Emotion Regulation, Mindfulness, and Substance Abuse
A growing literature is demonstrating the importance of emotion regulation in the treatment of substance abuse. For the sake of conceptual uniformity, this section uses the tobacco cessation as the chief example; however, since nicotine and other psychoactive substances such as cocaine activate similar psychopharmacological pathways, [14] an emotion regulation approach may be similarly applicable to a wider array of substances of abuse. Proposed models of affect-driven tobacco use have focused on negative reinforcement as the primary driving force for addiction; according to such theories, tobacco is used because it helps one escape from the undesirable effects of nicotine withdrawal or other negative moods. [15] Currently, research is being conducted to determine the efficacy of mindfulness based approaches to smoking cessation, in which patients are encouraged to identify and recognize their negative emotional states and prevent the maladaptive, impulsive/compulsive responses they have developed to deal with them (such as cigarette smoking or other substance use).
Wednesday, July 15, 2009
Cognitive Models of Addiction Recovery
Relapse Prevention
An influential cognitive-behavioral approach to addiction recovery and therapy has been Alan Marlatt’s (1985) Relapse Prevention approach. [12]. Marlatt describes four psychosocial processes relevant to the addiction and relapse processes: self-efficacy, outcome expectancies, attributions of causality, and decision-making processes. Self-efficacy refers to one’s ability to deal competently and effectively with high-risk, relapse-provoking situations. Outcome expectancies refer to an individual’s expectations about the psychoactive effects of an addictive substance. Attributions of causality refer to an individual’s pattern of beliefs relapse to drug use is a result of internal, or rather external, transient causes. Finally, decision-making processes are implicated in the relapse process as well. Substance use is the result of multiple decisions whose collective effects result in consumption of the intoxicant. Furthermore, Marlatt stresses some decisions—referred to as apparently irrelevant decisions—may seem inconsequential to relapse, but may actually have downstream implications that place the user in a high-risk situation.
Consider Figure 1 as an example. As a result of heavy traffic, a recovering alcoholic may decide one afternoon to exit the highway and travel on side roads. This will result in the creation of a high-risk situation when he realizes he is inadvertently driving by his old favorite bar. If this individual is able to employ successful coping strategies, such as distracting himself from his cravings by turning on his favorite music, then he will avoid the relapse risk (PATH 1) and heighten his efficacy for future abstinence. If, however, he lacks coping mechanisms—for instance, he may begin ruminating on his cravings (PATH 2)—then his efficacy for abstinence will decrease, his expectations of positive outcomes will increase, and he may experience a lapse—an isolated return to substance intoxication. So doing results in what Marlatt refers to as the Abstinence Violation Effect, characterized by guilt for having gotten intoxicated and low efficacy for future abstinence in similar tempting situations. This is a dangerous pathway, Marlatt proposes, to full-blown relapse. Figure 1 presents a schematic diagram, adapted from Marlatt & Gordon (p. 38) [12], which has been modified to present examples of the cognitive and behavioral processes that may occur at each juncture of the model.
Cognitive Therapy of Substance Abuse
An additional cognitively-based model of substance abuse recovery has been offered by Aaron Beck, the father of cognitive therapy and championed in his 1993 book, Cognitive Therapy of Substance Abuse.[13] This therapy rests upon the assumption addicted individuals possess core beliefs, often not accessible to immediate consciousness (unless the patient is also depressed). These core beliefs, such as “I am undesirable,” activate a system of addictive beliefs that result in imagined anticipatory benefits of substance use and, consequentially, craving. Once craving has been activated, permissive beliefs (“I can handle getting high just this one more time”) are facilitated. Once a permissive set of beliefs have been activated, then the individual will activate drug-seeking and drug-ingesting behaviors. The cognitive therapist’s job is to uncover this underlying system of beliefs, analyze it with the patient, and thereby demonstrate its dysfunctionality. As with any cognitive-behavioral therapy, homework assignments and behavioral exercises serve to solidify what is learned and discussed during treatment.
