Addiction E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: BPS Textbooks in Psychology
• Sprache: Englisch

Seitenzahl: 724

Veröffentlichungsjahr: 2017

Beschreibung

Addiction: Psychology and Treatment brings together leading psychologists to provide a comprehensive overview of the psychology of addictions and their treatment across specialities and types of services.

• Emphasises the use of several approaches including CBT, psychodynamic and systemic and family treatments, and consideration of the wider picture of addictions
• As well as the theories, gives a clear overview of the application of these models
• Reflects the very latest developments in the role played by psychological perspectives and interventions in the recovery agenda for problem drug and alcohol users

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Addiction: Psychology and Treatment

EDITED BY

PAUL DAVISROBERT PATTONSUE JACKSON

This edition first published 2018

© 2018 John Wiley & Sons Ltd

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Library of Congress Cataloging-in-Publication Data

hardback: 9781118489741

paperback: 9781118489758

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CONTENTS

List of Contributors

EDITORS

FOREWORD

CHAPTER AUTHORS

Foreword

REFERENCES

Preface

REFERENCE

Notes on Contributors

EDITORS

FOREWORD

CHAPTER AUTHORS

Part 1: Understanding the Psychology and Treatment of Addictions

1: Addiction: A Comprehensive Approach

1.1 INTRODUCTION

1.2 EXISTING THEORIES

1.3 THE HUMAN MOTIVATIONAL SYSTEM

1.4 INTERNAL AND EXTERNAL SOURCES OF INFLUENCE

1.5 THE DYNAMICS OF THE SYSTEM

1.6 CHANGING DISPOSITIONS

1.7 TESTING THE THEORY

SUGGESTIONS FOR FURTHER READING

REFERENCES

2: An Attachment-Informed Approach to Working with Addiction

2.1 INTRODUCTION TO ATTACHMENT

2.2 ATTACHMENT AND PSYCHOPATHOLOGY

2.3 ATTACHMENT AND ADDICTION

2.4 ATTACHMENT STYLES IN CLINICAL SAMPLES

2.5 ASSESSMENT AND FORMULATION THROUGH AN ATTACHMENT LENS

2.6 TREATMENT IMPLICATIONS

2.7 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

3: Families, Friends and Addiction: Impacts, Psychological Models and Interventions

3.1 INTRODUCTION

3.2 THE COMPOSITION OF ALCOHOL AND DRUG USERS’ SOCIAL NETWORKS

3.3 IMPACTS OF ADDICTIONS ON OTHERS

3.4 THEORETICAL MODELS OF ADDICTION AND THE FAMILY: STRESS-STRAIN-COPING-SUPPORT

3.5 FROM MODELS TO INTERVENTIONS

3.6 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

4: Working Systemically with Alcohol Misuse

4.1 INTRODUCTION

4.2 FAMILY LIFE

4.3 FAMILY SYSTEMS APPROACHES

4.4 WORKING THERAPEUTICALLY WITH VIOLENCE AND ABUSE

4.5 ENGAGEMENT AND THE THERAPEUTIC RELATIONSHIP

4.6 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

5: ‘Dangerous Desires and Inanimate Attachments’: Modern Psychodynamic Approaches to Substance Misuse

5.1 INTRODUCTION

5.2 PRIMITIVE EMOTIONAL STATES: KLEINIAN VIEWS

CASE STUDY 5.1  PETER

5.3 COMFORTING SELF-OBJECTS: KOHUTIAN VIEWS

CASE STUDY 5.2 MARY

5.4 INANIMATE ATTACHMENTS: BOWLBIAN VIEWS

CASE STUDY 5.3 CARL

5.5 BRINGING IT TOGETHER: ADDICTION AS A DISORDER OF SELF-REGULATION

5.6 REFLECTIVE PRACTICE

CASE STUDY 5.4 MILLIE

5.7 INTERNAL RECOVERY

CASE STUDY 5.5 FAITH

5.8 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

6: Mindfulness, Acceptance and Values in Substance Misuse Services

6.1 INTRODUCTION: WHAT ARE THE PRINCIPLES AND METHODS OF MINDFULNESS, ACCEPTANCE AND VALUES?

6.2 HOW DOES ACT INTEGRATE WITH OTHER APPROACHES?

6.3 HOW DOES THE SERVICE USE THESE PRINCIPLES AND METHODS OF ACT?

6.4 HOW DO MINDFULNESS, ACCEPTANCE AND VALUES SUPPORT THE RESILIENCE OF STAFF IN THE FACE OF SEEMINGLY RELENTLESS RELAPSE AND OTHER BEHAVIOURS?

