Cognitive Therapy for Addiction: Motivation and Change

This edition first published 2013

© 2013 Frank Ryan

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Library of Congress Cataloging-in-Publication Data

Ryan, Frank, 1944–

Cognitive therapy for addiction : motivation and change / Frank Ryan.

p. cm.

Includes bibliographical references and index.

ISBN 978-0-470-66996-9 (cloth)—ISBN 978-0-470-66995-2 (pbk.)

1. Compulsive behavior–Treatment. 2. Substance abuse–Treatment. 3. Cognitive therapy. I. Title.

RC533.R93 2013

616.85′227–dc23

2012034393

A catalogue record for this book is available from the British Library.

Cover image: Die Furbige (The Intercessor) by Paul Klee, 1929. Photo © Geoffrey Clements / Corbis.

Cover design by Richard Boxall Design Associates

About the Author

Dr Frank Ryan trained as a clinical psychologist at Edinburgh University and works as a consultant in Camden & Islington National Health Service Foundation Trust in London, UK. He practices as a cognitive behaviour therapist with a special interest in addiction and co-occurring disorders. He is an Honorary Senior Lecturer in the Centre for Mental Health, Faculty of Medicine at Imperial College and an Honorary Research Fellow at the School of Psychology, Birkbeck College, University of London. He is a former Chair of the Addiction Faculty of the British Psychological Society's Division of Clinical Psychology. He has also served as consultant in cognitive therapy to the United Nations Office on Drugs and Crime. The focus of his research is behavioural and cognitive processes in addiction and translating research into practice, with particular emphasis on findings derived from cognitive neuroscience.

Preface

The story begins with Bill, who was addicted to alcohol. He was attending 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 experienced problems associated with their use of alcohol and were trying to abstain or reduce their level of alcohol consumption. As group facilitator, 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, the lapses and the coping. When it was Bill's turn to say something about the week just passed, he froze momentarily. Unlike some in the group, Bill did not experience anxiety in social situations; on the contrary, he was usually a fluent, relaxed speaker. I asked whether he wanted to collect his thoughts and let someone else speak in the interim but he declined. He quickly recovered his composure and said that his pause was due to hearing the word ‘binge’ uttered by the woman sitting next to him. Bill apparently found this word distracting and he was unable to concentrate on what he had intended to say about his own ups and downs in the preceding week.

I was intrigued by this episode: if the mere mention of an alcohol-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 revealed just one study of what is termed attentional bias in addiction. This investigation (Gross et al., 1993) found that when cigarette smokers were deprived of nicotine for 12 hours they were more likely to be distracted by smoking related cues compared with fellow smokers who did not experience deprivation. Distraction was indexed by the slightly longer time it took the deprived smokers to name the colour used to print smoking-related words such as tobacco or lighter. Thus, they were slower to correctly respond with ‘red’ or ‘blue’ to these words than to neutral words such as locker or man. It was as if the words associated with cigarette smoking exerted a magnetic effect on the minds of abstinent smokers and distracted them from the primary task of simply naming a colour. The difference in reaction time between smoking-related and neutral words was tiny, a few milliseconds (ms), but was not observed with current smokers or people who had never 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’ was slower if the word was connected with alcohol, but unaffected by the neutral words.

Although a definitive role for selective attention in anxiety disorders had by then been proposed (Williams et al., 1988), it was clear to me that attentional bias was equally important in relation to addictive disorders. The seminal work of Marlatt and Gordon (1985) had already highlighted the cue-specific nature of relapse in addiction, and how people could learn alternative coping strategies to forestall this. But what if an encounter with these so-called ‘high-risk situations’ reflected a cognitive bias rather than chance or circumstance? What if, after leaving the treatment centre or the rehabilitation unit, individuals were drawn to precisely the situations they were advised to avoid? Important questions, it seemed to me. But not just to me: cigarette smoking is estimated to cause 5 million deaths worldwide each year (Thome et al., 2009). In the United Kingdom in 2009, 8,664 deaths were attributed to alcohol-use disorders (ONS, 2011). It is estimated in the World Drug Report (UNODC, 2009) that between 11 and 21 million 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 member states plus Iceland, Norway and Switzerland) addictive disorders cost €65.7 billion in direct and indirect healthcare costs. For comparison, anxiety disorders were estimated to cost €74.4 billion, and mood disorders (unipolar and bipolar depression) €43.3. An entire volume would be needed to describe the full extent of human misery and costs attributable to the spectrum of substance misuse and addiction.

