Cognitive motivational processes underlying addiction treatment - summary of chapter 9 of Frontiers in social psychology

Frontiers in social psychology
Chapter 9
Cognitive motivational processes underlying addiction treatment

Introduction

The currently standard treatment approaches are based on the assumption that human behaviour is controlled and largely determined by personal intentions and propositional knowledge, reflective processes. The more novel treatment approaches view human behaviour as unfolding (more or less) automatically in reaction to motivationally significant stimuli, impulsive processes. Behaviour can best be understood and influenced when taking both types of processes into account as well as different goals.

Behaviour as intentional action

Several theories on behaviour regulation stress the pivotal role of conscious goals attitudes and subjective norms.

In goal-setting theory, goals are consciously accessible action plans aimed at meeting a certain standard. They serve as reference points against which current states are evaluated and on the basis of which further action is taken. If a discrepancy between the current and the desired end state is perceived, motivation to reduce this discrepancy increases and action will be taken. The higher the commitment, importance or accessibility of the goal, the more likely such a behavioural adjustment becomes.

According to the theory of reasoned action, there are additional factors that influence whether and what action will be taken. Those are one’s explicit beliefs about the action and the evaluation of its outcome, as well as normative pressures. There is an emphasis on the intentional process by which goals and attitudes control action.

For behaviour change to occur in a meaningful and sustained manner, it is necessary that the person feels able to perform the action and that the person expects the action to lead to the expected outcome. Perceived behavioural control is often compared to perceptions of self-efficacy which has positive effects on planning and goals setting, commitment, task performance and persistence in the face of obstacles. Increased control can help to break with maladaptive habits and explore new behavioural alternatives. Self-efficacy is a central determinant of whether action is taken, but goals and intentions are equally necessary in providing to behavioural standards to act upon.

Behaviour change can be achieved and maintained by setting goal-incompatible with continued unhealthy behaviour, and by strengthening commitment to these alternative goals.

Behaviour as automatic action

Deciding which actions to take through assessing their utility for goal-attainment or through weighing attitudes against norms consumes scare cognitive resources.

Considering the complexity and efficiency of behaviour, it seems implausible to assume that it is mainly mediated by conscious intentional thought. Most of our daily behaviour is evolving as part of behavioural schemata or as reaction initiated automatically by relevant internal or external cues. Automatic processes are often motivationally charged, people have a strong tendency to automatically approach anything desirable.

One way in which stimuli gain motivational significance is through being repeatedly paired or followed by immediate reward or punishment. Those rudimentary evaluations are automatically activated by the respective cues and are believed to form the basis of implicit attitudes. In the case of addiction, this process is stronger through direct action of the substance on the mesolimbic dopaminergic system, which results in increased incentive salience for stimuli associated with the drug and the subsequent peak in dopamine. Addiction cues gain strong motivational significance, and a strong ‘wanting’ response, which can influence behaviour outside conscious awareness.

There are three neurocognitive mechanisms which can lead to stronger automatic responses to drug related stimuli. These are: 1) Incentive sensitization. 2) Habit formation, a process in which an overlearned stimulus elicits a response, even when the original expected outcome is no longer fulfilled by the action. This shifts of control over behaviour form a circuit involving the ventral striatum to a circuit involving the dorsal striatum. 3) Negative reinforcement, substances are used in order to alleviate negative feelings, which are often caused by the long-term effect of (prolonged) substance use. Negative bodily states may automatically trigger motivational states, which serve to trigger behaviour that counters these negative states  

Behaviour regulation operates efficiently through responding to motivational properties form the environment. Behavioural change can be achieved through adjusting the associated motivational properties of certain stimuli, or by intervening with the cognitive processes involved in the regulation of impulses.

Behaviour as an interplay between intentionality and automaticity

Both the relatively reflective and relatively automatic processes are important in cognitive motivational processes underlying human behaviour.

General dual-process and dual-systems models have bene criticized for lack of clear mechanisms and lack of evidence for dissociable systems.