6.5 WHAT ARE THE EXPERIENCES OF STAFF WORKING WITH ACT?

6.6 WHAT ARE THE EXPERIENCES OF CLIENTS WORKING THIS WAY?

6.7 OUR EXPERIENCE OF ACT

SUGGESTIONS FOR FURTHER READING

REFERENCES

Part 2: Clinical Applications of Addiction Psychology

7: The Role of Clinical Psychology within Alcohol Related Brain Damage

7.1 INTRODUCTION

7.2 CLINICAL DEFINITION OF ALCOHOL RELATED BRAIN DAMAGE AND RELATED SYNDROMES

7.3 EPIDEMIOLOGY OF ARBD AND RELATED SYNDROMES

7.4 COGNITIVE FUNCTION IN ARBD

7.5 PSYCHOSOCIAL AND COGNITIVE REHABILITATION

7.6 LEGAL FRAMEWORK: MENTAL CAPACITY

7.7 RECOVERY

SUGGESTIONS FOR FURTHER READING

REFERENCES

8: Trauma and Addiction

8.1 PSYCHOLOGICAL TRAUMA AND PTSD

8.2 THE RELATIONSHIP BETWEEN ADDICTION AND PSYCHOLOGICAL TRAUMA

8.3 ASSESSMENT

8.4 TREATMENT OF CO-EXISTING TRAUMA AND SUBSTANCE USE DISORDERS

8.5 CLINICAL IMPLICATIONS

8.6 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

9: Narrative Identity and Change: Addiction and Recovery

9.1 NARRATIVE THEORY

9.2 NARRATIVE THERAPY

9.3 NARRATIVE THEORY AND ADDICTION

9.4 CLIENT TALK

CASE STUDY 9.1 TONY’S RECORD

CASE STUDY 9.2 SARAH’S SLIP

9.5 GENERATING NARRATIVE

CASE STUDY 9.3 EPISODES IN TERRY’S DRUG STORY

9.6 NARRATIVES OF RECOVERY

9.7 VARIETIES OF RECOVERY STORY

9.8 CONCLUSION

ACKNOWLEDGEMENTS

NOTES

SUGGESTIONS FOR FURTHER READING

REFERENCES

10: Addiction and Mental Health

10.1 INTRODUCTION

10.2 ASSOCIATION BETWEEN SUBSTANCE MISUSE AND PSYCHOSIS

10.3 PREVALENCE AND EPIDEMIOLOGY

10.4 OUTCOMES ASSOCIATED WITH CO-OCCURRING DISORDERS

10.5 TREATMENT APPROACH AND EFFECTIVENESS

10.6 EVIDENCE FOR EFFECTIVENESS

10.7 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

11: Substance Misuse in Older Adults

11.1 INTRODUCTION

11.2 DEFINITION OF OLDER ADULT

11.3 ALCOHOL

11.4 ILLICIT DRUG USE

11.5 MEDICATION MISUSE

11.6 ASSESSMENT OF OLDER PEOPLE WITH SUBSTANCE MISUSE

CASE STUDY 11.1 MR BE

11.7 PSYCHOSOCIAL INTERVENTIONS

11.8 LEGAL AND ETHICAL CONSIDERATIONS

11.9 USING AND EVALUATING HEALTH AND SOCIAL OUTCOMES

11.10 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

12: Issues Arising in Hepatitis C Work: The Role of the Clinical Psychologist

12.1 INTRODUCTION

12.2 HEPATITIS C BACKGROUND: THE VIRUS AND TREATMENT

12.3 SOCIAL AND CLINICAL CHARACTERISTICS OF THE HCV PATIENT POPULATION

12.4 HCV TREATMENT CHALLENGES

12.5 PEGYLATED INTERFERON-RELATED ADVERSE PSYCHIATRIC SIDE-EFFECTS

12.6 HCV-INFECTED MENTAL HEALTH POPULATIONS

12.7 SO WHAT IS THE ROLE OF THE PSYCHOLOGIST?

CASE STUDY 12.1 AN EXAMPLE OF AN HCV PSYCHOLOGICAL STEPPED-CARE MODEL

12.8 PSYCHOLOGICAL STEPPED-CARE MODEL IN HCV TREATMENT

12.9 FUTURE CHALLENGE

12.10 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

13: The Psychology and Treatment of Gambling Disorders

