































Graduate Student Journal of  Psychology
2014, Vol. 15

Copyright 2014 by the Department of  Counseling and Clinical Psychology
Teachers College, Columbia University

57

Expanding the Biopsychosocial Model: 
The Active Reinforcement Model of  Addiction

Annie Hunt
Teachers College, Columbia University

The contemporary understanding of  addiction is expanding rapidly as emerging research across multidisciplinary 
fields informs treatment and intervention techniques.  Current prevention efforts work from the well-accepted bio-
psychosocial model and are aimed at identifying the underlying causes of  addiction and attempting to block them 
from manifesting, primarily through educational methods.  However, once an addiction has already emerged, inter-
vention and treatment efforts should operate from a more comprehensive conceptualization of  addiction that takes 
into account more than just underlying factors – these efforts must address how these factors are currently operating 
and reinforcing one another.  The active reinforcement model proposed in this paper addresses the mechanisms of  
action that govern the relationships among three primary elements of  addiction: a) impaired neurological mechanisms; 
b) unmet psychological needs; and c) dysfunctional behavior. This model serves as a more comprehensive concep-
tualization of  addiction as it accounts for each of  the present factors and places them in an interdependent context.  
Thus, while the biopsychosocial model effectively addresses the underlying causes of  addiction, the proposed active 
reinforcement model addresses the mechanisms of  existing addictions in a more comprehensive manner.  A better 
description of  the relationship between each element provides a deeper understanding of  the full phenomenon of  
addiction, and may therefore be more effective in generating successful treatment outcomes than previous models.  

Introduction to Addiction
Medical, psychological, and social understandings 
of  addiction have evolved rapidly over the past 
century, and contemporary addiction research and 
treatment is becoming increasingly interdisciplinary.  
Addiction studies, initially based in the field of  
pharmacology, now incorporate psychological, 
neurobiological, genetic, environmental, social, and 
spiritual considerations.  Furthermore, addiction 
is being studied in schools of  social work, public 
health, medicine, and psychology.  Addiction 
has thus become a multi-disciplinary construct 
that necessitates a wide range of  understanding 
from contemporary practitioners, and as this 
understanding expands, the professional obligation 
to maintain a consistent and regulated standard of  
practice becomes significantly more challenging.  
 Standardized clinical practices in the field of  
addiction are developed, tested, and disseminated 
through clinical research, and the myriad factors 
influencing this field present an interesting 
challenge for researchers who must take them into 
consideration when designing and implementing 
studies.  These studies are the mechanism for 
generating empirically based findings, which are the 

necessary prerequisite in allowing new considerations 
to be incorporated into standardized treatment 
options.  In order to increase evidence-based 
treatment options in response to the expanding 
conceptualization of  addiction, one must first begin 
with a clear understanding of  the current state of  the 
field, and then propose areas for further academic 
consideration and research.  The starting point for 
this process is the Diagnostic and Statistical Manual 
of  Mental Disorders (DSM), originally published 
in 1952, which significantly influences treatment 
options, research, insurance policies, public opinion, 
and social stigma.  While the DSM acknowledges that 
the diagnostic classification process is a challenging 
one, and that there are no strict boundaries dividing 
one disorder from the others or from no mental 
disorder at all, it does offer a professional consensus 
about the categorization and identification of  
mental disorders at the time of  its publication 
(DSM-5; American Psychiatric Association, 2013).  
Thus, it provides a reliable tool for establishing 
standards of  diagnoses, terminology, and criteria for 
classification while at the same time emphasizing 
the importance of  flexibility, appropriate training, 
and cultural sensitivity during clinical application.
 Addiction terminology. Chemical and 
behavioral addictions have long been recognized 
as serious and prevalent psychological problems 
throughout history, so it is interesting that the most 
recent version of  the DSM—the Fifth Edition, 

 Annie Hunt is now a Clinical Case Manager at the Mental 
Health Center of  Denver.     
 Correspondence concerning this article should be ad-
dressed to Annie Hunt, 1850 Bassett Street, Apt. 307, Den-
ver, CO 80202. Email address: anniehunt1@gmail.com.



58

published in May 2013—does not actually include 
the term “addiction” (APA, 2013). The category 
used in the DSM-5 to describe the phenomenon 
colloquially referred to as chemical or substance 
addiction is titled “Substance Use Disorder,” and it 
combines the former categories of  substance abuse 
and substance dependence (from the DSM-IV) into 
a single disorder that is to be measured on a scale 
from mild to severe (APA, 2013).  Neither did the 
previous edition, the Fourth Edition, Text Revision, 
published in 2000 by the American Psychological 
Association, include the term “addiction,” as the 
term ‘dependence’ won out over ‘addiction’ by 
one vote during the last revision process (DSM-
IV-TR, APA, 2000; O’Brien, Volkow, & Li, 2006).  
 Specific and accurate terminology plays an 
important role in the conceptualization of  this 
phenomenon.  According to the National Institute on 
Drug Abuse (NIDA), the term “dependence” indicates 
a physiological need or dependency on a substance. 
This is evidenced by a biological adaptation to the 
substance in which the body requires more of  it to 
achieve an effect (the phenomenon of  tolerance) and 
also manifests physical indicators if  use is suddenly 
stopped (the phenomenon of  withdrawal; NIDA, 
2012).  Physical dependence, however, can occur with 
continued use of  many different substances, including 
those taken as prescribed, and does not necessarily 
include the psychological or behavioral consequences 
that characterize an “addiction” or “disorder.”  
 The term “disorder,” according to 
the APA (2012), includes the following:

1. A behavioral or psychological syndrome 
or pattern that occurs in an individual
2. That reflects an underlying 
psychobiological dysfunction 
3. The consequences of  which are clinically 
significant distress or disability
4. Must not be merely an expectable 
response to common stressors and losses 
or a culturally sanctioned response to a 
particular event
5. That is not primarily a result of  social 
deviance or conflicts with society.

