Griffiths, M.D. (2011). The preventing and treating addictive behaviour. Psychology Review, 17(2), 18-21. more

Preventing and treating addictive behaviour People can become addicted to various chemical substances, but also to behaviours like gambling or sex. Mark Griffiths examines the most common techniques for prevention and treatment of addiction My name's X and I'm an alcoholic' Yon may recognise this line from one of the many media portray- als of the 12-Step programme used by Alcoholics Anonymous. But the treat- ment of addiction comes in many forms, as do attempts at its prevention. Addiction prevention Addiction prevention has typically been divided into three stages: Primary prevention measures are used to prevent the onset of addiction. Secondary prevention measures identify and treat people who have already developed risk factors but in whom addiction is not yet clinically apparent. Tertiary prevention measures target indi- viduals who are addicted and where the goals are to restore individual function, including minimising or preventing addiction-related adverse consequences. These three divisions of prevention focus on different target populations: primary efforts tend to target the general population— secondary efforts focus on at-risk or vul- nerable groups tertiary efforts are directed towards addicted individuals The content and impact of primary pre- vention are strongly influenced by knowledge of the impact of the behaviour or disorder being prevented. Therefore, it is difficult to draw a definite conclusion about what type of preventive intervention works in terms of behavioural change related to addiction. Nevertheless, findings from universal cog- nitive-based approaches demonstrate that inappropriate perceptions related to addictive and Meyer 2005). The elements of effective prevention models are shown in Figure I. Studies suggest that simply giving infor- mation is not enough to create positive 18 Psycridoij* Hcvicv, effects. Furthermore, information in the form of a 'teaching session' may not be the optimum method for providing information. The social inoculation model Since research has generally shown that 'fear induction' and 'information only' techniques are unsuccessful, some social psychologists have explored how psychosocial models and constructs can be applied to the prevention of health-threatening behaviours in adoles- cents. At the heart of these approaches is the concept of social inoculation. The social inoculation model involves 'inoculating' adolescents with the know- ledge and social skills (i.e. 'resistance skills') necessary to resist various social pressures to engage in risky behaviours to which they may be exposed (including, in this case, poten- tially addictive behaviours). The stages of change model There has also been a move towards getting addicts motivated to want to change their behaviour. The most influential model world- wide is probably the stages of change model (Prochaska et ai 1992). This identi- fies an individual's 'readiness for change' and tries to get people to a position where they are highly motivated to change their behav- iour. The individual stages of this model are shown in Figure 2. People can stay in one stage for a long time. Unassisted change is also possible, such as 'maturing out' or 'spontaneous remission'. Various techniques can be used to help people prepare for readiness, including motivational techniques, behavioural self-training, skills training, stress management training, anger management training, relaxation training, aerobic exercise, relapse prevention and life- style modification. The goal of treatment can be either abstinence or simply to cut down. Change attitudes Correct Z^*-* toward addiction Enhance knowledge about addiction and its consequences Increase inappropriate \__^ and adopt a more cognitions related balanced view to addiction Teach eff( awareness of addiction and its consequences Addiction treatment The intervention and treatment options for the treatment of addic- tion include, but are not limited to, counselling/ psychotherapies, behav- ioural therapies, cognitive-behavioural therapies, self-help therapies, pharmaco- therapies, residential therapies, minimal interventions and combinations of these (i.e. multi-modal treatment packages). The most important of these are briefly reviewed below. Pharmacologic al interventions basically consist of addicts being given a drug to help overcome their addiction. These are mainly given to people with chemical addictions (e.g. nicotine, alcohol, heroin, etc.) but are increasingly being used for those with behav- ioural addictions (e.g. gambling, sex). Some drugs produce an unpleasant reaction when used in combination with the drug of dependence, replacing the positive effects of the drug of dependence with a negative reaction. For instance, alcoholics are sometimes prescribed disulfiram (more Teach effective coping and adaptive skills _> I_J Figure 1 effective [/'•■vention morkl; commonly known as antabuse) which, when combined with alcohol, may produce nausea and vomiting. Other common therapies include methadone and the use of opioid antagonists (such as nalaxone