13.1 INTRODUCTION

13.2 DEFINITION

13.3 PREVALENCE

13.4 DEMOGRAPHIC RISK FACTORS

13.5 TREATMENT OF GAMBLING DISORDERS

13.6 PERSONAL COMMENT AND REFLECTIONS

13.7 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

14: Alcoholics Anonymous and 12 Step Therapy: A Psychologist’s View

14.1 INTRODUCTION: PERSONAL CONTEXT

14.2 HISTORY

14.3 PHILOSOPHY

14.4 HOW DOES IT WORK?

14.5 WHAT CAN PSYCHOLOGISTS AND HELPING PROFESSIONALS DO?

14.6 CRITICISMS OF AA

14.7 POSTSCRIPT

NOTES

SUGGESTIONS FOR FURTHER READING

REFERENCES

15: Relapse Prevention: Underlying Assumptions and Current Thinking

15.1 INTRODUCTION

15.2 WHAT IS RELAPSE PREVENTION?

15.3 MODELS OF RELAPSE PREVENTION

15.4 ADDRESSING CO-EXISTING MENTAL HEALTH

15.5 NEUROPSYCHOLOGICAL AND ASSOCIATED DIFFICULTIES WHEN UNDERTAKING RP

15.6 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

16: Working with Ambivalence about Change: Motivational Interviewing

16.1 INTRODUCTION

16.2 DEFINITION

16.3 HISTORICAL PERSPECTIVE

16.4 THEORETICAL INFLUENCES

16.5 THE SPIRIT OF MI

16.6 CHANGE TALK, SUSTAIN TALK AND DISCORD

16.7 THE FOUR MI PROCESSES

16.8 CORE MI SKILLS

16.9 MI STRATEGIES MORE SPECIFIC TO PARTICULAR PROCESSES

16.10 EVIDENCE FOR THE EFFICACY OF MI

16.11 INTEGRATING MI WITH OTHER APPROACHES

16.12 USING MI IN GROUPS

16.13 LEARNING MI

16.14 CONCLUSION

SUGGESTIONS FOR FURTHER READING

REFERENCES

17: ‘Beyond Workshops’: Turning Evidence for Psychosocial Interventions into Embedded Practice

17.1 INTRODUCTION

17.2 WHAT IS IMPLEMENTATION?

17.3 IMPLEMENTATION SCIENCE

17.4 CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH (CFIR; DAMSCHRODER ET AL., 2009)

17.5 IMPLEMENT WHAT? EVIDENCE-BASED INTERVENTIONS VERSUS EVIDENCE-BASED PRACTICES

17.6 CASE STUDIES IN MOTIVATIONAL INTERVIEWING AND TREATMENT EFFECTIVENESS (MAPPING)

17.7 CONCLUSION

NOTES

SUGGESTIONS FOR FURTHER READING

REFERENCES

Index

EULA

List of Tables

Chapter 3

Table 3.1

Chapter 11

Table 11.1

Table 11.2

Chapter 12

Table 12.1

Table 12.2

Chapter 16

Table 16.1

Table 16.2

Table 16.3

List of Illustrations

Chapter 1

Figure 1.1

Structure of the human motivational system

Figure 1.2

Example of an epigenetic landscape

Guide

Cover

Table of Contents

Preface

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List of Contributors

EDITORS

Paul Davis, Department of Psychology, University of Surrey, Guildford, UK

Sue Jackson, Psychology Department, University of the West of England, Bristol, UK

Bob Patton, Department of Psychology, University of Surrey, Guildford, UK

FOREWORD

Jim Orford, School of Psychology, University of Birmingham, UK

CHAPTER AUTHORS

Jamie Brown, Cancer Research UK Health Behaviour Research Centre, University College London, UK