 

Thus, “disorder” indicates the presence of  
behavioral and psychological symptoms, but fails 
to clearly articulate the aspect of  compulsory 
repetition that the terms “dependence” 
or “addiction” include in their definitions.
 Finally, the term “addiction,” according to 
the National Institute on Drug Abuse, indicates 
compulsive use of  a substance despite harmful 
consequences, such as failure to fulfill social, work, 
or family responsibilities, and an inability to stop 
using the substance of  one’s own accord (2013).  
Additionally, according to the APA website, addiction 
falls under the category of  “Mental Health Disorders/
Issues,” and is defined as “a chronic brain disease that 
causes compulsive substance use despite harmful 
consequences” (APA, 2012).  Arguably, the most 
comprehensive and specific definition of  addiction 
comes from the American Society of  Addiction 
Medicine (ASAM; 2010), who define an addiction as:

a primary, chronic disease of  brain reward, 
motivation, memory and related circuitry . . . 
[which] is reflected in an individual pathologically 
pursuing reward and/or relief  by substance use 
and other behaviors.  Addiction is characterized 
by inability to consistently abstain, impairment 
in behavioral control, craving, diminished 
recognition of  significant problems with one’s 
behaviors and interpersonal relationships, and a 
dysfunctional emotional response. (ASAM, 2010)   

 It is interesting to compare the terms to identify 
differences as well as overlaps. According to the 
above definitions, dependence on a substance does 
not necessarily constitute an addiction, and an 
addiction does not necessarily involve physiological 
dependence (NIDA, 2012).  Furthermore, a disorder 
does not necessarily constitute an addiction. These 
terms therefore cannot be used interchangeably, as 
they each indicate the presence of  different symptoms
 It should be noted, however, that the DSM-5 does 
use the category of  “Addictive Disorders” to describe 
pathological gambling as a behavioral addiction 
(APA, 2013).  This is the only condition listed in 
this category, despite general clinical recognition of  
other non-chemical, behavioral addictions such as 
sex addiction, internet addiction, compulsive tanning, 

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and compulsive shoplifting (e.g., Grant, Potenza, 
Weinstein, & Gorelick, 2010).  Neither the NIDA 
definition of  disorder nor the APA definition of  
addiction include non-chemical addictions, despite 
the widespread social, medical, and cultural call 
for recognition and treatment of  these particular 
problems (Griffiths, 2000; Wang et al., 2013).
 This paper argues that one of  the most 
critical aspects of  active addiction treatment is 
addressing the phenomenon of  being unable to 
stop certain substance use or behaviors solely of  
one’s own volition – namely, the compulsive aspect 
of  the condition regardless of  known negative 
consequences. As of  the most current edition, the 
DSM still does not comprehensively articulate the 
presence and significance of  this symptom.  The 
continued exclusion of  this component indicates 
that at this point in time, contemporary research 
has still not sufficiently pinpointed what exactly this 
phenomenon is, what it involves, how it operates, and 
how to address it.  It is this phenomenon that the 
proposed active reinforcement model attempts to 
describe, validate, and address by drawing together 
parts of  prior conceptualizations and constructing a 
more comprehensive model.  This paper argues that 
once an addiction is manifest, it is actively reinforced 
by the relationships between three essential factors: 
a) impaired neurological mechanisms; b) unmet 
psychological needs; and c) dysfunctional behavior, the 
combination of  which results in the compulsive aspect 
of  the phenomenon.  Understanding the relationship 
between these factors and how they actively reinforce 
addiction would offer a starting point for developing 
interventions aimed at disrupting these relationships.  

Previous conceptualizations of  addiction.   
 Addiction has previously been conceptualized 
using different models, with the most historically 
prominent being the “adaptive” and the “disease” 
models.  The adaptive model preceded the disease 
model, and suggested that addictions develop when 
specific psychological needs – such as acceptance, 
autonomy, competence, or confidence – are not met; 
this was also termed “integration failure” (Alexander, 
1990).  The adaptive model argues that addictions 
develop to meet these specific psychological needs, 

and that the addictive behavior provides a sense of  
support, reassurance, or meaning that individuals 
feel is missing in their lives.  The disease model, also 
sometimes called the medical model, posited that 
addiction is neither an issue of  failed willpower nor 
the result of  conscious repeated habitual behavior, 
but is rather a chronic, progressive medical illness 
characterized by abnormalities or defects in brain 
functioning (Sheehan & Owen, 1999).  Silkworth 
(1939) was one of  the pioneers of  this model, 
originally applying it to alcohol dependence.  In the 
primary text of  the Alcoholics Anonymous program, 
he described alcoholism as an unusual or distorted 
behavioral response to alcohol consumption, 
and described problematic chronic drinking as a 
manifestation of  a “physical allergy” to alcohol 
(Alcoholics Anonymous, 2001).  Sheehan and Owen 
(1999) argue that the disease model represents a 
more comprehensive explanation of  addiction 
through its depiction of  neurological deficits and 
abnormal behavioral responses.  These models 
offered initial foundations for the development 
of  addiction studies and treatment, and they 
remained prominent until the emergence of  George 
Engel’s “biopsychosocial model” (Engel, 1978).

