Article summary with Increasing the efficacy of cue exposure treatment in preventing relapse of addictive behaviour by Havermans & Jansen - 2003

Introduction

The treatment in which a drug addict is repeatedly exposed to stimuli associated with addicted behaviour is known as Cue Exposure with Response Prevention (CERP). The response that these cues evoke is generally considered to be conditioned drug responses. These can be psychophysiological (changes in heart rate), behavioural (drug-seeking behaviour), or subjective (craving). These responses increase the chance than an addict will take drugs.  The treatment leads to the gradual extinction of the conditioned drug response. Unfortunately, no research has yet found a substantial effect on relapse by extinguishing cue reactivity. Apparently the effect (extinction of cue reactivity) does not generalize beyond the treatment setting. This can be explained by the fact that conditioned responses can recover after extinction, and extinction is seeing as the ‘unlearning’ of something which is meant to be permanent.

This article describes a number of ways in which CERP can be improved so that it’s more effective in combating relapse. First it describes how contemporary learning theory defines extinction and how it explains the recovery of conditioned responding. Second, different methods to prevent the recovery of extinguished cue reactivity are discussed. Then suggestions for future research are addressed.

Theoretical Notes

Pavlov indicated that extinction is not forever. Extinguished responses can recover; he calls this spontaneous recovery. In addition, the renewal effect shows that extinction is not the same as learning form an association. The renewal effect means that a conditioned response after cancellation can be renewed if the conditioned stimulus is presented in an environmental context different form the context in which the extinction took place. The statement by Bouton (1994) reads as follows: conditioned stimulus has acquired an ambiguous meaning after extinction. After extinction, a stimulus predicts the presentation and absence of an unconditioned stimulus. So the conditioned stimulus has a stimulating meaning during conditioning and an inhibitory meaning during extinction. Spontaneous recovery of a response can occur because someone doesn’t understand the meaning of a conditioned response when it’s presented in a different environment than the one it was learned in.

The treatment of drug addicts is difficult because they use drugs in many different places and situations. So there are too many practical problems to offer a ‘standard’ CERP. Offering CERP in different environments would increase the chance of generalization. However, offering CERP in multiple environmental contexts could cause a delay of extinction. Moreover, it’s unclear how many different contexts are needed. The perfect CERP would be a treatment that considers and controls for the probability of renewal effects and spontaneous recovery, and takes into account the above problems.

A promising option is to add so-called retrieval cues in the CERP treatment. Retrieval cues are striking features of an extinction environment, whereby the inhibitory meaning of the conditioned response is recognized outside the environment. If a retrieval cue is presented outside the original environment, this reduces the chance of renewals. An example of a retrieval cue would be using a reminder card.

Conclusion

learning and motivation is a dynamic research area, and so, contemporary learning theory continues to be an important resource for the implementation and development of behavioural therapy. Based on principles derived from contemporary learning theory, CERP incorporating retrieval cues can be a promising adjustment of standard cue exposure treatment. It doesn’t require extending the length of treatment and may control for the previously mentioned limitations.

When cue reactivity is extinguished and recovery of conditioned drug responding can be prevented by cue exposure with retrieval cues, it’s predicted that relapse of addictive behaviour can be more successfully prevented.