Alex Copello, School of Psychology, University of Birmingham, UK; and the Addiction Service, Birmingham and Solihull Mental Health NHS Foundation Trust, UK

David Curran, School of Psychology, Queens University, Belfast, Northern Ireland; and the NHSCT Addiction Service, Northern Ireland, UK

Rudi Dallos, Department of Psychology, Plymouth University, Plymouth, UK

Lisa Dutheil, Camden and Islington NHS Foundation Trust, London, UK

Rebecca Fisher, Camden and Islington NHS Foundation Trust, London, UK

Alina Galis, Camden and Islington NHS Foundation Trust, London, UK

Andre Geel, Addictions Service, Central and North West London NHS Foundation Trust, London, UK

Jennifer Harris, Addictions Clinical and Academic Group, South London and Maudsley NHS Foundation Trust, London, UK

Robert Hill, Addictions Clinical and Academic Group, South London and Maudsley NHS Foundation Trust, London, UK

Adam Huxley, Change Grow Live, London, UK

Edward J. Khantzian, Department of Psychiatry, Harvard Medical School, Cambridge, MA, USA

Aska Matsunaga, Central and North West London NHS Foundation Trust, London, UK

Liz McGrath, Camden and Islington NHS Foundation Trust, London, UK

Mani Mehdikhani, Specialist Services Network, Greater Manchester West Trust, Manchester, UK

Luke Mitcheson, Addictions Services, South London and Maudsley NHS Foundation Trust, London, UK; and Alcohol, Drugs & Tobacco Division, Public Health England, London, UK

Fraser Morrison, NHS Lanarkshire, Scotland, UK

Jo M. Nicholson, Sheffield Teaching Hospitals, Sheffield, UK

Dominic O'Ryan, Camden and Islington NHS Foundation Trust, London, UK

Tony Rao, Psychiatry Department, South London and Maudsley NHS Foundation Trust, London, UK

Jenny Svanberg, Substance Misuse Department, NHS Forth Valley, Falkirk, UK

Arlene Vetere, VID Specialized University, Oslo, Norway

Sarah Wadd, Substance Misuse and Ageing Research Team (SMART), University of Bedfordshire, Luton, UK

Kathryn Walsh, Psychology Department, University of Birmingham, Birmingham, UK

Martin Weegmann, NHS; and Independent Practice London, UK

Robert West, Cancer Research UK Health Behaviour Research Centre, University College London, UK

Christopher Whiteley, Psychology Department, South London and Maudsley NHS Foundation Trust, London, UK

Foreword

Addiction is highly prevalent. The World Health Organization (WHO) estimates that the number of people globally who suffer from an alcohol or drug use disorder annually is in the region of 100 million. Harmful and hazardous alcohol use, like tobacco, is considered by WHO to be a major preventable contributor to the global burden of disease and disability. There is no estimate, to my knowledge, of the worldwide prevalence of gambling disorder, but in Britain alone the adult annual prevalence is in the region of a third to a half million, which is very similar to the prevalence of disorders associated with illicit drug use. So prevalent is addiction that it can reasonably be thought of, along with anxiety and/or depression, as one of the two most common forms of psychological disorder. Yet in most relevant professions and disciplines, including psychology, it remains strangely marginalized. In Chapter 14 in this volume, on AA and 12 Step programmes, Martin Weegmann admits that when he first worked in the area of the addictions he had had virtually no experience of this client group, and minimal training in the area during his clinical psychology course. My experience was even worse. I led two clinical psychology training courses, in Exeter for 17 years in the 1970s and 1980s, and then in Birmingham for five years in the 1990s. Despite my passionate interest in the addictions, the British Psychological Society requirements for a training course, plus the lack of availability of supervised practice, plus I suspect a lot of prejudice about the topic, meant that my success in giving trainees a better grounding in the subject than Martin and I had had was only minimally successful. Perhaps everything has changed. I hope so, but suspect not. That is one of the main reasons why this book is so important.

Judging by the enthusiasm shown by all the authors of the chapters of this book, it seems their experience of finding themselves working in the addiction field – like me, often by accident, I suspect – was of entering a field that is endlessly rewarding and fascinating. Large numbers of people overcome their addictions, often with our help and sometimes even without it, and when they do, their recoveries are frequently impressive, given the depths to which their lives have been harmed. Addiction has more than its share of sadness and despair, but it is also replete with hope and inspiration.