Current conceptualization of  addiction.  
 The biopsychosocial model, which is used to 
describe many different mental disorders, is arguably 
the most prominent construct used to conceptualize 
addiction today (Alonso, 2004).  This model built upon 
the disease model by accepting that addiction involves 
abnormalities in brain functioning, but then expanded 
that model by integrating the subjective psychological 
experiences of  individuals into the conceptualization 
of  illness.  It suggests that an understanding of  the 
patient’s subjective experience is critical in developing 
accurate diagnoses and successful treatment options 
(Borrel-Carrio, Suchman, & Epstein, 2004).  The 
biopsychosocial model thus seeks to explain 
suffering, disease, and illness as generated by multiple 
causes, including social, biological, and psychological 
factors.  This inclusion of  subjective psychological 
components into the disease model expands the 
concept of  addiction to include individual experiences, 
perceptions, stressors, and perspectives as mediating 

THE ACTIVE REINFORCEMENT MODEL OF ADDICTION



60

factors in the expression of  clinical illnesses and 
medical problems.  Thus, this model helps to bridge 
the gap between the medical and psychological fields, 
and is extensively accepted in the field of  addiction 
studies and psychology today (Alonso, 2004).
 Drawing from the above-mentioned previous 
and contemporary definitions of  addiction, three 
core elements of  addiction can be identified – 
unmet psychological needs, impaired neurological 
mechanisms, and problematic behaviors.  However, 
the adaptive and disease models do not sufficiently 
describe the relationships involved in the 
phenomenon of  addiction because they suggest 
simple linear causality between either coping and 
problematic behaviors or disease and problematic 
behaviors. This paper argues that the previous 
conceptualizations of  addiction, including the 
biopsychosocial model, do identify the core elements 
of  addiction, but fail to sufficiently demonstrate the 
reciprocal relationships among them.  Emerging 
research reveals evidence that unmet psychological 
needs, impaired neurological mechanisms, and 
problematic behaviors can act as both causes and 
effects in the construct of  addiction (Castellani, 
Wedgeworth, Wootton, & Rugle, 1997; Grant, 
Brewer, & Potenza, 2006; Hyman & Malenka, 2001). 
 While the biopsychosocial model offers a 
more substantive argument for acknowledging the 
presence of  combined psychological and biological/
pharmacological factors in the development of  
addiction, and partially identifies some of  the 
relationships involved among these factors, it does 
not offer a comprehensive conceptualization of  
all of  the relationships between these factors that 
contribute to active addiction and compulsive 
behaviors.  It states that these different factors 
play a role in impacting outcomes, and that there 
is a relationship between biological/psychological 
elements and external functioning, but it makes use 
of  an eclectic approach that does not specifically or 
explicitly describe how that relationship functions 
and impacts addiction (Ghaemi, 2009).  Furthermore, 
it fails to establish the impact that psychological 
factors have on neurobiological factors, the impact 
that neurobiological factors have on psychological 
factors, and the reverse impact that dysfunctional 

behaviors may have upon psychological and biological 
functioning—an important new relationship that has 
been demonstrated in emerging research (Hyman 
& Malenka, 2001).  This paper will propose a new 
model that includes the critical elements of  addiction 
and places them in an interdependent context that 
offers a more comprehensive understanding of  
how addictions function.  It will also defend each 
of  these relationships with recent research findings.

Proposed “Active Reinforcement Model of  
Addiction.”  
 Current research consistently indicates the 
presence of  neurological, psychological, and 
external/behavioral components in the overall 
conceptualization of  addiction, though each element 
may have varying degrees of  intensity and causality 
(i.e., one element may be more powerful or have more 
influence than others, depending on the individual; 
Grant, Brewer, & Potenza, 2006).  This paper argues 
that there is a cause-effect relationship between all 
three elements, meaning that each element both 
influences and is reinforced by the other two elements.  
In light of  this knowledge, a new model, entitled the 
“Active Reinforcement Model of  Addiction” (Figure 
1), is proposed.  From this conceptualization, the 
critical principle that emerges is not the importance 
of  determining which element came first, or finding 
an underlying reason for why the addiction emerged.  
Rather, the focus is shifted to the importance of  
acknowledging how all three coexist and reinforce 
one another in an interdependent context once 
an addiction has become active.  From there, an 
altered focus for treatment and interventions can 
be proposed, again shifting the focus of  treatment 
techniques from why to how addictions function. 
 Prevention efforts generally focus on the question 
of  why addictions develop and use education, risk 
protection techniques, and resilience training based 
on the proposed answers to this question, though 
there still is no consensus on exactly what causes 
addiction (SAMHSA, 2013).  The field is full of  
varying hypotheses and theories that attempt to 
explain addiction’s underlying causes in order to 
create successful prevention efforts and education 
programs aimed at stopping addiction before it starts.  

