homeostasis of our neurotransmitters so if those are wonky, either by, from biology, you know, organic causes, or from taking drugs, the brain is going to try to balance itself out. That's the cool thing about our bodies. It wants to survive. Our brain wants to survive. Our body wants to survive, and it knows it survives by maintaining homeostasis. So when those homeostatic mechanisms are thrown out of whack, there are cravings. The strengths of this is it does sort of explain the withdrawal and craving thing. And many urges and cravings have characteristics similar to naturally occurring drives. Sleeping. Your body wants to maintain certain sleep wake cycles, homeostasis, Believe it or not. Sleeping, there are neurotransmitters involved. Your body is secreting serotonin that makes melatonin and helps you get to sleep. So there are neurotransmitters involved in sleeping, in eating, in just about everything that we do. Our sleep, wake cycles. The drawback to drive theories is that not all addictions follow a pattern suggestive of the need for homeostasis. At a certain point, people may. Or rats, you know, he said they would hit a lever tens of thousands of times and avoid eating. Is that a survival drive? No. Is that maintaining a balance? No, that is a complete dopamine pleasure driven reaction. Now, can that explain a drive? Yeah, if you're driven by dopamine. Even addictions that suggest a homeostatic drive mechanism also show evidence of other important influences. Social environment, the interaction between the person and the environment. We want to help people identify what functions the addiction is serving for them. What's the drive motivating this behavior. And help them find alternative ways to achieve that same end, as well as to maintain homeostasis, if you will. What are some ways they can maintain a balance? It's not 100% high all the time. It's not 100% depressed all the time. There's a middle ground. There's an ebb and flow. And finally, the public health theory. Public health has a three pronged approach to prevention and intervention. The agent, host, environment, if you will. And this is more of a socioecological theory, but it applies to public health issues just like diseases do. So I put it in this one. Threats to public health require a susceptible host. That would be, in the case of addiction, a person, an infectious agent. In the case of addiction, something that causes a dopamine rush. And I'm avoiding intentionally saying drugs, because we can get addicted to just about anything that produces enough dopamine. So a person, an infectious agent, and a supportive environment. So that's an environment that condones or supports engagement in addictive behaviors. And maybe creates a situation where there's a need for numbing for some reason. High stress environments, very depressive environments, natural disasters. There are times when life just throws a load of crap at people. And I wouldn't expect them to be able to deal with life on life's terms with the normal skills and tools they have, which is why social support is so important in the middle of crisis situations. But in any event, the public health model, and this is what we use in a lot of prevention programs and the CDC uses when it's addressing violence and a bunch of other things, says there has to be a host, an agent, and a supportive environment. Strengths. There's no doubt that an interplay between the individual, the environment, and the reward from the behavior lead to addiction. We don't exactly understand what this interplay is, but we know that you can't just take one out and explain addiction. Interventions in any one of these prongs will help prevent or intervene in addiction. Well, so let's look at the individual. If we take the individual and we start looking at that organ again, trying to figure out if there's any organic underpinnings to this addiction. And that could be letting the brain recover through a detox period. Or that could be addressing underlying biochemical imbalances that are leading to depression, bipolar disorder, schizophrenia, etc. So with the individual, we can look at the organization. We can also look at cognitive patterns. We've come to understand that our thinking can impact our mood. The way we interpret event can impact whether we feel the need to fight or flee. When we fight or flee, there is an adrenaline rush. And all kinds of cascades of effects happen within the person. Biochemically, the environment. If the environment is not supportive of addiction, if addictive behaviors and addictive substances are not easily available, if there are alternatives to meeting those addictive needs, if you will, then there will be a reduction in addiction. And it's important to remember, like Dr. Matei talked about in one of the other classes that I did, it's just as important to look at all the reasons the person doesn't want to use or all the problems addiction caused, as well as all of the reasons the person did use. What did they get out of it? What was the benefit? We've got to figure out what the benefit was. Because people do what's rewarding and they avoid what's punishing. So if we don't help them meet those rewards or find another way to meet those rewards, we're setting them up for failure. Drawbacks. We still don't know exactly what characterizes the host, agent or environment. Like I said, we don't know in large part what character it characteristics of a person. Say you are at really high risk for addiction. We have some idea, but not from a statistically significant point of view which would be able be being able to predict it. Like a 97% accuracy rate. The agent. We know that people can get addicted to a whole lot of things. So why one person gets addicted to gambling and one person gets addicted to cocaine? Maybe exposure, maybe something completely different, an environment. We can take two people that come from the same environment and one may end up being a pillar of the community and another may have difficulty dealing with life on a day to day basis. So we need to look at the interplay between these things. My old boss is a perfect example. He was one of 13 children and he was the only one of 13 children that did not have an addiction. So what was different with him? What you know, I don't know. The recovery goals in the public health model are to prevent further harm caused by the addictive behavior. Well, that makes sense. Develop a supportive recovery environment. Eliminate anything that made the host susceptible. Physical pain, emotional pain, poor coping skills, lack of social support, and eliminate the infectious agent or develop an immunity to it. So in the example of addiction, you know, if we make the drugs and alcohol less available, if we make the porn less available, that's eliminating the effect infectious agent. Some things like alcohol. We figured out how to counter condition, if you will. You're not going to develop an immunity to it. But someone who is taking Antabuse, for example, will get violently ill if they drink. So that prevents the reward from occurring. People who take opiate antagonists, the opiate antagonists block the action of the opiates so they don't get the high. And it's like, well, what's the point? There are a lot of different things we can do to make the addictive behaviors less rewarding and to help people find rewards elsewhere. So the moral model is one of the earliest conceptualizations of addiction. Like most others, it provides only a unifaceted explanation for behavior. The medical and disease model takes the responsibility off the person with the addiction who has the biological or genetic weaknesses or defects. In lieu of understanding the function of the behavior and trying to develop alternatives, it encourages avoiding a lot of behaviors altogether. The public health model begins to look at the issue as a more complex one. But it's failed to identify with any reliability or validity what factors in the host and or environment actually contribute to a recreational activity or recreational use of a substance becoming an addiction? If you've watched this and participated for CEUs, you can log into the classroom@allce.com and take the quiz. If you've watched and participated in this presentation and want CEUS but have not yet registered, you can purchase access to the quiz@allce.com live interactive webinars I am here and open for questions, discussion, anything you would like to part throw out there. You can also reach me on my personal chat page at purechat me qtvx. If you think of a question later that you want to ask, or you want to debate a point with me, or provide your own insights from your clinical experience, I'd love to hear from you.