Cognitive Therapy for Addiction

Frank Ryan is a consultant clinical psychologist in Camden and Islington NHS Foundation Trust in London, UK. An Honorary Senior Lecturer in the Faculty of Medicine at Imperial College and an Honorary Research Fellow at Birkbeck, University of London, he is a practicing cognitive therapist and an active trainer, lecturer and researcher.

About the Author ix

Preface xi

1 The Tenacity of Addiction 1

Introduction and Overview 1

Discovering Cognition 5

Implicit Cognition and Addiction 6

Neuropsychological Findings 9

Addictive Behaviour is Primary, Not Compensatory 11

Changing Habits is the Priority 14

Diagnostic Criteria 15

Towards Integration 15

Equivocal Findings from Research Trials 16

Time for CHANGE 16

Evolution, Not Revolution 17

Something Old, Something New 18

2 Existing Cognitive Behavioural Accounts of Addiction and Substance Misuse 21

The Evidential Basis of CBT for Addiction 23

Meta-analytic Findings 23

Behavioural Approaches 24

Diverse Treatments Mostly Deliver Equivalent Outcomes 25

What are the Mechanisms of Change? 26

The Missing Variable? 27

A Dual-Processing Framework 28

3 Core Motivational Processes in Addiction 33

Is Addiction About Avoiding Pain or Seeking Reward? 33

How Formulation Can Go Astray 34

Incentive Theories of Addiction 35

Learning Mechanisms in Addiction 36

Distorted Motivation and Aberrant Learning: the Emergence of Compulsion 41

‘Wanting and Liking’ in the Clinic 41

The Role of Secondary Reinforcers 43

Beyond Pleasure and Pain: a Psychoanalytic Perspective 43

Conclusion 44

4 A Cognitive Approach to Understanding the Compulsive Nature of Addiction 45

Theories of Attention 46

Top-Down Influences Can Be Automatic 47

Automatic Processes Can Be Practically Limitless 48

Motivationally Relevant Cues are Prioritized 48

Biased Competition 50

Attention and Volition 51

Appetitive Cues Usually Win 52

Purposeful Behaviour Can Occur in the Absence of Consciousness 53

Attentional Bias and Craving 54

Cognitive Cycle of Preoccupation 56

5 Vulnerability Factors In Addiction 63

Individual Differences in Addiction Liability 63

Personality Traits 63

The ‘Big Five’ Personality Factors 65

Personality Disorders 66

Affective Vulnerability Factors 67

Brain-Derived Neurotrophic Factors 69

Neurocognitive Vulnerability 70

Findings from the Addiction Clinic 71

From Research to Practice 72

6 Motivation and Engagement 75

Impaired Insight and the Therapeutic Relationship 75

The Sad Case of Julia 80

Conflicted Motivation is the Key 81

Goal Setting and Maintenance 82

The Importance of Between-Session Change 83

Neurocognitive Perspectives on Motivation 83

Motivational Interviewing in Practice 84

Formulating and Planning the Intervention 88

Attributional Biases: the Blame Game 90

Case Formulation 91

Summary 97

7 Managing Impulses 99

Introduction and Overview 99

Structuring the Session 99

Building Resilience 100

Impulse Control 102

Craving and Urge Report 103

Cognitive Processing and Craving 104

Cognitive Bias Modification 105

Attentional Bias in the Context of Addiction 106

The Alcohol Attention-Control Training Programme 108

Modifying Implicit Approach Tendencies 110

Reversing the Bias: Conclusion 112

Brain Training and Neurocognitive Rehabilitation Approaches 112

Clinical Implications of Delayed Reward Discounting 117

Tried and Tested Techniques 119

The Road to Recovery is Paved with Good Implementation Intentions! 125

Neurophysiological Techniques 129

Neuropsychopharmacological Approaches 130

8 Managing Mood 135

The Reciprocal Relationship Between Mood and Addiction 135

Pre-existing Vulnerability to Emotional Distress 137

Negative Affect Due To Drug Effects 141

Stepped Care for Addiction 145

An Integrated Approach to Addressing Negative Emotion 147

9 Maintaining Change 155

Relapse Prevention Strategies from a Neurocognitive Perspective 155

The Importance of Goal Maintenance in the Long Term 158

A Neurocognitive Perspective on Relapse 159

Twelve-Step Facilitation Therapy 161

Implicit Denial 162

10 Future Directions 171

Neurocognitive Therapy 171

Increasing Cognitive Control is the Goal 172

Do We Know Anything New? 173

Appendix Self-Help Guide Six Tips – a Pocket Guide to Preventing Relapse 179

Introduction: Why Six Tips? 179

1. Don’t Always Trust Your Memory! 180

2. Beware of the ‘Booze Bias’! 180

3. Separate Thoughts from Actions 181

4. Learn How to Distract Yourself 181

5. Willpower is Sometimes Not Enough 182

6. Beware of the Dog that Doesn’t Bark. . . 182

References 185

Index 201