Here, the focus is on the cognitive and motivational processes that enable diverse behaviours such as smoking a cigarette, sipping an alcoholic beverage or injecting heroin to persist in parallel with awareness of the harmful consequences that ensue and a sincere desire to desist. In order to learn more about the role of cognitive bias in addiction, I conducted an experimental study using a modified Stroop test (Ryan, 2002a) with the invaluable help of the clients and colleagues in the clinic. It seemed to me that if attentional bias could operate at an early stage of cue reactivity it could thereby influence the frequency and intensity of urges and clinical outcome as indexed by relapse rates. I began to explore the theoretical and clinical implications of this mental process, which seems to occur unconsciously, involuntarily and, by all accounts, relentlessly. This, I thought, helped to explain the disparity between the commitment to recovery shown by many addicted individuals and the high frequency with which they failed. It still seemed sensible to teach coping strategies in anticipation of encountering the people, places and things that might trigger appetitive impulses. But sometimes this seemed to be too little, too late.

By then, I realized that my interest in the role of cognition in addiction was shared by many talented researchers and clinicians. This helped me recognize that selective attention can only be understood, or at least partially grasped, when seen as a property of a highly sophisticated system of cognitive or executive control. Inspired by their efforts and continuing my clinical practice in parallel, I began to develop the ideas that form the basis of this book. These were elaborated through a series of presentations and workshops at events such as the European Association of Behavioural and Cognitive Therapies and the World Congress of Behavioural and Cognitive Therapies in exotic locations such as Acapulco, Vancouver, Paris and Dubrovnik. This entailed a reappraisal of cognitive therapy for addiction that accentuated the core theme of this text: addiction is quintessentially a disorder of conflicted motivation that is reflected in impaired cognitive control, defined as the ability to flexibly guide behaviour in the pursuit of desired outcomes or goals.

However, in the clinical arena within which many of the readers of this book operate, this cognitive–motivational process can often be obscured by the diversity of the presenting problems associated with addictive behaviour. Accordingly, it is necessary to place this focus on cognitive control in a broader therapeutic framework known as CHANGE, an acronym of Change Habits and the Negative Generation of Emotion. An acronym is always a compromise but CHANGE serves to remind those tasked with overcoming addiction, whether therapist or treatment seeker, that this entails reversing compulsive habits and managing emotions. The journey of the book thus began in the clinic, then detoured through a process of research and innovation only to return once again to the clinical arena. Along the way, academic and clinical colleagues have generously shared their knowledge and skills. I am deeply indebted to them. In particular, I would like to thank W. Miles Cox (who kindly commented on a draft of this book) Michael Eysenck, Matt Field, Hugh Garavan, John Green, Marcus Munafò, Mick Power, Anne Richards, David Soto, Philip Tata and Reinout Wiers. I remain, however, responsible for any shortcomings in the text! I am equally indebted to those who came my way in the clinic with insightful and authentic accounts of their own addictions.

Chapter 1

The Tenacity of Addiction

Introduction and Overview

Why does addiction exert such a tenacious grip on those who fall under its spell? In this book I propose that the answer to this question lies largely within the cognitive domain: the persistence of addiction is viewed as a failure or aberration of cognitive control motivated by the enduring and unconditional value assigned to substances or behaviours that activate neural reward systems. I shall outline how addictive behaviour endures because it recruits core cognitive processes such as attention, memory and decision making in pursuit of the goal of gratification, the associated alleviation of negative emotions, or both. This recruitment process is often covert, if not subversive, and operates implicitly or automatically in the context of impaired inhibitory control. The habituated drug user is effectively disarmed when exposed to a wide range of cues that generate powerful involuntary responses. The best, and often the only, option is to mount a rear-guard action from the command and control centre of the brain. This sets the scene for a reappraisal of cognitive therapy applied to addiction. Beginning with an overview of the plan and scope of the book, this introductory chapter outlines a cognitive perspective on addiction. It goes on to address shortcomings in historical and current therapeutic approaches to addictive behaviour and includes a brief review of the equivocal and occasionally puzzling findings generated in clinical trials. It concludes with an overview of CHANGE, the re-formulated account of psychological intervention based on cognitive, motivational and behavioural principles in a cognitive neuroscience framework that forms the basis of this text.