In many cases, first an impulsive or preconscious reaction to a stimulus is generated, which subsequently unfolds, which progressively more influence from conscious goals and desires, which can down-regulate the initial response within the second.

In  the hierarchical levels of control over behaviour perspective, a hierarchy of different neural systems exert control over behaviour. This is at the basic level, there are reinforcement processes. Here conditioned stimuli gain ‘incentive salience’, which creates a strong motivation to engage with them. Further process the information to cognitively represent the expected outcomes and organize them into goals

It has been argued that consciousness may have developed to deal with goal-conflict, when two neural processes generate incompatible output.

In the case of addition, the different pharmacologically enhanced neural mechanisms create stronger direct associations between a substance-related cue and action tendencies to approach the cue. At least a subgroup of people with addiction problems manage to overcome these impulses. Alternative goals and motivation to change play a crucial role in this process.

Conflict between different cognitively represented goals is of crucial importance for understanding addiction and related problems. Management of conflicting goals is the central task of executive functions, in which the formal cortices play a major role. Relatively weak development of executive functions has been recognized as a risk factor for the development of addictions. Prolonged substance use may impair frontal functions.

‘Rational’ goal management in relation to addictive behaviours may be especially difficult for people with an addiction problem for two reasons. These are: 1) different neuroadaptations (sensitization) will make addiction-related stimuli ‘motivational magnets’, which generate a very strong bottom-up goal-activation. 2) The neural systems important in managing different goals often function in a suboptimal way in people with addiction problems, partly due to premorbid impairments, partly due to acquired impairments through prolonged drug use, and partly through sub-acute effects

Prolonged abstinence can improve some executive functions, and there are also ways to reduce the strong bottom-up motivational responses to drug-cues. Behavioural regulation can be improved through strengthening those cognitive processes and executive functions, which are crucial for successfully solving conflicts between the higher order goals and bottom up motivational stimulation.

Current psychosocial approaches to treat addictive behaviours

Most common approaches to changing addictive behaviours aim to increase self-control over addictive behaviour. The central aim is to prevent patients from relapse once abstinence has been established.

Motivational enhancement therapy (MET)

The process of enhancing motivation to change addictive behaviours has two phases. 1) The counsellor works with patients to understand and resolve resistance to change. She can do this by: asking open questions, reflective listening, affirmation, attempting to increase the self-efficacy to change by change, or a confidence talk. 2) When the patient shows readiness to change, the counsellor starts working on strengthening commitment to change. She does this through the development of a change plan by setting goals and considering change options

The core component of motivational enhancement therapy is motivational interviewing (MI). This is a directive, client-centred counselling style for eliciting behaviour change by helping the client to explore and resolve ambivalence. It is based on four principles. These are: 1) Roll with resistance, explores reasons for substance use and difficulties of trying to change in a non-confrontational and authoritative style. 2) express empathy, an attempt to accurately understand a patient’s dilemma without judgment or criticism. 3) develop discrepancy, helps patient’s become aware of the discrepancy between their current addictive behaviour and important values and goals by reflecting these discrepancies and exploring how behavioural change may help patients to live in accordance with their values and goals. 4) support self-efficacy, helps patients recognizing their strengths and personal and social resources and acknowledging patients’ past successful change efforts

Motivational enhancement therapy tries to increase the salience of the association between the addictive behaviours and negative consequences, and activate alternative goals, incompatible with continued (heavy) drug use.

Cognitive behavioural therapies (CBT)

Cognitive behavioural therapy is a set of intervention elements that share theoretical assumptions form behavioural and/or cognitive therapy traditions, and often drawing from basic research testing these theoretical assumptions.