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This paper, however, is not focused on prevention 
efforts, but rather proposes use of  a different model 
to guide treatment of  active addictions. Prevention 
efforts are distinctive from treatment efforts, 
according to the American Society of  Addiction 
Medicine, though they may both be used concurrently 
in certain circumstances (ASAM, 2005).  Treatment, 
according to ASAM, is aimed at helping individuals 
currently suffering from an addiction.  Once 
addiction symptoms (according to either the DSM or 
APA criteria) are manifest, prevention models should 
be substituted for a working understanding of  how 
the addiction is actively functioning.  While research 
on preventive measures is valuable and will continue 
to hold its place in the field, this paper argues 
that addiction treatment and intervention should 
be based on a more comprehensive conceptual 
model of  how addictions are actively sustained. 

 As demonstrated by the figure above, the 
phenomenon of  addiction is sustained by the presence 
of  and relationship among three elements: a) impaired 
neurological mechanisms; b) unmet psychological 
needs; and c) dysfunctional behavior.  This model 
serves as a comprehensive conceptualization of  
addiction that incorporates the main elements of  
addiction and places them in an interdependent 
context.  It helps to organize the concept of  active 
addiction into a structured mechanism defined by 
reinforcing relationships, which may allow studies 

and interventions to specifically focus on particular 
sections or relationships in the model.  At the 
same time, it also offers a full depiction of  the 
phenomenon, which may help to remind practitioners 
that each element and relationship must be attended 
to in treatment.  This paper will describe how many 
existing theories and interventions fit directly into 
the active reinforcement model, and will explain 
how each encompasses one or some of  the six 
relationships described: a → (causing) b, a → c, b → 
a, b → c, c → b, and c → a.  Any element, standing 
alone or impacting only one of  the other elements, 
does not necessarily lead to the emergence of  an 
addiction.  This model theorizes that all relationships 
must be present to some degree in order to constitute 
an active addiction.  This paper will begin to justify 
this theory by examining the current working 
definition of  what the term “addiction” means.

 Definition of  Addiction (a, b & c)
 All people engage in self-regulatory behaviors in 
response to their biological, psychological, social, and 
spiritual wants and needs (Bandura, Adams, & Beyer, 
1977).  Many people use substances or engage in 
risky behaviors to meet these needs, and these do not 
always develop into disruptive or chronic patterns of  
use.  The crossover from substance use or occasional 
dysfunctional behavior to the full manifestation of  
addiction is ambiguous and difficult to define.  One 
must consider the motivations for, frequency and 
intensity of, and consequences of  the substance 
use or dysfunctional behavior in order to determine 
whether it can be considered problematic (c).  
 As noted previously, the DSM acknowledges 
that there are no absolute boundaries in diagnoses, 
and the same flexibility must be utilized when 
attempting to define addiction (APA, 2013).  Despite 
the challenge the phenomenon of  addiction 
poses, it is still critical to develop a generally 
accepted working definition so that researchers 
and clinicians can work toward standardizing the 
field, developing best practices, and regulating 
the associated treatment options for addiction.  
 The American Society of  Addiction Medicine’s 
definition of  addiction, previously quoted in this 
paper, clearly supports the concept of  a biological 

THE ACTIVE REINFORCEMENT MODEL OF ADDICTION

Figure 1: Active Reinforcement Model of  Addiction.  This figure 
illustrates the critical relationships that reinforce active addiction.



62

element in the reinforcement model of  addiction, 
suggesting that neurological dysfunction (a) directly 
causes problematic psychological (b) and behavioral 
(c) manifestations (a → b, a → c).  It also indicates 
that the behavior (c) in turn can affect psychological 
and emotional components (b) of  the individual’s 
life (c → b).  In the longer definition, ASAM goes 
on to explain that brain “morphology, connectivity, 
and functioning are still in the process of  maturation 
during development and young adulthood, and early 
exposure to substance use is another significant factor 
in the development of  addiction” (ASAM, 2011).  
This suggests that dysfunctional behaviors such as 
chemical abuse (c) also impact brain development 
(a) in a phenomenon known as “neuroadaptation” (c 
→a; ASAM, 2011).  It is worthwhile to note that this 
definition includes both “substance use and other 
behaviors” in its definition, and that the inclusion 
of  both chemical and non-chemical addictions is a 
critical element to the reinforcement model, as will be 
discussed later.  Thus, ASAM’s definition of  addiction 
fits into the proposed model, and supports some of  the 
relationships it describes (a →b, a → c, c → − a, c → b).
 Another widely-recognized definition of  
addiction came from the former president 
of  the American Society of  Addiction 
Medicine, Dr. Michael Miller, who stated:

At its core, addiction isn’t just a social problem 
or a moral problem or a criminal problem.  It’s 
a brain problem whose behaviors manifest in all 
these other areas . . . [the] disease is about brains, 
not drugs.  It is about underlying neurology, 
not outward actions. (Smith, 2011, p. 901)  

 This statement also directly supports the 
reinforcement model, and demonstrates the 
significance of  neurophysiology in affecting 
the full conceptualization of  addiction (a 
→ b, a → c).  Goodman (1990) proposed a 
similarly well-accepted definition of  addiction:

Addiction may be defined as a process 
whereby a behavior that can function to 
produce pleasure and provide relief  from 
internal discomfort, [and] is employed as a 
pattern characterized by (1) recurrent failure 
to control the behavior (powerlessness) and 

(2) continuation of  the behavior despite severe 
negative consequences (unmanageability).

