One way that many mental health researchers conceptualize the development of some particular type of disorder is the use of a stage model of development.
Stage models of development have been extremely popular in the fields of psychology and sociology for decades, and they have been used to explain how many types of attributes progress over time. One of the first psychological stage models of human development came from Sigmund Freud where he outlined his famous stages of human personality development (e.g., oral stage, anal stage, etc.). Other stage models of development have attempted to outline the development of numerous physical, emotional, and mental factors.
Stage models of development typically have the following assumptions:
However, scholarly theorists of behavior (particularly psychologists) point out that these models have a number of limitations, and they do not always fully describe the development of an attribute, a specific behavior, or a disorder.
There are numerous stage models that attempt to explain the development of addictive behaviors. Many of these models originally described the development of alcoholism or alcohol use disorders. Several of the more prominent models are discussed below.
Jelinek also outlined five types of alcoholics, such as the alpha alcoholic, beta alcoholic, gamma alcoholic, etc. This basic stage model originally outlined by Jellinek has also been adapted by a number of other organizations as a general outline for the development of addictive behaviors.
This model of addiction is extremely popular in the 12-Step community and has been adopted to explain a number of different types of addictive behaviors. However, the model has serious flaws in both its content and its methodology.
First, Jellinek used a very small sample of AA members to validate the stages in his model. Most of these individuals already believed his hypothesized progression of alcoholism. His data collection and data analysis was extremely biased. Second, a number of the signature markers in the stages, such as blackouts, a complete loss of control over alcohol use, etc., are not universally recognized in individuals who may even have severe alcohol use disorders. In addition, Jellinek’s original model did not apply to women who may actually demonstrate a slightly different progression in addictive behaviors than men. Finally, there is very little empirical research evidence to support Jellinek’s model of the development and progression of alcoholism or his different types of alcoholics.
Dr. George E. Valliant was a psychiatrist who specialized in addiction, particularly addiction to alcohol. Valliant developed a very simple approach to conceptualizing the development of alcoholism (and hence addiction) in his classic works The Natural History of Alcoholism and a later revision The Natural History of Alcoholism Revisited. The approach describes three general stages:
As one may gather from Valliant’s three-stage model, the progression also parallels the general diagnostic scheme used in the diagnosis of substance use disorders and behavioral addictions. Because the model is very general, simple, and has significant diagnostic validity, the model became quite popular in formal psychological and psychiatric circles. However, the current conceptualization of substance use disorders does not require the development of physical dependence (tolerance and withdrawal) for an individual to be diagnosed with even a serious substance use disorder. One of the reasons for this is during Valliant’s time, the number of drugs that were considered to be “addictive” were far fewer in number then in the current era; hence, addictive behaviors were often defined by the development of physical dependence. Thus, while the model is simple, descriptive, and had diagnostic utility at one time, many people who are diagnosed with substance use disorders these days would not follow the progression associated with this stage model, as they do not develop significant issues with withdrawal symptoms.
Over the last two decades, the development of neuroimaging techniques has led to a whole different approach to conceptualizing human development. Instead of looking specifically at behavior, many researchers use animal models, behavioral studies of people, and neuroimaging studies to help them explain how specific mental health disorders may develop.
A recent model that strongly resembles a reworking of Valliant’s model came from addiction researchers Nora D. Volkow, MD; George F. Koob, PhD; and A. Thomas McLellan, PhD, and it is heavily based on neurobiological studies of individuals with certain types of addictions and on animal models of addiction. The researchers separate the current diagnostic terminology used in the diagnosis of addictive behaviors, substance use disorder, as being separate from their personal definition of addiction, which is the most severe presentation of a substance use disorder where the individual has no control over their drug use despite a complete lack of research evidence to suggest that these two categories actually exist and that individuals diagnosed with even the most severe substance use disorders have absolutely no control over their substance use. Nonetheless, the researchers propose the following three stages associated with their definition of addiction (but not of substance use disorders):
The explanation and the features that occur in this stage are heavily borrowed from an earlier theory of addictive behaviors known as the incentive sensitization theory. Again, the changes are primarily due to alterations in an individual’s neurobiology that occur as a result of interaction between experience and physiology.
The major issue with this stage model is it that it describes the behavior of a very circumscribed group of individuals with severe substance use disorders and significant physical dependence. The model is not applicable to the majority of individuals who are diagnosed with substance use disorders (even those who may be diagnosed with severe substance use disorders). The model relies heavily on the development of physical dependence, and even individuals who are diagnosed with severe substance use disorders may not develop significant physical dependence to drugs or alcohol. Moreover, if any form of addiction at any level is primarily a neurobiological event then individuals who attempt to recover from addictions would find the best available forms of treatment, such as therapy, support group participation, etc., useless as their brains have been rewired to the point where they can no longer choose not to use drugs. Even all of the assistance and support of others would not significantly help individuals whose brains drive them to choose to use drugs and whose brains do not allow them not to make a choice not to use drugs.
While many theorists now view addiction as a disease, these theorists view the disease model of addiction as an extreme manifestation of purely biological events that rob a person of their reasoning abilities. This model has little diagnostic utility and most likely explains the behavior of a very small proportion of individuals with substance use disorders.
There are no formal diagnostic neurobiological markers that can diagnose any substance use disorder or any level of substance abuse (e.g., levels of mild, moderate, severe, extremely severe, etc.). Thus, any hypothesized neurobiological changes that may occur in individuals who have even the most severe forms of substance abuse cannot be used to delineate the stages of addiction hypothesized by the researchers. Moreover, a number of other sources point out that many individuals with even severe addictions choose to change their behavior once they are motivated to do so (see Addiction: A Disorder of Choice; Choice, Behavioral Economics, and Addiction).
Very often, clinical researchers suffer from a cognitive bias referred to as “the clinician’s illusion” where clinicians who most often see extreme cases attempt to make generalizations based on extreme aspects of behavior and significant dysfunction. Often, these theories do not apply to the majority of individuals who are actually diagnosed with substance use disorders. For instance, epidemiological research has consistently found that the majority of individuals who were once diagnosed with substance use disorders and who report successfully changing their behavior have done so by choosing to no longer engage in their drug use to the extent that they did previously.
There are numerous different stage theories that attempt to explain the progression of an addiction. Even the most popular and most recent of these theories have a number of significant flaws. However, based on the above stage models, it can be surmised that the development of a substance use disorder (addiction) in most individuals occurs over the following general course:
One of the interesting observations regarding these theories is that the stage theories of recovery or change are far better developed than the stage theories that attempt to describe how an addiction develops in the first place. Perhaps one reason for this is that the development of addictive behaviors across individuals has quite a bit of individual variation, whereas recovery from substance use disorders or addictive behaviors typically follows a very set and general template.