Cognitive therapy for addiction: motivation and change

220 Pages·2013·1.18 MB·English

by  Frank Ryan

Cognitive Therapy for Addiction
Cognitive Therapy
for Addiction
Motivation and Change
Frank Ryan
A John Wiley & Sons, Ltd., Publication
Thiseditionfirstpublished2013
©2013FrankRyan
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Ryan,Frank,1944–
Cognitivetherapyforaddiction:motivationandchange/FrankRyan.
p.cm.
Includesbibliographicalreferencesandindex.
ISBN978-0-470-66996-9(cloth)–ISBN978-0-470-66995-2(pbk.)
1.Compulsivebehavior–Treatment. 2.Substanceabuse–Treatment. 3.Cognitivetherapy. I.Title.
RC533.R932013
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2012034393
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Contents
AbouttheAuthor ix
Preface xi
1 TheTenacityofAddiction 1
IntroductionandOverview 1
DiscoveringCognition 5
ImplicitCognitionandAddiction 6
NeuropsychologicalFindings 9
AddictiveBehaviourisPrimary,NotCompensatory 11
ChangingHabitsisthePriority 14
DiagnosticCriteria 15
TowardsIntegration 15
EquivocalFindingsfromResearchTrials 16
TimeforCHANGE 16
Evolution,NotRevolution 17
SomethingOld,SomethingNew 18
2 ExistingCognitiveBehaviouralAccountsofAddiction
andSubstanceMisuse 21
TheEvidentialBasisofCBTforAddiction 23
Meta-analyticFindings 23
BehaviouralApproaches 24
DiverseTreatmentsMostlyDeliverEquivalentOutcomes 25
WhatAretheMechanismsofChange? 26
TheMissingVariable? 27
ADual-ProcessingFramework 28
3 CoreMotivationalProcessesinAddiction 33
IsAddictionAboutAvoidingPainorSeekingReward? 33
HowFormulationCanGoAstray 34
IncentiveTheoriesofAddiction 35
LearningMechanismsinAddiction 36
vi Contents
DistortedMotivationandAberrantLearning:theEmergence
ofCompulsion 41
‘WantingandLiking’intheClinic 41
TheRoleofSecondaryReinforcers 43
BeyondPleasureandPain:aPsychoanalyticPerspective 43
Conclusion 44
4 ACognitiveApproachtoUnderstandingtheCompulsive
NatureofAddiction 45
TheoriesofAttention 46
Top-DownInfluencesCanBeAutomatic 47
AutomaticProcessesCanBePracticallyLimitless 48
MotivationallyRelevantCuesarePrioritized 48
BiasedCompetition 50
AttentionandVolition 51
AppetitiveCuesUsuallyWin 52
PurposefulBehaviourCanOccurintheAbsenceofConsciousness 53
AttentionalBiasandCraving 54
CognitiveCycleofPreoccupation 56
5 VulnerabilityFactorsInAddiction 63
IndividualDifferencesinAddictionLiability 63
PersonalityTraits 63
The‘BigFive’PersonalityFactors 65
PersonalityDisorders 66
AffectiveVulnerabilityFactors 67
Brain-DerivedNeurotrophicFactors 69
NeurocognitiveVulnerability 70
FindingsfromtheAddictionClinic 71
FromResearchtoPractice 72
6 MotivationandEngagement 75
ImpairedInsightandtheTherapeuticRelationship 75
TheSadCaseofJulia 80
ConflictedMotivationistheKey 81
GoalSettingandMaintenance 82
TheImportanceofBetween-SessionChange 83
NeurocognitivePerspectivesonMotivation 83
MotivationalInterviewinginPractice 84
FormulatingandPlanningtheIntervention 88
AttributionalBiases:theBlameGame 90
CaseFormulation 91
Summary 97
Contents vii
7 ManagingImpulses 99
IntroductionandOverview 99
StructuringtheSession 99
BuildingResilience 100
ImpulseControl 102
CravingandUrgeReport 103
CognitiveProcessingandCraving 104
CognitiveBiasModification 105
AttentionalBiasintheContextofAddiction 106