 This definition highlights the behavioral element 
included in the reinforcement model, and defines 
what is meant by “dysfunctional” behavior (c) and 
psychological causes and consequences (b).  While 
it does not specifically mention non-chemical 
behaviors, it does not explicitly exclude them, 
and as such they too can be incorporated into this 
conceptualization.  Furthermore, this definition 
addresses the impact that these behaviors have 
on psychological functioning, and supports and 
fits into the reinforcement model (b → c, c → b).
 Smith and Seymour (2004) included the additional 
element of  “compulsive use or engagement in 
the behavior” to this definition, which suggests an 
underlying biological urge (a → c). Moreover, they 
suggested that addictive behaviors (c) are used to 
gain either psychic (mood-related), recreational 
(social or activity-related), or instrumental 
achievement (performance-related) rewards (b).  
This also directly ties into the reinforcement 
model in that it explains the relationship that 
dysfunctional behaviors can have on psychological 
functioning and the attainment of  needs (c→ b).

Application of  the term “addiction” to 
both chemical and behavioral disorders.  
 One critical theoretical consideration that 
supports the reinforcement model is the inclusion of  
non-chemical or behavioral dependencies (c) in the 
broader conceptualization of  addiction.  Chemical 
dependencies alone are not necessarily considered 
dysfunctional, as many medical patients develop 
dependencies even when they take their medications 
as prescribed.  These dependencies do not necessarily 
result in a compulsive or disruptive pursuit of  
chronic use.  Dependencies become dysfunctional 
only once they develop causal relationships with 
psychological and biological processes (c → b, 
c → a).  Additionally, certain behaviors, such as 
gambling, hand-washing, or exercising, are not 
considered dysfunctional on their own—these 
behaviors only become dysfunctional when they 
disrupt psychological and biological processes (c →b, 

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63

c → a), resulting in a non-chemical addiction.  For 
example, hand-washing is a normal human behavior, 
but if  it becomes a psychological obsession and an 
individual feels compelled to do it repetitively, then 
it has developed into an addiction (c → a, c → b).
 Traditionally, the clinical terms “addiction” and 
“addictive behavior” have been applied exclusively to 
substance abuse and dependency, but there is growing 
empirical evidence of  a related category of  “non-
chemical” addictive behaviors, “including gambling, 
eating disorders, and sexual behavior,” that have 
recently been included in the conceptualization of  
addiction (Donovan & Marlatt, 2005, p. 4).  There are 
easily recognizable external patterns that are similar 
between chemical and behavioral addictions, including 
tolerance, withdrawal, repeated unsuccessful attempts 
to stop, and significant impairment in areas of  life 
functioning.  However, the emerging recognition 
of  biology’s influence on addiction has encouraged 
researchers to explore whether behavioral addictions 
and substance addictions recruit similar biological 
processes (a → c, c → a; Grant, Brewer, & Potenza, 
2006).  Brain science and neural imaging have begun 
to validate food and sex addictions, compulsive 
shopping and gambling, and eating disorders, 
among others, as “process,” “non-chemical,” or 
“behavioral” addictions that can be included in 
the new, broader category of  addiction disorders.
 Emerging research indicates that dysfunctional 
behaviors can be powerful determinants of  
psychological functioning (c → b) and can also 
cause neuroadaptation (c → a; Lubman, Yucel, & 
Pantelis, 2004; Hyman & Malenka, 2001).  It has also 
been demonstrated that dysfunctional behavior can 
be the direct result of  brain deficits or maladaptive 
psychological states (a → c, b → c) (Grant et al., 
2006).  These findings support the incorporation 
of  non-chemical addictions into the reinforcement 
model, as they follow the same relationship patterns 
of  chemical addictions.  This recognition greatly 
enhances the argument for the reinforcement 
model of  addiction, as it helps to illuminate the 
interconnectedness of  both internal and external 
factors involved in this phenomenon, regardless 
of  the involvement of  substances and chemicals.  

 The 2013 DSM revisions reflect this increasing 
awareness of  the role of  non-chemical dysfunctional 
behaviors in the construct of  addictions through their 
inclusion of  “Gambling Disorder” (APA, 2012).  This 
movement to include a non-chemical addictive disor-
der demonstrates that researchers and practitioners 
are migrating toward the general understanding that 
both chemicals as well as behaviors can impact neuro-
adaptation within the brain’s reward system (c → a).  
Smith (2012) reinforced this by stating that addiction 
disrupts the areas of  the brain responsible for regu-
lating cognitive, emotional, and social behaviors, and 
Marks suggested that “syndromes of  behavioral ad-
diction share [similar neurological] features with those 
of  substance abuse . . . [including] obsessive-com-
pulsive disorder, compulsive spending (including 
gambling), overeating, hypersexuality, kleptomania, 
and perhaps trichotillomania, tics, and the Tourette 
syndrome” (c → a, c → b;  Marks, 1990, p. 1389). 
 As supported by these findings, both chemical 
and behavioral dependencies can be included in the 
reinforcement conceptualization of  addiction.  The 
emerging understanding of  the ability of  external be-
haviors to influence brain chemistry, as well as the rec-
ognition that brain chemistry affects external behav-
iors, demonstrates that these two factors are mutually 
influential (a → c, c → a).  Thus, including problematic 
and dysfunctional behaviors that do not include chem-
icals greatly supports the active reinforcement model, 
and further illuminates the extent to which external 
factors influence internal processes and vice versa.

