Cognitive therapy for addiction: motivation and change PDF
Preview Cognitive therapy for addiction: motivation and change
Cognitive Therapy for Addiction Cognitive Therapy for Addiction Motivation and Change Frank Ryan A John Wiley & Sons, Ltd., Publication Thiseditionfirstpublished2013 ©2013FrankRyan Wiley-BlackwellisanimprintofJohnWiley&Sons,formedbythemergerofWiley’sglobalScientific, TechnicalandMedicalbusinesswithBlackwellPublishing. RegisteredOffice JohnWiley&SonsLtd,TheAtrium,SouthernGate,Chichester,WestSussex,PO198SQ,UK EditorialOffices 350MainStreet,Malden,MA02148-5020,USA 9600GarsingtonRoad,Oxford,OX42DQ,UK TheAtrium,SouthernGate,Chichester,WestSussex,PO198SQ,UK Fordetailsofourglobaleditorialoffices,forcustomerservices,andforinformationabouthowtoapply forpermissiontoreusethecopyrightmaterialinthisbookpleaseseeourwebsiteat www.wiley.com/wiley-blackwell. TherightofFrankRyantobeidentifiedastheauthorofthisworkhasbeenassertedinaccordancewith theUKCopyright,DesignsandPatentsAct1988. 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LibraryofCongressCataloging-in-PublicationData 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 616.85(cid:2)227–dc23 2012034393 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Coverimage:DieFurbige(TheIntercessor)byPaulKlee,1929.Photo©GeoffreyClements/Corbis. CoverdesignbyRichardBoxallDesignAssociates Setin10.5/13ptMinionbyLaserwordsPrivateLimited,Chennai,India. 12013 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
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