or naltrexene) for heroin addiction. The methadone prevents withdrawal symptoms, blocks the effects of heroin use and decreases craving. The main criticism of all these treat- ments is that although the symptoms may be being treated, the underlying reasons for the addictions may be being ignored. On a more Precontemplation The person is unaware of the consequences of his or her own behaviour and no change in behaviour is foreseeable fContemplation The person is aware a problem exists and is contemplating change Preparation The person has decided to change in the near future (e.g. New Year's resolution) Action The person effects change (e.g. gets rid of all association items related to the behaviour) Maintenance The person consolidates behaviour change overtime Relapse- The person reverts to a former behaviour pattern (e.g. contemplation, preparation) Figure 2 19 pragmatic level, what happens when the drug is taken away? Often, the addicts return to their addiction if this is the only method of treatment used. Behavioural therapy Behavioural therapies are based on the view that addiction is a learned maladaptive behaviour and can therefore be 'unlearned'. These have mainly been based on the classical conditioning paradigm and include aversion therapy, in vivo desensitisation, imaginal desensitisation, systematic desensitisation, relaxation therapy, covert sensitisation and satiation therapy (Box 1). All of these therapies focus on cue exposure and relapse triggers (like the sight and smell of alcohol/drugs, walking through a neigh- bourhood where casinos are abundant, pay day, arguments, pressure, etc.). The theory is that through repeated exposure to 'relapse triggers' in the absence of the addiction, the addict learns to stay addiction-free in high- risk situations. It could be argued that if the addiction is caused by some underlying psychological problem (rather than a learned maladaptive behaviour), then behavioural therapy would at best only eliminate the behaviour but not the problem. This therefore means that the addictive behaviour may well have been cur- tailed but the problem is still there so the person will perhaps engage in a different addictive behaviour instead. A more recent development in the treatment of addictive behaviours is the use of cog- nitive behavioural therapies (CBT). There are many different CBT approaches that have been used in the treatment of addic- tive behaviours, including rational emotive therapy, motivational interviewing and relapse prevention. The techniques assume that addiction is a means of coping with dif- ficult situations, dysphoric mood and peer pressure. Treatment aims to help addicts rec- ognise high-risk situations and either avoid or cope with them without use of the addic- tive behaviour. In relapse prevention, the therapist helps to identify situations that present a risk for relapse (both intrapersonal and inter- personal). Relapse prevention provides the addict with techniques to learn how to cope with temptation (positive self statements, Box 1 Types of behavioural therapy for addictive behaviour (adapted from Walker 1992)_ • Aversion therapy Involves the pairing of an aversive stimulus (electric shock or an emetic) with a specific addiction response or may be randomly interspersed while engaging in the addictive behaviour. • In vivo desensitisation (IVD) Involves pairing cues for addiction with no addiction behaviour and feelings of boredom. Typically the addict is taken to the environment where the addiction normally takes place and stands by without engaging in the addictive behaviour for extended periods of time The therapist suggests the whole situation is uninteresting. • Imaginal desensitisation Differs from IVD by having the addict imagine the cues for addiction and then pairing these imagined cues with a competing response such as feelings of boredom. • Systematic desensitisation Refers to a gradient of increasingly powerful cues for the addiction. At each step any arousal that the addict is experiencing is extinguished by imagined scenes of tranquility or direct muscular relaxation. • Relaxation therapy Consists of training in relaxation techniques that can be used when the urge to engage in the behaviour arises. • Satiation therapy Involves presenting the addict with no other stimuli and no other activities but those associated with the addiction. decision review and distraction activities), coupled with the use of covert modelling (i.e. practising coping skills in one's imagina- tion). It also provides skills for coping with lapses (by redefining what is happening) and utilises graded practice (a desensiti- sation technique where addicts encounter real-life situations slowly). Overall, CBT approaches are better researched than the other psychological methods in addiction but are probably no more effective (Luty 2003). Psychotherapy can include everything from Freudian psychoanalysis and transactional analysis, to more recent innovations like drama therapy, family therapy and mini- malist intervention strategies. The therapy can take place as an individual, as a couple, as a family or as a group, and is basically viewed as a 'talking