Cognitive behavioural interventions in addictive disorders PMC

The merger of mindfulness and cognitive-behavioral approaches is appealing from both theoretical and practical standpoints [115] and MBRP is a potentially effective and cost-efficient adjunct to CBT-based treatments. In contrast to the cognitive restructuring strategies typical of traditional CBT, MBRP stresses nonjudgmental attention to thoughts or urges. From this standpoint, urges/cravings abstinence violation effect are labeled as transient events that need not be acted upon reflexively. This approach is exemplified by the «urge surfing» technique [115], whereby clients are taught to view urges as analogous to an ocean wave that rises, crests, and diminishes. Rather than being overwhelmed by the wave, the goal is to «surf» its crest, attending to thoughts and sensations as the urge peaks and subsides.

Definitions of relapse and relapse prevention

• There is also a need for updated research examining standards of practice in community SUD treatment, including acceptance of non-abstinence goals and facility policies such as administrative discharge.
• Examples of high-risk contexts include emotional or cognitive states (e.g., negative affect, diminished self-efficacy), environmental contingencies (e.g., conditioned drug cues), or physiological states (e.g., acute withdrawal).
• Recovery also requires discovery or rediscovery and development of interests that have the power to drive pursuit and deliver rewards, not only spurring the addicted brain to rewire itself but giving life real meaning—the ultimate goal of every person.
• Shiffman, Gwaltney and colleagues have used ecological momentary assessment (EMA; [44]) to examine temporal variations in SE in relation to smoking relapse.

He reported difficulty sleeping if he did not drink, could not get past the day without drinking or thinking about his next drink (establishment of a dependence pattern). His wife brought him for treatment and he was not keen on taking help He did not believe it was a problem (stage of change). He believed that drinking helped him across many domains of life (positive outcome expectancies regarding alcohol use and its effects, stage of change). Early learning theories and later social cognitive and cognitive theories have had a significant influence on the formulation CBT for addictive behaviours. Theoretical constructs such as self-efficacy, appraisal, outcome expectancies related to addictions arising out these models have impacted treatment models considerably. Given the abstinence focus of many SUD treatment centers, studies may need to recruit using community outreach, which can yield fewer participants compared to recruiting from treatment (Jaffee et al., 2009).

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Still, some have criticized the model for not emphasizing interpersonal factors as proximal or phasic influences [122,123]. Other critiques include that nonlinear dynamic systems approaches are not readily applicable to clinical interventions [124], and that the theory and statistical methods underlying these approaches are esoteric for many researchers and clinicians [14]. Rather than signaling weaknesses of the model, these issues could simply reflect methodological challenges that researchers must overcome in order to better understand dynamic aspects of behavior [45]. Ecological momentary assessment [44], either via electronic device or interactive voice response methodology, could provide the data necessary to fully test the dynamic model of relapse.

Balanced lifestyle and Positive addiction

These approaches have shown promise, and more recently the neurobiological underpinnings of mindfulness strategies have been studied. The article provides an overview of cognitive behavioural approaches to managing addictions. Unfortunately, there has been little empirical research evaluating this approach among individuals with DUD; evidence of effectiveness comes primarily from observational research. Participants with controlled use goals in this center are typically able to achieve less problematic (38%) or non-problematic (32%) use, while a minority achieve abstinence with (8%) or without (6%) incidental relapse (outcomes were not separately assessed for those with AUD vs. DUD; Schippers & Nelissen, 2006).

Integrating implicit cognition and neurocognition in relapse models

One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009). A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021). Unfortunately, few quantitative, survey-based studies have included substance use during treatment as a potential reason for treatment noncompletion, representing a significant gap in this body of literature (for a review, see Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013). Additionally, no studies identified in this review compared reasons for not completing treatment between abstinence-focused and nonabstinence treatment.

Systematic reviews and large-scale treatment outcome studies

• The RP model developed by Marlatt [7,16] provides both a conceptual framework for understanding relapse and a set of treatment strategies designed to limit relapse likelihood and severity.
• While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use.
• Research shows that those who forgive themselves for backsliding into old behavior perform better in the future.
• Overall, a large volume of research has yielded no consensus operational definition of the term [14,15].
• Addictive behaviours are characterized by a high degree of co-morbidity and these may interfere with treatment response.
• Consistent with the RP model, changes in coping skills, self-efficacy and/or outcome expectancies are the primary putative mechanisms by which CBT-based interventions work [126].
• Problem solving therapy (PST) is a cognitive behavioural program that addresses interpersonal problems and other problem situations that may trigger stress and thereby increase probability of the addictive behaviour.

Early attempts to establish pilot SSPs were met with public outcry and were blocked by politicians (Anderson, 1991). In 1988 legislation was passed prohibiting the use of federal funds to support syringe access, a policy which remained in effect until 2015 even as numerous studies demonstrated the effectiveness of SSPs in reducing disease transmission (Showalter, 2018; Vlahov et al., 2001). Despite these obstacles, SSPs and their advocates grew into a national and international harm reduction movement (Des Jarlais, 2017; Friedman, Southwell, Bueno, & Paone, 2001). The risk of relapse is greatest in the first 90 days of recovery, a period when, as a result of adjustments the body is making, sensitivity to stress is particularly acute while sensitivity to reward is low. It reflects the difficulty of resisting a return to substance use in response to what may be intense cravings but before new coping strategies have been learned and new routines have been established.

This literature – most of which has been conducted in the U.S. – suggests a strong link between abstinence goals and treatment entry. For example, in one study testing the predictive validity of a measure of treatment readiness among non-treatment-seeking people who use drugs, the authors found that the only item in their measure that significantly predicted future treatment entry was motivation to quit using (Neff & Zule, 2002). The study was especially notable because most other treatment readiness measures have been validated on treatment-seeking samples (see Freyer et al., 2004). This finding supplements the numerous studies that identify lack of readiness for abstinence as the top reason for non-engagement in SUD treatment, even among those who recognize a need for treatment (e.g., Chen, Strain, Crum, & Mojtabai, 2013; SAMHSA, 2019a). The client’s appraisal of lapses also serves as a pivotal intervention point in that these reactions can determine whether a lapse escalates or desists.

• Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018).
• In 1990, Marlatt was introduced to the philosophy of harm reduction during a trip to the Netherlands (Marlatt, 1998).
• In the last several years increasing emphasis has been placed on «dual process» models of addiction, which hypothesize that distinct (but related) cognitive networks, each reflective of specific neural pathways, act to influence substance use behavior.
• Individuals may be bargaining with themselves about when to use, imagining that they can do so in a controlled way.