Three Core Components and Six Core 
Relationships

 The psychological and behavioral components of  
addiction have been well established in contemporary 
research, so an extensive discussion of  these elements 
is not necessary in this paper and they will be only 
briefly mentioned below.  Research on the neurobio-
logical components, however, is the more recent and 
emerging area that will be discussed in more detail. 

Psychological Components of  Addiction (b → 
a, b → c)
 The active reinforcement model indicates a dis-
tinct relationship between psychological components 

THE ACTIVE REINFORCEMENT MODEL OF ADDICTION



64

(b), such as stressors, the effects of  environmental 
influences, thoughts, and emotions, upon both the 
brain as well as behavior (b → a, b → c).  There are 
numerous studies that support the causal relationship 
between unmet psychological needs and dysfunction-
al behaviors, as well as the impact of  psychological 
stress on brain chemistry and neurological function-
ing (b → c, b → a) (Castellani et al., 1997; Whang, 
Lee, & Chang, 2003; Young, Boyd, & Hubbel, 2000; 
Sinha, 2001).  These two relationships in the rein-
forcement model of  addiction are well established, 
and a detailed discussion of  these two mechanisms 
can be easily found in contemporary literature and is 
thus beyond the scope of  this paper.  One particularly 
good explanation of  these relationships can be found 
in Franken (2003), who explains the relationship be-
tween psychological urges and their impact upon 
neurological functioning and addictive behaviors.

Behavioral Components of  Addiction (c→ a, c→ b)
 As previously mentioned, dysfunctional or risky 
behaviors alone do not comprise addiction.  Dys-
functional behavioral or chemical dependencies only 
become addictions when they develop relationships 
with the psychological and neurobiological elements 
of  the active reinforcement model.  This means that 
when a behavior or chemical use becomes a method 
of  psychological coping to deal with stress, or when 
the individual feels compelled to engage in this behav-
ior due to pressing internal impulses, the full relation-
ship of  these factors manifests as an active addiction 
(c → a, c → b).  There are numerous studies that 
demonstrate the wide range of  addictive behaviors, 
including both non-chemical and chemical depen-
dencies, and a discussion of  all of  the behavioral ele-
ments associated with addiction is beyond the scope 
of  this paper.  For a more detailed discussion of  these 
relationships, see Smith (2012), Smith and Seymour 
(2004), Marks (1990), or Hyman and Malenka (2001). 

Neurobiological Components of  Addiction (a → 
b, a → c)
While the current definitions of  addiction explain 
some of  the neurological and psychological influenc-
es on behavior (a → c, b → c), it is critical to also in-
corporate recent research that indicates that behaviors 

influence neurological and psychological functioning 
(c → a, c → b).  This research indicates that behav-
iors can contribute to neuroadaptation and psycho-
logical problems (Lubman, Yucel & Pantelis, 2004).  
An individual may not necessarily have an underlying 
neurological deficit to begin with, but could develop 
one as a result of  engaging in dysfunctional behavior 
or encountering psychological stressors (Lubman et 
al. 2004).  Thus, neurobiology is not necessarily the 
primary causative factor of  this phenomenon.  The 
active reinforcement model effectively demonstrates 
both the significance as well as the relationship of  neu-
robiology to the overall conceptualization of  addic-
tion, instead of  placing it as the primary causal factor.
 The active reinforcement model indicates that 
neurobiology both influences and mediates the rela-
tionship between dysfunctional behaviors and psy-
chological issues, and in combination with these fac-
tors it can generate chemical or behavioral addictions.  
Neuroimaging and neuropsychological studies have 
revealed clear differences in brain function between 
chronically addicted and non-addicted individuals, 
suggesting that addiction is indeed associated with al-
terations in brain functioning and neuropsychological 
changes (Lubman, Yucel, & Patelis, 2004; a → c, c 
→ a).  The research they describe has been primari-
ly focused on the brain’s reward pathways, which in-
volve dopamine and serotonin receptors.  Dopamine 
and serotonin are neurotransmitters released by the 
brain as a result of  certain actions and behaviors, and 
they are associated with the experience of  pleasure 
and reinforcement and can function as ‘rewards’ in 
the brain.  Hyman and Malenka (2001) report that 
the chemicals released as a direct result of  engage-
ment in addictive behaviors are both rewarding, or 
interpreted as intrinsically positive by the brain, as 
well as reinforcing, meaning that the behaviors in-
volved with these rewards tend to be repeated (c 
→ a, a → c).  Thus, substances and behaviors that 
produce these neurotransmitters can become very 
powerful reinforcers that influence future behavior 
and can result in inhibitory dysregulation (Hyman & 
Malenka, 2001).  This means that individuals either 
develop lowered inhibitions against risky behavior 
or experience urges so strong that they overwhelm 
typical inhibitions (c → a; Lubman et al., 2004).