cure' consisting of regular sessions with a psychotherapist over a period of time. Most psychotherapies view mala- daptive behaviour as the symptom of other underlying problems. Psychotherapy is often highly eclectic as it tries to meet the needs of the individual and help the addict develop coping strat- egies. If the problem is resolved, the addiction should disappear. In some ways, this is the therapeutic opposite of pharmacotherapy and behavioural therapy (which treats the symptoms rather than the underlying cause). There has b een little evaluation of its effec- tiveness, although most addicts go through at least some form of counselling during the treatment process. The most popular self-help therapy worldwide is the Minnesota model 12-Step programme (e.g. Alcoholics Anonymous, Gamblers Anonymous, Narcotics Anonymous, Over- eaters Anonymous, Sexaholics Anonymous). This treatment programme uses a group therapy technique and uses only ex-addicts as helpers. The 12-step groups involve addicts accept- ing personal responsibility and view the behaviour as an addiction that cannot be cured but merely arrested. To some it becomes compared with almost all other treatments it is especially cost-effective (even if other treatments have greater success rates) as the organisation makes no financial demands on members or the community. 20 Psyi hology Review 7 s— No single treatment is appropriate for all individuals It does not seem to matter which treatment an addict engages in as no single treatment has been shown to be demonstrably better than any other There is a direct association between the length of time spent in treatment and positive outcomes It is better for an addict to be treated than not to be treated Medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies Recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment Remaining in treatment for an adequate period of time is critical for treatment effectiveness Treatment must be readily available V- The duration of treatment interventions is determined by individual needs, and there are no pre-set limits to the duration of treatment Individual needs of the addict have to be met (i.e. the treatment should be fitted to the addict including being gender-specific and culture-specific) A variety of treatments simultaneously appear to be beneficial to the addict Clients with co-existing addiction disorders should receive services that are integrated For the therapy to work, the 12-step pro- gramme asserts that addicts must come to it voluntarily and must really want to stop engaging in their addictive behaviour. Further to this, they are only allowed to join once they have reached 'rock bottom'. To date there has been little systematic study of 12-step groups but drop out rates are very high (typically 80-90%). There are a number of problems pre- venting evaluation, particularly anonymity, Figure 3 ictusi i sample bias and identifying the criteria for success. The empirical evidence suggests that self-help support groups complement formal treatment options and can support standard- ised psychosocial interventions. Conclusion In conclusion, the study of addictions is a complex and fascinating area for psychol- ogists, GPs and healthcare professionals to study. We know that the best predictor of human behaviour (including addictive behaviour) is previous behaviour, although stopping something starting in the first place is much easier said than done. Primary, sec- ondary and tertiary stages of prevention, with targeted strategies, have shown some success, although there are clearly no magic bullets here. In terms of treatments, these align them- selves well with the key approaches you have studied in psychology (e.g. biological, behavioural, cogni- tive), although an eclectic approach involving multi- modal treatment packages appears to be the most effective. This could be due to each treatment working in a targeted way on each compo- nent of the addiction disorder and/or contributing to the whole treatment programme. In addition, we now have robust evidence and key conclusions (Figure 3) that can be drawn when examining the literature in terms of 'what works' in the treatment of addictions. This has helped healthcare prac- titioners make more informed decisions on treatment options (National Institute on Drug Abuse, 1999; UN/WHO 2008). References Hayer, T, Griffiths, M. D. and Meyer, G. (2005) 'The prevention and treatment of problem gambling in adolescence' in T. P. Gullotta and G. Adams (eds) Handbook of Adolescent Behavioural Problems: Evidence- based Approaches to Prevention and Treatment, Springer, pp. 467-86. Luty, I. (2003) 'What works in drug addic- tion?' Advances in Psychiatric Treatment, Vol. 9, pp. 280-88. National Institute on Drug Abuse (1999) Principles of Drug Addiction Treatment: A Research-based Guide, NIDA. United Nations Office on Drugs and Crime/World Health Organization (2008) Principles of Drug Dependence Treatment: Discussion Paper, UN/WHO. Walker, M. B. (1992) The Psychology of Gambling, ■ Mark Griffiths is professor of gambling studies at Nottingham Trent University and has published widely on many forms of addictive behaviour.