TheAlcoholAttention-ControlTrainingProgramme 108
ModifyingImplicitApproachTendencies 110
ReversingtheBias:Conclusion 112
BrainTrainingandNeurocognitiveRehabilitationApproaches 112
ClinicalImplicationsofDelayedRewardDiscounting 117
TriedandTestedTechniques 119
TheRoadtoRecoveryisPavedwithGoodImplementationIntentions! 125
NeurophysiologicalTechniques 129
NeuropsychopharmacologicalApproaches 130
8 ManagingMood 135
TheReciprocalRelationshipBetweenMoodandAddiction 135
Pre-existingVulnerabilitytoEmotionalDistress 137
NegativeAffectDueToDrugEffects 141
SteppedCareforAddiction 145
AnIntegratedApproachtoAddressingNegativeEmotion 147
9 MaintainingChange 155
RelapsePreventionStrategiesfromaNeurocognitivePerspective 155
TheImportanceofGoalMaintenanceintheLongTerm 158
ANeurocognitivePerspectiveonRelapse 159
Twelve-StepFacilitationTherapy 161
ImplicitDenial 162
10 FutureDirections 171
NeurocognitiveTherapy 171
IncreasingCognitiveControlistheGoal 172
DoWeKnowAnythingNew? 173
AppendixSelf-HelpGuideSixTips–aPocketGuide
toPreventingRelapse 179
Introduction:WhySixTips? 179
1.Don’tAlwaysTrustYourMemory! 180
2.Bewareofthe‘BoozeBias’! 180
viii Contents
3.SeparateThoughtsfromActions 181
4.LearnHowtoDistractYourself 181
5.WillpowerIsSometimesNotEnough 182
6.BewareoftheDogthatDoesn’tBark... 182
References 185
Index 201
About the Author
Dr Frank Ryan trained as a clinical psychologist at Edinburgh University
andworksasaconsultantinCamden&IslingtonNationalHealthService
Foundation Trust in London, UK. He practices as a cognitive behaviour
therapist with a special interest in addiction and co-occurring disorders.
HeisanHonorarySeniorLecturerintheCentreforMentalHealth,Faculty
of Medicine at Imperial College and an Honorary Research Fellow at the
School of Psychology, Birkbeck College, University of London. He is a
formerChairoftheAddictionFacultyoftheBritishPsychologicalSociety’s
DivisionofClinicalPsychology.Hehasalsoservedasconsultantincognitive
therapytotheUnitedNationsOfficeonDrugsandCrime.Thefocusofhis
researchisbehaviouralandcognitiveprocessesinaddictionandtranslating
research into practice, with particular emphasis on findings derived from
cognitiveneuroscience.
Preface
ThestorybeginswithBill,whowasaddictedtoalcohol.Hewasattending
a group along with eight other men and women in a specialist clinic
in Hammersmith, West London, more than ten years ago. They also had
experiencedproblemsassociatedwiththeiruseofalcoholandweretryingto
abstainorreducetheirlevelofalcoholconsumption.Asgroupfacilitator,
my first task was usually to ask members to ‘check in’ with an update
on how the past week had been for them: the problems, the worries, the
cravings,thelapsesandthecoping.WhenitwasBill’sturntosaysomething
abouttheweekjustpassed,hefrozemomentarily.Unlikesomeinthegroup,
Billdidnotexperienceanxietyinsocialsituations;onthecontrary,hewas
usuallya fluent,relaxed speaker.I askedwhether he wanted to collecthis
thoughts and let someone else speak in the interim but he declined. He
quicklyrecoveredhiscomposureandsaidthathispausewasduetohearing
theword‘binge’utteredbythewomansittingnexttohim.Billapparently
foundthisworddistractingandhewasunabletoconcentrateonwhathe
hadintendedtosayabouthisownupsanddownsintheprecedingweek.
