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1. Psychological interventions in the treatment of Addiction<br />Learning Theory Approaches<br />If addiction is a learned maladaptive behaviour, it can be…
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  • 1. Psychological interventions in the treatment of Addiction<br />Learning Theory Approaches<br />If addiction is a learned maladaptive behaviour, it can be unlearned. <br />1 Classical Conditioning<br />In classical conditioning an unconscious association is formed between a stimulus and a response. The stimulii that produce an addictive response are triggers that become associated with the addictive behavioural response, such as seeing others smoking, the smell of tobacco, being in a place where you have smoked regularly, being in a social gathering where smoking occurs.<br />QSuggest possible gambling triggers.<br />………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………<br />Being in the presence of stimulii that initiate the repetition of addictive behaviour is known as<br />cue exposure and those that cause relapse are relapse triggers. The approach suggests that an addict repeatedly exposed to relapse triggers and cue exposure, without initiating the addictive behaviour, would learn to stay addiction-free. It is not always practical to avoid cue exposure in real life, but gaining coping strategies is part of the therapy used to overcome addictions. This is known as contingency contracting where addicts identify the environmental cues that trigger the addictive behaviour and the therapist helps them to develop coping strategies.<br />2 Operant Conditioning<br />In this approach the addict is encouraged to relearn behaviour by positive or negative reinforcement or punishment leading to extinction. <br />Aversive Therapy consists of applying an unpleasant stimulus, such as a small electric shock, while the patient reads phrases that describe their specific addictive behaviour. During the procedure's final phrase, the patient reads about an alternative activity to, for example, gambling, such as returning home, but receives no shock (McConaghy et al., 1991). However, this therapy is difficult to continue once the subject has left the clinic. <br />Q Write phrases which might be used in aversive therapy for<br />a) Smoking…………………………………………………………………………………………………………………………………………<br />b) Gambling…………………………………………………………………………………………………………………………………………<br />Emetics are drugs that cause nausea. Antabuse is an emetic that has been administered to alcoholics, which causes them to vomit when they consume alcohol. Addictive smokers can also be subjected to procedures which induce nausea. If asked to puff at 6 second intervals (more frequent than usual smoking behaviour) in an enclosed space, the effect is to induce nausea. Both procedures aim to incur an aversion to the addictive behaviour. <br />In imaginal desensitization patients are taught to relax. Then they are asked to imagine a series of scenes related to their addictive behaviour that they find arousing. They learn from this procedure to relax when they encounter opportunities to, for example gamble, rather than to submit to their cravings. An extension of imaginal desensitization is ‘in vivo’ (in real life) exposure, in which relaxation techniques are applied while the patient is actually experiencing a gambling situation. <br />The most rigorous work on behaviour treatments with pathological gamblers has been published by McConaghy, Blaszczynski, et al (1988). The effectiveness of imaginal desensitization was compared with aversion therapy. Although the early studies by this group had relatively small sample sizes, otherwise strong methodologies revealed that imaginal desensitisation treatment techniques were successful at one month and also at one year following treatment if the subjects could effectively use the techniques to reduce their anxiety.<br />http://bjp.rcpsych.org/cgi/content/abstract/142/4/366<br />Behavioural counselling has been used in both individual and group treatment settings. Subjects receive reward for reducing desired addictive behaviours, such as gambling at a reduced level, betting less money, and so on. Specific treatment goals can be more formalized in the form of contingency contracting, in which specific aspects of behaviour are rewarded or punished. <br />Because many drugs are illegal, society considers substance users to engage in illegal behaviours, and the courts and legal systems may mandate or coerce them into treatment. Thus, rather than reinforcing substance abusers for their progress and attempts at remaining abstinent, some clinics utilize confrontation techniques when patients are suspected and challenged for " using" or they discharge patients when they are not adhering to program rules. These techniques result in an unpleasant environment and context for recovery.<br />In the USA, a voucher-therapy approach has been used for cocaine addicts where subjects are given a schedule of increasing rewards for increasing lengths of drug free time. <br />Voucher-Based Therapy in Methadone Maintenance Treatment http://www.nida.nih.gov/BTDP/Effective/Silverman.html<br />Contingency Management in Addiction Treatment http://www.psychiatrictimes.com/display/article/10168/53961?verify=0<br />Q Which of the above treatments are;<br />Punishments leading to extinction ………………………………………………………………………………………………………………………………………………<br />Positive reinforcement ………………………………………………………………………………………………………………………………………………<br />Negative reinforcement ……………………………………………………………………………………………………………………………………………<br />Cognitive Behavioural Therapy Approach<br />Clinicians and researchers have convincingly argued that pathological and problem gamblers share irrational core beliefs about gambling risks, an illusion of control, biased evaluations of gambling outcomes, and a belief that gambling is a solution to their financial problems. Cognitive treatment aims to counteract underlying irrational beliefs and attitudes about gambling that are believed to initiate and maintain the undesirable behaviour. Treatment typically involves teaching subjects strategies to correct their erroneous thinking. Many, for example, do not understand the concepts of probability and randomness, believing that they can exert some control over whether they win or lose. This type of therapy usually uses a number of strategies.