There are two critical components of cognitive behavioural therapy designed to change addictive behaviour. These are a thorough functional analysis of the role the addictive behaviour plays in the patient’s life, including the identification of high risk situations for the behaviour and relapse, and highly individualized training programs that help patients’ developing cognitive and behavioural skills

Typical cognitive interventions in cognitive behavioural therapy focus on enhancing self-efficacy for change, strategies to increase thinking about negative consequences of drinking, and enhancing positive expectancies about outcomes of treatment. Typical behavioural skills training include assertiveness training, social skills training, relaxation, stress management techniques, and mood management training.

Cognitive behavioural therapy will primarily work on developing alternative means (behavioural strategies) to attain the client’s goals.

Contingency management (CM)

Contingency management involves a behavioural contract between the patient and a healthcare professional that specifies patient’s target behaviour to be closely monitored and to be rewarded by a professional. Incentives are withheld wen the target behaviour does not occur.

The idea is to increase the frequency of behaviour that is compatible with an drug-free life-style, which might translate into improved long-term outcomes.

Community reinforcement approach (CRA)

Community reinforcement approach combines contingency management with community psychology based on the belief that patient’s community plays a significant role in rewarding and supporting recovery and a clean and sober lifestyle. Access to a range of potentially desirable activities within the community is made contingent on abstinence and withdrawal of the activity contingent upon drinking or using drugs.

Key elements of this method are functional analysis, drug monitoring, treatment planning, learning communication, problem-solving, drug refusing, relapse prevention, job-finding skills, social and recreational counselling, and relationship therapy.

Behavioural couples therapy (BCT)

Behavioural couples therapy includes interventions to enhance positive and pleasurable exchanges between intimate partners, boost communication and problem-solving skills, and increase partner support for sobriety.

Behavioural activation (BA)

Behavioural activation focuses substance users on the values that they have in various life areas and attempts to organize their life such that their daily activities are more in line with these values. These more value-based activities will provide opportunities for immediate and meaningful reinforcement in the substance users sober life to compete with the reinforcement available for substance use.

Cue exposure treatment (CET)

Cue exposure treatment focuses on the modification of the automatically activated cue-reactivity. It focuses on two mechanisms, these are: reducing the strength of these associations by repeatedly presenting cues preventing alcohol use, and providing practice in using urge-specific coping skills while under influence of these conditioned responses to cues so that reactions to the cues will be less likely to disrupt coping efforts with the urge to use the substance in the natural environment  

But, associations cannot be unlearned.

New cognitive training paradigms

These paradigms aim at directly influencing some of the cognitive processes involved in addiction. They can be divided in two classes which are: varieties of training aimed at strengthening general cognitive control capacity and varieties of training aimed at changing cognitive biases

Working memory training (WM training)

Automatically triggered processes are a better predictor of addictive behaviours in participants with relatively weak cognitive control or working memory than in participants with relatively strong working memory.

Good cognitive control or working memory may help to overcome strong desires.

Self-control training

General self-control training yielded positive results in smoking cessation, or use of medication.

These interventions aim to increase the effect of cognitively represented goals on behaviour, and thereby weaken the effects of reinforced direct response tendencies. It trains general mechanisms important to goal-attainment.

Another class of cognitive training interventions aims at changing automatically triggered responses to addiction-related stimuli, known as cognitive biases. There are three biases, namely: attentional bias, memory bias, and biased action-tendencies

Attentional bias re-training

In a visual-probe task, a contingency is introduced, with the probe appearing more often on the location occupied by the neutral stimulus.

Attentional re-training affects the interplay between motivationally salient bottom-up processes, and top-down control processes.

Memory bias modification

One way to change evaluative associations is through evaluative conditioning. Stimuli of a specific category are paired with an evaluative category.

Another intervention involves counter-conditioning. A classically conditioned incentive cue is systematically coupled with a strong negative outcome.

A third intervention concerns selective inhibition, a procedure in which a specific category of responses is behaviourally paired with a NoGo response, using an adapted version of a Go/NoGo task.

Approach bias re-training

An alcohol approach task can be turned into a modification task, by changing the contingencies of the percentage of alcohol-related or control pictures that were presented in the format that trained in one session to either approach or avoid.