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65

 Tolerance.  Neurochemical changes in response 
to addiction often manifest in the development of  
tolerance, defined as a decrease in the effect of  an ad-
dictive substance that often results in more frequent 
or intense engagement in addictive behavior (a → c).  
Individuals who develop these altered brain states 
may demonstrate tolerance as “reward deficiency syn-
drome, a hypothesized hypo-dopaminergenic state 
involving multiple genes and environmental stimuli 
that puts an individual at high risk for multiple ad-
dictive, impulsive, and compulsive behaviors” (a→ c; 
Grant et al., 2006, p. 925).  This hypo-dopaminergen-
ic state is one of  the proposed mechanisms of  brain 
chemistry in addiction.   Lower levels of  dopamine 
(or decreased activation of  dopamine circuits and 
receptors) may result in an individual’s increased at-
tempts to compensate for these deficits through par-
ticular chemicals or behaviors (a → c).  Higher lev-
els of  tolerance can promote increased and frequent 
use, which may then result in dependence (c → a). 
 Sensitization. Another result of  chronic addic-
tion is sensitization. This occurs through enhanced 
reward responses in the brain resulting from repeat-
ed administration of  a substance or engagement in 
an addictive behavior (c → a; Hyman & Malenka, 
2001).  Individuals who develop more sensitive brain 
states may experience a higher level of  euphoria after 
engaging in behaviors that release dopamine or se-
rotonin.  Due to the experience of  more substantial 
“rewards,” they may have greater difficulty in con-
trolling impulses to engage in and continue addictive 
behavior (c → a, a → c).  With chronic use of  or 
engagement in these behaviors, adaptations at genet-
ic, molecular, and cellular levels occur within distinct 
brain regions that counter acute drug effects in an 
attempt to maintain internal homeostasis (c → a). 
When intake of  the substance ceases, these neuroad-
aptations initially persist and act unopposed, result-
ing in a characteristic rebound syndrome, or “with-
drawal” (Lubman et al., 2004).  Hyman and Malenka 
(2001) note that this response can develop beyond 
just a physical or psychological liking of  one’s addic-
tive behavior into the experience of  intense urges or 
“wanting.”  It is at that point that physical depen-
dence can cross over to compulsive desire and pur-
suit as neurological systems become hypersensitive, 

which significantly increases the incentive to seek out 
these stimuli (a → c, c→ a; Hyman & Malenka, 2001).

Disrupting the Relationships between the Ac-
tive Elements of  Addiction

As discussed, the active reinforcement model of  ad-
diction demonstrates six relationships between three 
primary elements of  addiction: biological deficits (a), 
unmet psychological needs (b), and dysfunctional be-
haviors (c); these relationships are described as a → 
b, a → c, b → a, b → c, c → a, and c → b.  Any of  
these elements in isolation do not necessarily indicate 
an addiction, and as such cannot be considered pri-
mary causal factors of  this phenomenon.  For exam-
ple, an individual can engage in dysfunctional or risky 
behavior without it affecting their psychological or 
biological functioning. Similarly, one may experience 
stress from unmet psychological needs but never turn 
to dysfunctional behavior as a coping mechanism, or 
may suffer from neurological deficits without the ad-
ditional experience of  unmet psychological needs or 
attempting to compensate for these deficits behav-
iorally.  Rather, it is the relationships among these 
factors – not the factors themselves – that indicate 
an active addiction.  Therefore, this model suggests 
that addiction treatment research should be devoted 
to disrupting these mechanisms and developing in-
terventions to block the relationships between the 
factors that combine to sustain addiction (indicated 
by the sign X).  A comprehensive treatment plan 
must therefore involve interventions to disrupt these 
relationships (a X b, a X c, b X a, b X c, c X a, c 
X b).  Addressing and resolving one element can re-
duce the severity of  the addictive behavior, but this 
paper argues that attention to all three factors and 
their respective relationships with one another is vi-
tal to successful, comprehensive addiction treatment.

Treatment of  Biological Factors (a X b, a X c)
 Emergency care. The very first step in addic-
tion treatment is to focus on the most urgent needs 
of  the client (Wallace, 2005).  This typically involves 
meeting essential physiological requirements and en-
suring that basic physical functioning is supported 
and maintained, as many clients cannot take action 
in addressing problem behaviors if  they are not first 

THE ACTIVE REINFORCEMENT MODEL OF ADDICTION



66

stabilized (Wallace, 2005).  Regardless of  whether cli-
ents enter addiction treatment voluntarily or not, they 
can initially present in a state of  shock, trauma, se-
vere emotional disturbance, despair, depression, and 
other varying states of  instability, and at that stage 
they may not be capable of  identifying or attend-
ing to their basic needs.  Thus, prior to any psycho-
logical interventions, the client must be placed in a 
safe, calm environment without easy access to their 
addictive drug or behavior, and they must be thor-
oughly screened for any pressing physiological prob-
lems that can be immediately addressed (a X b, a X 
c).  This includes any kind of  treatment of  overdose 
symptoms, medicine for management of  withdrawal 
symptoms during detoxification, administration of  
essential nutrients or electrolytes for severe cases of  
eating disorders, and other related medical treatment. 
 Pharmacological treatment.  The use of  pre-
scription drugs to treat neurobiological deficits is a 
critical component of  addiction treatment.  This 
has become the subject of  extensive research as the 
conceptualization of  addiction as a brain disease be-
comes more prevalent.  While a full discussion of  the 
pharmacological component of  addiction treatment 
is beyond the scope of  this paper, it is worth noting 
that the emerging trends of  successful prescription 
drug use in the treatment of  addiction often involve 
drugs associated with supporting or enhancing the 
serotonin or dopamine pathways of  the brain (Grant 
et al., 2006).  Alleviating these neurological deficits 
can directly promote psychological health and re-
duce engagement in dysfunctional behaviors as cop-
ing mechanisms (a X b, a X c; Grant et al., 2006). 