<br />Rational emotive behaviour therapy is based on the premise that humans construct their own views of reality through their language, beliefs and philosophies about the world, themselves and others. In REBT, clients usually learn and apply the ‘A-B-C-model of psychological disturbance and change’. The A-B-C model states that it is not merely an A, adversity (or activating event) that contributes to disturbed and dysfunctional emotional and behavioral C’s, consequences, but also what people B, believe about the A, adversity. An adversity can be either an external situation or a thought or other kind of internal event, and it can refer to an event in the past, present, or future.<br />Through REBT, by understanding the role of their illogical, unrealistic and self-defeating meanings, interpretations and assumptions, people often can learn to identify them, begin to D, dispute, refute, challenge and question them, distinguish them from healthy constructs, and subscribe to more constructive and self-helping constructs.<br />Q Write a possible ABC&D statements for <br />Smoking;<br />A………………………………………………………………………..B……………………………………………………………………………C…………………………………………………………………………D…………………………………………………………………………… <br />Gambling;<br />A………………………………………………………………………..B……………………………………………………………………………C…………………………………………………………………………D…………………………………………………………………………… <br />The motivational interview technique is a client-centred approach which involves interaction between the therapist and client about attitudes to the addiction. It incorporates a number of strategies including cognitive dissonance. This is the feeling of uncomfortable tension which comes from holding two conflicting thoughts in the mind at the same time. Dissonance is often strong when we believe something about ourselves and then do something against that belief. ‘If I believe I am ‘good’ but do something ‘bad’, such as gambling or smoking, then the discomfort I feel as a result is cognitive dissonance’. Cognitive dissonance is a very powerful motivator which will often lead us to change one or other of the conflicting beliefs or actions. <br /> Cycle of Change<br /> Motivational Interviewing (Prochaska et al 1982) http://localenterprise.wordpress.com/2008/06/25/cycle-of-change-prochaska-and-diclemente-and-enterprise/<br />Q Write down conflicting expressions that a smoker or gambler might make that exemplify cognitive dissonance;<br />Smoker……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Gambler……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………<br />Psychoanalytic/Psychodynamic Approach<br />Psychoanalysts seek to understand the basis of all human behaviours by considering the motivational forces that derive from unconscious mental processes. <br />It is based on the principle that all human behaviour has meaning and is functional. Even the most self-destructive behaviours can serve a defensive or adaptive purpose. This perspective suggests that pathological gambling is a symptom or expression of an underlying psychological condition. <br />Psychoanalytic and psychodynamic therapy attempts to help pathological gamblers to understand the underlying source of their distress and confront it. The psychoanalytic understanding of gambling problems rests on the foundation formulated by Freud (1928), who thought that it was not for money that the gambler gambled, but for the excitement. In fact, Freud speculated that some people gamble to lose. He thought this tendency was rooted in a need for self-punishment, to expiate guilt, and for the male gambler, because of ambivalence toward the father. <br />The psychoanalytic literature provides individual case histories of gamblers treated successfully (Harkavy, 1954; http://www.pep-web.org/document.php?id=PAQ.023.0153A ). The only analyst to present information about a series of treated gamblers was Bergler (1958). In his account of 200 referrals, 80 appeared to be severe cases and, of those, 60 remained in treatment. According to Bergler, 45 were cured and 15 experienced symptom removal. By a cure, he meant not only that they stopped gambling, but also that they addressed core conflicts and gave up their pattern of self-destructiveness. There is no information on whether " cured" patients were followed-up after treatment. <br />(Further detail of Berglers view is illustrated in these web book pages; http://books.google.co.uk/books?id=fk0DGWFiW6QC&pg=PA191&lpg=PA191&dq=Bergler+1958+gambling&source=bl&ots=9BFErhV_Ly&sig=inmcJUDaVtdMPn7cUn7tynjXskY&hl=en&ei=wb9AS578NuSNjAe0lPGADg&sa=X&oi=book_result&ct=result&resnum=3&ved=0CBUQ6AEwAjgK#v=onepage&q=Bergler%201958%20gambling&f=false )<br />Psychoanalytic and psychodynamic treatment approaches have not been proven effective through evaluative research. However, they have been common forms of treatment for pathological gambling. It is necessary to deconstruct psychoanalytically and psychodynamically oriented interventions and techniques to see what specific components contribute to favourable treatment outcomes. And of course there are differences between one therapist and another with regard to their capacities for empathy, timing, tact, role-modelling, and support—which can complicate research on treatment effectiveness in general and psychodynamic treatment in particular.<br />Q Give 4 reasons why is it so difficult to evaluate effectiveness in psychodynamic treatments of addiction;<br />……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………<br />Glossary <br />Key TermMeaningClassical conditioningCue exposureRelapse TriggerContingency contractingOperant conditioningAversive TherapyImaginal Desensitization Voucher TherapyCognitive Behaviour TherapyRational Emotive Behaviour TherapyMotivational InterviewCognitive DissonancePsychoanalytic approach<br />
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