Terminology

I have avoided the use of the term addict unless quoting from other sources. I do not think the manifestation of a particular behaviour should be used to denote an individual, in the same way that I would avoid use of terms such as a depressive or an obsessive in other circumstances. Of course, many of those who develop addictive disorders choose to refer to themselves as ‘addicts’. That is entirely appropriate for them, but I believe choosing to designate oneself as an addict is different from being so labelled by another. However, beginning with the title, I readily adopt the term addiction. Here, I apply a functional definition emphasizing the apparent involitional nature of addictive behaviour, its persistence in the face of repeated harm to self and others, and a tendency for drug seeking and taking to recur following cessation. In truth, addictive behaviour and its concomitant cognitive, behavioural and neurobiological facets occur on a continuum of varying, but often escalating, frequency and quantity or dosage. This is why attributing a static label such as addict is likely to miss the point, even if occasionally seeming to hit the nail on the head. There will be some interchange between the terms addiction, substance use and substance misuse according to the context. Generally, however, my use of the term addiction implies that the individual or group referred to meet standard diagnostic criteria for addictive disorders or dependence syndromes. Similarly, and again given pride of place on the front cover, I have opted for the term cognitive therapy rather than cognitive behavioural therapy. This decision is pragmatic rather than doctrinal but does authenticate the emphasis on cognition throughout the book. Both terms feature in the text, and anything deemed purely cognitive can easily be assimilated into the broader church of CBT.

Scope

Addiction has long been a source of fascination for theorists from a wide variety of scientific backgrounds. West (2001) listed a total of 98 theoretical models of addiction, which he classified broadly as either biological, psychological or social in orientation and content. Here, I do not attempt to review this diverse body of work. Nonetheless, West's taxonomy, referencing a ‘biopsychosocial’ framework, serves as a reminder that addiction is a complex, multifactorial, phenomenon. The main focus here is on understanding the neurocognitive and behavioural mechanisms of addiction and translating this knowledge into more effective therapeutic intervention. Most of the theoretical and empirical findings cited are based on either clinical trials or experimental paradigms involving drug administration, drug ingestion and drug withdrawal in humans and other species. For the most part, the substances at the root of the problems addressed in this text will therefore include opiates, cocaine, amphetamines, alcohol, nicotine and cannabis. At the time of writing, preparations for the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) are well underway. The term dependence, also central to the ICD-10 (WHO, 1992), is apparently being dropped. This is apparently due mainly to the possibility of conceptual confusion stemming from its dual meaning referring to either uncontrolled drug use, or normal neuroadaptation when, for example, narcotic analgesics are prescribed to alleviate chronic pain (O'Brien, 2011). The forthcoming taxonomy, due to be published in 2013, will therefore refer to ‘Addiction and Related Disorders’. Subcategories will refer to ‘alcohol use disorder’, ‘heroin use disorder’ and so on.

Gambling and other compulsive appetitive behaviours

In the forthcoming diagnostic manual on addictive disorders, the chapter on addiction will also include compulsive gambling, currently classified as an impulse control disorder along with trichotillomania and kleptomania in DSM-IV (American Psychiatric Association, 1994). Consistent with this, Castellani and Rugle (1995) demonstrated that problem gambling is associated with tolerance, withdrawal, urges and cravings, high rates of relapse and high levels of co-morbidity for mental health problems. More fundamentally, from a cognitive neuroscience point of view, it is what goes on in the brain that matters, whether this is triggered by heroin, cocaine, alcohol or indeed gambling. By way of illustration, an intriguing series of case studies provides a more clinical dimension to the motivational power of dopamine, a key neurotransmitter in reward processing, in relation to gambling. Dodd et al. (2005) reported how they encountered 11 patients over a two-year period at a movement disorders clinic with idiopathic Parkinson's disease who developed pathological gambling. All of these patients were given dopamine agonist therapy such as pramipexole dihydrochloride. Seven of these patients developed pathological or compulsive gambling within 1–3 months of achieving the maintenance dose or with dose escalation. One 68-year-old man, with no history of gambling, acquired $200,000 of gambling debt. On cessation of dopamine agonist therapy his urge to gamble subsided and eventually ceased, an outcome also observed in the seven other patients that were available for follow-up. More generally, other behaviours with a propensity to become compulsive include online activities such as Internet addiction and gaming. My view is that a behaviour such as gambling that activates reward neurocircuitry with wins, and probably downregulates the same system with losses, is liable to become compulsive in susceptible individuals. Consequently, aspects of compulsive gambling and other behaviours where motivation to desist is compromised fall within the scope of this book.