Treatment of  Psychological Factors (b X a, b X c)
 Interdisciplinary approaches to addiction studies 
have allowed for more comprehensive incorporation 
of  the psychological aspects of  addiction.  There 
have been several widely recognized movements 
that have defined and influenced the field as it re-
lates to addiction treatment, and while there are many 
different orientations to psychological counseling, 
one of  the primary approaches – cognitive behav-
ioral therapy – will be discussed here as an exam-
ple of  a psychological treatment that can be directly 
incorporated into the active reinforcement model. 

 The cognitive-behavioral orientation is one of  
the main approaches used in addiction treatment to-
day, and it purports that that human thoughts and 
behavior are driven by the conditioning and rein-
forcement that people experience throughout their 
lives (b → c).  Dysfunctional thoughts and behav-
ior, such as behavioral and chemical addictions, are 
considered to be the result of  the development of  
inaccurate and unhealthy life schemas, which are 
the mental framework used to organize informa-
tion about the self  and the external world (b → c) 
(Alford & Beck, 1997).  The goals of  cognitive-be-
havioral therapy are therefore to focus on individual 
problematic behaviors and thoughts, identify their or-
igins and influences, and challenge and change them 
as needed to promote healthier psychological func-
tioning and recovery (b X c).  Cognitive-behavioral 
therapy, or CBT, developed out of  this psychological 
orientation and is prominent in addiction treatment 
programs today.  It is a highly standardized therapeu-
tic process that utilizes such techniques as identify-
ing individual goals, focusing on present problems, 
exposure therapy, cognitive restructuring, behavior 
change, and psychoeducation (b X c).  Thus, while 
there are many approaches to the treatment of  the 
psychological factors of  addiction, CBT is one exam-
ple of  a well-established practice that is compatible 
with and supports the active reinforcement model.

Treatment of  Behavioral Factors (c X a, c X b)
 A final critical component of  the active rein-
forcement model is the existence and relationship 
of  dysfunctional behaviors and their impact on both 
psychological functioning and neurology.  The most 
prominent treatment approach is the promotion and 
facilitation of  abstinence or sobriety from dysfunc-
tional behaviors or chemical dependencies as a way 
to disrupt the final relationships in this model (c X 
a, c X b).  Other approaches, such as the harm-re-
duction model, emphasize the importance of  mod-
eration, self-regulation, honest and open self-report-
ing of  engagement in problematic behaviors, and 
other measures to significantly reduce engagement 
in disordered behavior (Marlatt & Tapert, 1993).  
One critical aspect of  intervention efforts aimed at 
treatment of  behavioral factors is the consideration 

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67

of  replacement behaviors that may be utilized in the 
absence of  the typical addictive behavior, and the 
importance of  providing the client with adaptive 
rather than harmful substitutes for these behaviors 
(Shaffer et al., 2004).  Treatment of  behavioral fac-
tors also involves a combination of  the techniques 
used to treat the neurological and psychological as-
pects of  addiction, and each of  the interventions 
described above also work to disrupt the relation-
ships between dysfunctional behaviors and psycho-
logical or neurological mechanisms (c X a, c X b).  

Conclusion
 The working conceptualization of  addiction 
continues to develop as emerging research across 
multidisciplinary fields informs treatment and in-
tervention techniques.  While prevention efforts are 
often aimed at identifying the underlying causes of  
addiction, intervention and treatment should oper-
ate from a more comprehensive conceptualization 
of  addiction that is focused on the mechanisms of  
action among three primary elements: a) impaired 
neurological mechanisms; b) unmet psychological 
needs; and c) dysfunctional behavior.  This paper ar-
gues that all three must be present and involved in 
an active relationship with one another for an active 
addiction to be manifest.  Thus, the proposed active 
reinforcement model serves as a more comprehen-
sive conceptualization of  addiction that accounts for 
and incorporates all of  the elements of  addiction 
and places them in an interdependent context that 
may be more effective in generating successful ad-
diction treatment outcomes than previous models.  
 The next steps in validating the proposed model 
are to evaluate it using research studies and psycho-
metric evaluations.  One of  the most critical aspects 
of  this model is its comprehensive incorporation of  
multiple concepts of  addiction, and demonstrating 
its effectiveness empirically could start with an evalu-
ation of  each of  these elements and the six relation-
ships described by the active reinforcement model.  
Demonstrating the validity of  these individual rela-
tionships empirically and introducing intervention 
efforts intended to disrupt them would support the 
relevance of  this model and demonstrate the need 
for continued exploration of  this conceptualization 

of  addiction.  Once the individual relationships have 
been empirically validated, a treatment approach that 
addresses all components should be implemented, 
evaluated, and compared to models that operate from 
a less comprehensive conceptualization of  addiction.
 In conclusion, the active reinforcement model 
serves as a more comprehensive conceptualization 
of  addiction as it accounts for multiple interrelated 
factors.  While the currently accepted biopsychoso-
cial model effectively addresses the underlying caus-
es of  addiction, the proposed active reinforcement 
model addresses the mechanisms of  existing addic-
tions in a more comprehensive manner.  A better de-
scription of  the relationship between each element 
provides a deeper understanding of  the full phenom-
enon of  addiction, and may therefore be more ef-
fective in generating successful treatment outcomes.  

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