Iwasintriguedbythisepisode:ifthemerementionofanalcohol-related
word could be so distracting, how potent could other addiction-related
cues be in capturing attention, especially outside the confines of the
clinic, where temptation was everywhere? A subsequent literature search
revealedjustonestudyofwhatistermedattentionalbiasinaddiction.This
investigation (Gross et al., 1993) found that when cigarette smokers were
deprivedofnicotinefor12hourstheyweremorelikelytobedistractedby
smokingrelatedcuescomparedwithfellowsmokerswhodidnotexperience
deprivation.Distractionwasindexedbytheslightlylongertimeittookthe
deprivedsmokerstonamethecolourusedtoprintsmoking-relatedwords
suchastobaccoorlighter.Thus,theywereslowertocorrectlyrespondwith
‘red’or‘blue’tothesewordsthantoneutralwordssuchaslocker orman.
Itwasasifthewordsassociatedwithcigarettesmokingexertedamagnetic
effect on the minds of abstinent smokers and distracted them from the
xii Preface
primary task of simply naming a colour. The difference in reaction time
between smoking-related and neutral words was tiny, a few milliseconds
(ms),butwasnotobservedwithcurrentsmokersorpeoplewhohadnever
smoked. To me, this appeared to be an analogue of what happened with
Bill. Regardless of the task in hand, simply saying ‘red’, ‘blue’ ‘green’ or
‘yellow’wasslowerifthewordwasconnectedwithalcohol,butunaffected
bytheneutralwords.
Although a definitive role for selective attention in anxiety disorders
hadbythenbeenproposed(Williamsetal.,1988),itwascleartomethat
attentional bias was equally important in relation to addictive disorders.
The seminal work of Marlatt and Gordon (1985) had already highlighted
thecue-specificnatureofrelapseinaddiction,andhowpeoplecouldlearn
alternativecopingstrategiestoforestallthis.Butwhatifanencounterwith
these so-called ‘high-risk situations’ reflected a cognitive bias rather than
chanceorcircumstance?Whatif,afterleavingthetreatmentcentreorthe
rehabilitationunit,individualsweredrawntopreciselythesituationsthey
wereadvisedtoavoid?Importantquestions,itseemedtome.Butnotjust
tome:cigarettesmokingisestimatedtocause5milliondeathsworldwide
each year (Thome et al., 2009). In the United Kingdom in 2009, 8,664
deathswereattributedtoalcohol-usedisorders(ONS,2011).Itisestimated
intheWorldDrugReport (UNODC,2009)thatbetween11and21million
people in 148 countries worldwide inject drugs, of whom between 0.8
and 6.6 million are infected with human immunodeficiency virus (HIV).
Addiction is also associated with massive healthcare costs: Gustavsson et
al. (2011) estimated that in 30 European countries (27 European Union
memberstatesplusIceland,NorwayandSwitzerland)addictivedisorders
cost¤65.7billionindirectandindirecthealthcarecosts.Forcomparison,
anxietydisorderswereestimatedtocost¤74.4billion,andmooddisorders
(unipolarandbipolardepression)¤43.3.Anentirevolumewouldbeneeded
to describe the full extent of human misery and costs attributable to the
spectrumofsubstancemisuseandaddiction.
Here, the focus is on the cognitive and motivational processes that
enablediversebehaviourssuchassmokingacigarette,sippinganalcoholic
beverage or injecting heroin to persist in parallel with awareness of the
harmfulconsequencesthatensueandasinceredesiretodesist.Inorderto
learn more about the role of cognitive bias in addiction, I conducted an
experimental study using a modified Stroop test (Ryan, 2002a) with the
invaluablehelpoftheclientsandcolleaguesintheclinic.Itseemedtome