An influential cognitive-behavioral approach to addiction recovery and therapy has been Alan Marlatt’s (1985) Relapse Prevention approach. [12]. Marlatt describes four psychosocial processes relevant to the addiction and relapse processes: self-efficacy, outcome expectancies, attributions of causality, and decision-making processes. Self-efficacy refers to one’s ability to deal competently and effectively with high-risk, relapse-provoking situations. Outcome expectancies refer to an individual’s expectations about the psychoactive effects of an addictive substance. Attributions of causality refer to an individual’s pattern of beliefs relapse to drug use is a result of internal, or rather external, transient causes. Finally, decision-making processes are implicated in the relapse process as well. Substance use is the result of multiple decisions whose collective effects result in consumption of the intoxicant. Furthermore, Marlatt stresses some decisions—referred to as apparently irrelevant decisions—may seem inconsequential to relapse, but may actually have downstream implications that place the user in a high-risk situation.
Consider Figure 1 as an example. As a result of heavy traffic, a recovering alcoholic may decide one afternoon to exit the highway and travel on side roads. This will result in the creation of a high-risk situation when he realizes he is inadvertently driving by his old favorite bar. If this individual is able to employ successful coping strategies, such as distracting himself from his cravings by turning on his favorite music, then he will avoid the relapse risk (PATH 1) and heighten his efficacy for future abstinence. If, however, he lacks coping mechanisms—for instance, he may begin ruminating on his cravings (PATH 2)—then his efficacy for abstinence will decrease, his expectations of positive outcomes will increase, and he may experience a lapse—an isolated return to substance intoxication. So doing results in what Marlatt refers to as the Abstinence Violation Effect, characterized by guilt for having gotten intoxicated and low efficacy for future abstinence in similar tempting situations. This is a dangerous pathway, Marlatt proposes, to full-blown relapse. Figure 1 presents a schematic diagram, adapted from Marlatt & Gordon (p. 38) [12], which has been modified to present examples of the cognitive and behavioral processes that may occur at each juncture of the model.
Cognitive Therapy of Substance Abuse
An additional cognitively-based model of substance abuse recovery has been offered by Aaron Beck, the father of cognitive therapy and championed in his 1993 book, Cognitive Therapy of Substance Abuse.[13] This therapy rests upon the assumption addicted individuals possess core beliefs, often not accessible to immediate consciousness (unless the patient is also depressed). These core beliefs, such as “I am undesirable,” activate a system of addictive beliefs that result in imagined anticipatory benefits of substance use and, consequentially, craving. Once craving has been activated, permissive beliefs (“I can handle getting high just this one more time”) are facilitated. Once a permissive set of beliefs have been activated, then the individual will activate drug-seeking and drug-ingesting behaviors. The cognitive therapist’s job is to uncover this underlying system of beliefs, analyze it with the patient, and thereby demonstrate its dysfunctionality. As with any cognitive-behavioral therapy, homework assignments and behavioral exercises serve to solidify what is learned and discussed during treatment.
Historical Approaches to Substance Abuse Treatment
Disease Model and Twelve-Step Programs
The disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displayed by addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. This conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness are unable to fight the disease by themselves without medication. Behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network who can help them remain sober. Such approaches are the quintessential features of Twelve-step programs, originally published in the book Alcoholics Anonymous in 1939 [5]. These approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological [6] and legal [7] grounds. Nonetheless, despite this criticism, outcome studies have revealed that affiliation with twelve-step programs predicts abstinence success at 1-year follow-up [8].
Client-Centered Approaches
In his influential book, Client-Centered Therapy, in which he presented the client-centered approach to therapeutic change, psychologist Carl Rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. Rogers believed the presence of these three items in the therapeutic relationship could help an individual overcome any troublesome issue, including alcohol abuse. To this end, a 1957 study [9] compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. Though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in outcome. Surprisingly, client-centered therapy proved most effective. It has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques per se [10]. The authors note two-factor theory involves stark disapproval of the clients’ “irrational behavior” (p. 350); this notably negative outlook could explain the results.as in some other cases
Psychoanalytic Approaches
Psychoanalysis, a psychotherapeutic approach to behavior change developed by Sigmund Freud and modified by his followers, has also offered an explanation of substance abuse. This orientation suggests the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. It is hypothesised specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesised to be associated with life trajectories that have occurred within the context of traumatogenic processes, the phases of which include social, cultural and political factors, encapsulation, traumatophilia, and masturbation as a form of self-soothing. [11] Such an approach lies in stark contrast to the approaches of social cognitive theory to addiction—and indeed, to behavior in general—which holds human beings regulate and control their own environmental and cognitive environments, and are not merely driven by internal, driving impulses. Additionally, homosexual content is not implicated as a necessary feature in addiction.
The disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displayed by addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. This conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness are unable to fight the disease by themselves without medication. Behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network who can help them remain sober. Such approaches are the quintessential features of Twelve-step programs, originally published in the book Alcoholics Anonymous in 1939 [5]. These approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological [6] and legal [7] grounds. Nonetheless, despite this criticism, outcome studies have revealed that affiliation with twelve-step programs predicts abstinence success at 1-year follow-up [8].
Client-Centered Approaches
In his influential book, Client-Centered Therapy, in which he presented the client-centered approach to therapeutic change, psychologist Carl Rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. Rogers believed the presence of these three items in the therapeutic relationship could help an individual overcome any troublesome issue, including alcohol abuse. To this end, a 1957 study [9] compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. Though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in outcome. Surprisingly, client-centered therapy proved most effective. It has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques per se [10]. The authors note two-factor theory involves stark disapproval of the clients’ “irrational behavior” (p. 350); this notably negative outlook could explain the results.as in some other cases
Psychoanalytic Approaches
Psychoanalysis, a psychotherapeutic approach to behavior change developed by Sigmund Freud and modified by his followers, has also offered an explanation of substance abuse. This orientation suggests the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. It is hypothesised specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesised to be associated with life trajectories that have occurred within the context of traumatogenic processes, the phases of which include social, cultural and political factors, encapsulation, traumatophilia, and masturbation as a form of self-soothing. [11] Such an approach lies in stark contrast to the approaches of social cognitive theory to addiction—and indeed, to behavior in general—which holds human beings regulate and control their own environmental and cognitive environments, and are not merely driven by internal, driving impulses. Additionally, homosexual content is not implicated as a necessary feature in addiction.
Counseling
Traditional addiction treatment is based primarily on counseling. However, recent discoveries have shown those suffering from addiction often have chemical imbalances that make the recovery process more difficult.
Diseased person model
Some psychotherapists question the validity of the "diseased person" model used within the drug rehabilitation environment. Instead, they state the individual person is entirely capable of rejecting previous behaviors. Further, they contend the use of the disease model of addiction simply perpetuates the addicts' feelings of worthlessness, powerlessness, and inevitably causes inner conflicts that could be resolved if the addict were to approach addiction as behavior that is no longer productive, the same as childhood tantrums.
Criminal justice
Drug rehabilitation is sometimes part of the criminal justice system. People convicted of minor drug offenses may be sentenced to rehabilitation instead of prison, and those convicted of driving while intoxicated are sometimes required to attend Alcoholics Anonymous meetings. There have been lawsuits filed, and won, regarding the requirement of attending Alcoholics Anonymous and other twelve-step meetings as being inconsistent with the Establishment Clause of the First Amendment of the U. S. Constitution, mandating separation of church and state.[3][4]
Pharmacotherapies
Certain opioid medications such as methadone and more recently buprenorphine are widely used to treat addiction and dependence on other opioids such as heroin, morphine or oxycodone. Methadone and buprenorphine are maintenance therapies used with an intent of stabilizing an abnormal opioid system and used for long durations of time though both may be used to withdraw patients from narcotics over short term periods as well. Ibogaine is an experimental medication proposed to interrupt both physical dependence and psychological craving to a broad range or drugs including narcotics, stimulants, alcohol and nicotine. Some antidepressants also show use in moderating drug use, particularly to nicotine, and it has become common for researchers to re-examine already approved drugs for new uses in drug rehabilitation.
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