The plan of the book

The book begins with a brief critical appraisal of existing approaches, in particular cognitive and behavioural approaches such as cognitive behavioural therapy (CBT) and cognitive therapy itself (Chapter 2). This review is highly selective insofar as it focuses on shortcomings and unanswered questions, such as the finding that markedly diverse therapeutic approaches, including CBT, deliver broadly equivalent clinical outcomes. In successive chapters (3 and 4), I address first the core learning processes that contribute to the development of addiction and their neurocognitive bases, as well as delineating the predispositional role of exposure to adversity. Next, a conceptual framework that accommodates implicit cognitive and behavioural processes along with more familiar targets such as consciously available beliefs is outlined. The conclusion is that the most plausible way to regulate the former is by augmenting the latter: strategies that enhance executive control, metacognition or awareness are more likely to deliver better outcomes. By emphasizing a component process such as executive or ‘top-down’ control, the therapist and client are provided with a conceptual compass with which to navigate through the voyage of recovery. Chapter 5 addresses the question of individual susceptibility to addiction: if, indeed, drugs and gambling wins are such powerful rewards, why, ultimately, do not all but a small minority develop compulsive or addictive syndromes? This marks the transition from the more theoretical and research based chapters to content that is more directly relevant to the clinical or applied arena, although remaining grounded in a cognitive neuroscience paradigm.

Most of the remainder of the book (Chapters 6, 7, 8 and 9) explicates key therapeutic phases from a cognitive control standpoint. The sequence that unfolds follows the ‘Four M’ structure (see Figure 1.1), which is the enactment of the CHANGE approach:

Motivation and engagement

Managing urges and craving

Mood management

Maintaining change.

Figure 1.1 The Four M Model. Clockwise, these are the four key stages.

Chapter 10 aims to summarize, integrate and look forward in the context of a vibrant research arena with major implications for the concept and conduct of cognitive therapy.

Discovering Cognition

Existing accounts of cognitive therapy for addiction have not accommodated findings that cognitive processes, in particular those deemed automatic or implicit, are influential in maintaining addiction, or indeed as a potential means of leveraging change. In cognitive parlance, these models do not legislate for ‘parallel processing’ across controlled or automatic modes, with the latter being largely overlooked. Simply put, existing accounts fail to address what is the hallmark of addiction: compulsive drug seeking behaviour that appears to occur with little insight and often in the face of an explicit desire for restraint. Moreover, existing cognitive therapy approaches do not accommodate findings that cognitive efficiency is often impaired in those presenting with addictive disorders, whether stemming from pre-existing or acquired deficiencies. The client has developed a strong tendency for preferential cognitive processing and facilitated behavioural approach in the face of impaired cognitive control. Failure to acknowledge this leaves the therapist and client in the dark about an important source of variance that is influential at all stages of the therapeutic journey.

The findings of Childress and her colleagues (2008), who used advanced functional magnetic resonance imaging (fMRI) techniques to explore the neural signature of very briefly presented appetitive stimuli, are noteworthy. They found early activation of limbic structures such as the amygdala when the 22 participating abstinent cocaine addicts were shown subliminal, backward masked drug associated cues. A similar pattern was observed when covert sexual stimuli were presented. This design effectively eliminated the possibility of conscious recognition with backward masked exposure for a mere 33 ms, yet participants showed a clear pattern of activation in limbic structures implicated in reward processing. When tested with visible versions of these cues ‘off-magnet’ two days later, initial higher levels of brain activity in response to invisible cues was predictive of positive affective evaluation among the participants. As well as demonstrating the exquisite sensitivity of neural reward mechanisms to drug-related stimuli, these findings