Addictions and their Treatment (Psychological Theories of Addiction and…
Addictions and their Treatment
Illicit drugs overview
Types of drugs
Drugs being categories by the effects they have on the central nervous system (some drugs might cross over in different categories)
Has been suggested that depending on how fast drugs reach the brain, the faster the addiction
What do drugs feel like
Smoking being the fastes way to reach the brain, than injection, than snorting, and the slowest way being ingestion
Epidemiology: UK Prevalencec
Alcohol: 1.6 million dependent drinkers, approx. 10,000 deaths/yesr
Opiates and cocaine: c. 400,000 users in the UK; approx. 2,000 deaths/year
Tabacco: approx 100,000 tabacco related deaths/year
30% population have ever used an illegal drug;
16 - 24 - year - olds: c. 20% have used an illegal drug in the last month ;
11 - 15 year olds: 22% had used an illegal drug at least once .
Alcohol: in 2008, 87% of the adult population drank alcohol;
Tobacco: approx 22%.
What is Addiction
“Addiction can be defined as a chronic condition involving powerful motivation to engage an activity to an extent that is harmful. It undermines and overwhelms attempts at restraint” (WEST, 2006)
Can also be defined as a multilevel phenomena, including biological, social, and psychological processes
Why do people use drugs?
West (2001) broadly categorised addiction theories into three main domains: Psychological (behavioural); social and biological
There is general consensus that no one theoretical framework adequately describes addiction
Any understanding of addiction comes from looking at the interaction between the biological, psychological and social spheres
And the general consensus is that addiction is a biopsychosocial phenomena (Wanigaratne, 2006).
The Biopsychosocial Model
The Biological Part
Dopamine being involved in the effects of all drugs (in different regions)
Incentive motivational theories (Robinson & Berridge, 2003) suggests that the phenomena of ‘cravings’ provides a good illustration of how the psychological and biological spheres interact
Addicted individuals will pay close attention (attentional bias) to substance-related cues. These then trigger a response which includes an ‘urge to act’ and a hyper-attentive state (craving). Cognitive processes (e.g “I need to score or I’ll not cope with the pain” then mediate between the stimulus and response (Franken et al, 2003)
There is emerging evidence of the neurobiological link between stress and craving (Breese et al, 2005)
The Psychological Part
The process of developing an addiction from experimenting to dependence has been explained by:
Learning theories (classical/operant conditioning; and social learning theories)
Personal factors (to meet personal needs and dispositions, identity, meaning in relationships
Adaptational Factors (physical, belief or lifestyle adaptation)
Cravings can also be understood via classical conditioning processes (e.g. Drummond, 2001)
That is, externa stimuli can trigger cravings in addicted individuals, especially in presence of weak inhibitory controls
These cravings can lead to permission-giving beliefs resulting in lapses/relapses
OP is also to play a major role in development and maintenance of addictions
Drugs (as well as food/sed) are all reinforcers in the conditioning process
A positive reinforcer (e.g. alcohol makes me sociable) is rewarding and the underlying motivation relative to alternative behaviours becomes amplified through repetition
A negative reinforcer is the removal of aversive state (e.g. drinking to take away social lanxiety)
Personality factors, such as, impulsivity anxiety sensitivity, sensation-seeking and harm avoidance are thought to be risk factors in addictive behaviours (Sher et al., 2000)
Traumatic early experiences play a part in development and maintenance (e.g. self-medication hypothesis, Khantziian, 1977)
The Social Part
Substance use always taking place within a context. Often this within a social context
Social and environmental factors, such as availability, encouragement, learning all contributing to the development and maintenance of addictions.
Culture setting social norms, of what is permissible
Peer pressure will have an impact
Psychological Theories of Addiction and Recovery
Developmental theories of addiction (e.g. Beck et al., 1993 - Cognitive Therapy Model)
Theories of motivation (e.g. West, 2006 - Prime Theory)
Theories of change (e.g. Prochaska et al., 1992 - Spiral of Change; Miller and Rollnick, 2002 - Motivational Interviewing)
Theories to explain relapse and desistance (Marlatt and Gordon, 2005)
Theory driven interventions to treat addiction and promote recovery, i.e. "psychological interventions" (mapping, structured advice, goal setting, problem solving)
When attempting to understand addictions, it is important to consider value of differnt levels of explanations including genetic predispositions, neurophysiological adaptations to SM, personality factors, social norms and social context
It is vital to consider the biopsychosocial spheres as well as the interplay between each in when delivering treatments for addictions
From a biopsychosocial perspective, addiction is the result of maladaptive behaviours, which originate from an interaction various biological, psychological and social/environmental factors
Assessment and Treatment
Screening followed by
Comprehensive assessment of SM use and history; related disorders (depression, trauma)
Identify interrelated factors (biopsychosocial factors)
Comprehensive, Integrated Treatment Approach
Programmes should incorporate approaches that directly address additional concerns (e.g. depression, trauma ..)
Treatment should consider "the whole person"
Use of evidence-based informed practices
In the UK: NICE guidelines is the main framework
Guiding SUs in making informed choices for treatments
What treatment(s) might help me best and why?
What are the pros and cons of this treatment?
What does the treatment involve?
How will it help me?
What other tretamnets are available?
Tell me more about incentives programmes
Can I have help for anxiety and depression and other mental health problems as well as for my drug problem?
Key Tasks of Treatment
First establish therapeutic allience, then do assessment, then formulation, then start intervention (engagement being important in every stage)
The Proceess of assessment
(asapted from Westbook et al., 2007)
Assessment is not just traweling for "facts"
Active process of generating and testing hypotheses
Assessment is on-going throughout interventions
Purpose of Assessment
Development of presenting difficulties
Context - biological, psychological, social factors
Leads to treatment/relapse prevention management plan
Ongoing evaluation of intervention
Change treatment is necessary
Planning and developing future services
Comprehensive assessment allows generation fo hypotheses for ... formulation
Formulation is ...
Provisional explanations of difficulties
"Lynch pin that holds theory and practive together" (Butler, 1998)
Includes causes, triggers and maintaining factors
Provides hypotheses which can be tested
Identifies targets for change / management
Links past and present
Constantly chacked and revised throughout
Formulation at a case level vs. at a situational level
Formulation in different clinical modalities
Never named as such, never shared with client explicitly
Case conceptualisation - CBT
Functional analysis - 1950s - Behavioural Therapy
Scientist - practitioner model
1970s Beck added cognitive principle thus CBT: personal appraisal is everything
Working hypotheses - 1970s
Cognitive longitudinal formulation of problematic SM