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 ixPreface xi1 The Tenacity of Addiction 1Introduction and Overview 1Discovering Cognition 5Implicit Cognition and Addiction 6Neuropsychological Findings 9Addictive Behaviour is Primary, Not Compensatory 11Changing Habits is the Priority 14Diagnostic Criteria 15Towards Integration 15Equivocal Findings from Research Trials 16Time for CHANGE 16Evolution, Not Revolution 17Something Old, Something New 182 Existing Cognitive Behavioural Accounts of Addiction and Substance Misuse 21The Evidential Basis of CBT for Addiction 23Meta-analytic Findings 23Behavioural Approaches 24Diverse Treatments Mostly Deliver Equivalent Outcomes 25What are the Mechanisms of Change? 26The Missing Variable? 27A Dual-Processing Framework 283 Core Motivational Processes in Addiction 33Is Addiction About Avoiding Pain or Seeking Reward? 33How Formulation Can Go Astray 34Incentive Theories of Addiction 35Learning Mechanisms in Addiction 36Distorted Motivation and Aberrant Learning: the Emergence of Compulsion 41‘Wanting and Liking’ in the Clinic 41The Role of Secondary Reinforcers 43Beyond Pleasure and Pain: a Psychoanalytic Perspective 43Conclusion 444 A Cognitive Approach to Understanding the Compulsive Nature of Addiction 45Theories of Attention 46Top-Down Influences Can Be Automatic 47Automatic Processes Can Be Practically Limitless 48Motivationally Relevant Cues are Prioritized 48Biased Competition 50Attention and Volition 51Appetitive Cues Usually Win 52Purposeful Behaviour Can Occur in the Absence of Consciousness 53Attentional Bias and Craving 54Cognitive Cycle of Preoccupation 565 Vulnerability Factors In Addiction 63Individual Differences in Addiction Liability 63Personality Traits 63The ‘Big Five’ Personality Factors 65Personality Disorders 66Affective Vulnerability Factors 67Brain-Derived Neurotrophic Factors 69Neurocognitive Vulnerability 70Findings from the Addiction Clinic 71From Research to Practice 726 Motivation and Engagement 75Impaired Insight and the Therapeutic Relationship 75The Sad Case of Julia 80Conflicted Motivation is the Key 81Goal Setting and Maintenance 82The Importance of Between-Session Change 83Neurocognitive Perspectives on Motivation 83Motivational Interviewing in Practice 84Formulating and Planning the Intervention 88Attributional Biases: the Blame Game 90Case Formulation 91Summary 977 Managing Impulses 99Introduction and Overview 99Structuring the Session 99Building Resilience 100Impulse Control 102Craving and Urge Report 103Cognitive Processing and Craving 104Cognitive Bias Modification 105Attentional Bias in the Context of Addiction 106The Alcohol Attention-Control Training Programme 108Modifying Implicit Approach Tendencies 110Reversing the Bias: Conclusion 112Brain Training and Neurocognitive Rehabilitation Approaches 112Clinical Implications of Delayed Reward Discounting 117Tried and Tested Techniques 119The Road to Recovery is Paved with Good Implementation Intentions! 125Neurophysiological Techniques 129Neuropsychopharmacological Approaches 1308 Managing Mood 135The Reciprocal Relationship Between Mood and Addiction 135Pre-existing Vulnerability to Emotional Distress 137Negative Affect Due To Drug Effects 141Stepped Care for Addiction 145An Integrated Approach to Addressing Negative Emotion 1479 Maintaining Change 155Relapse Prevention Strategies from a Neurocognitive Perspective 155The Importance of Goal Maintenance in the Long Term 158A Neurocognitive Perspective on Relapse 159Twelve-Step Facilitation Therapy 161Implicit Denial 16210 Future Directions 171Neurocognitive Therapy 171Increasing Cognitive Control is the Goal 172Do We Know Anything New? 173Appendix Self-Help Guide Six Tips – a Pocket Guide to Preventing Relapse 179Introduction: Why Six Tips? 1791. Don’t Always Trust Your Memory! 1802. Beware of the ‘Booze Bias’! 1803. Separate Thoughts from Actions 1814. Learn How to Distract Yourself 1815. Willpower is Sometimes Not Enough 1826. Beware of the Dog that Doesn’t Bark. . . 182References 185Index 201

“Nevertheless, I would recommend this book to practitioners in the alcohol and other drugs, and gambling treatment field, and to postgraduate students in health sciences.”  (Drug And Alcohol Review, 1 May 2015“It is refreshing to read a book of quality that is not only relevant to the UK but is also authored by a UK clinical practitioner.”  (DrugLink, 1 September 2013)