For all that we have learned about addiction and its treatment – including so much that is included in these chapters – there remains a great deal that is mysterious about it, and about recovery from it. The scope for researching and theorizing about addiction, for developing and evaluating forms of treatment, for applying knowledge and methods for understanding and treating such complications of addiction as brain damage or Hepatitis C – both topics accorded chapters here – is endless. In fact, no one book can explore anything like all the intriguing issues that surround addiction. How do gender roles influence the prevalence of the different forms of addiction? What insights does psychology offer about how we might prevent addiction? What has psychology to say about what our relationships should be, if any, with the suppliers of the products to which people can become addicted – the commercial suppliers of alcohol, tobacco and gambling products and the legal and illegal suppliers of other substances? These are among the questions that must wait for a second edition.

This book treads dangerous ground in a number of ways, departing often from dominant thinking in the field. The latter is under the sway of a bio-psychological model of addiction which privileges diagnosis (very little mention of DSM can be found in this book), a rather limited approach to evidence-based treatment, and a greater emphasis on aggregated statistics than on a detailed understanding of the experiences of people who suffer from addiction and those others who are affected by it. Certain vital issues are neglected because of that dominant model of addiction, but they get proper attention here. One, which is repeatedly mentioned, is the importance for addiction of emotions and emotional regulation. This receives some attention in the dominant paradigm – the idea of self-medication, for example – but is rarely explored in any detail. Cognition tends to rule and emotion sits in second place. Emotions and emotional regulation have the great strength of being something that unites sub-topic areas such as attachment, psychodynamic and systemic approaches, and relapse prevention and mindfulness, albeit dealt with differently under those various headings.

There are chapters in this book which reach other parts of the mystery and despair of addiction which the dominant paradigm does not reach. One feature of addiction, rarely addressed elsewhere, is its effect on a person's ability to relate to others, variously described in different chapters as the replacement of affectional bonds by ‘addictional bonds', empathic blunting, and the way addiction can interfere with sensitivities and capacities (see Nussbaum, 2000, a favourite book of mine, for an explication of the capabilities approach). Family members affected by their relatives' addictions, who are equally as numerous as those who experience addiction at first hand, and probably more so, often talk of how their relatives have ceased to be the people they knew and loved and how addiction seems to have robbed their relatives of the capacity to care for the family. For family members, addiction is truly a mystery – how can this person they knew be investing so much in something that seems so pointless and so damaging, and relatively less in what really matters? It is good, therefore, to see families highlighted early on in the book, and in more than one token chapter, as is often the case.

Another central feature, infrequently given the attention it deserves but properly addressed here, is the ambivalence and fragmentation that come with addiction (Adams, 2008). This can be seen as a surface phenomenon, as in the instability of motivation to change (an idea that West derives from PRIME theory), or the ambivalence which is central to motivational interviewing theory, or the conflict which is central to my Excessive Appetites model (Orford, 2001). But it can also be seen, as it is in a number of chapters, as a deeper fragmentation of the self. Rarely dealt with in psychology, one otherwise needs to go to the philosopher Levy (2011) for an appreciation of fragmentation of self as being close to the essence of addiction. His key idea was that an addicted person's preferences are inconsistent: the ability to make judgements about action is not impaired, but judgements shift from time to time. What characterizes addiction, therefore, is the fragmentation of agency, an inability to consistently exert will across time, and the loss of full capacity to effectively make plans and put in place long-term projects. I see this as a form of disempowerment, and I found it extremely helpful in developing my attempt to use the concept of power to integrate otherwise disparate areas of addiction studies (Orford, 2013).

Yet another topic which it is good to see given attention is the importance for change and recovery of the relationship with helpers or therapists. As I put it in my article, ‘Asking the right questions in the right way' (Orford, 2008):

The prevailing model of psychological treatment for addiction can be described, aptly, as a technology model. It is likened to a technique which, supported by a manual and good training and supervision, can be delivered to a high standard so that ‘therapist differences' cease to be important. The therapist is the medium through which a standard technique is applied at a high level of fidelity. Some have referred to this as the ‘drug metaphor', implying that treatment is seen, like a medication, as a piece of technology that requires only therapist skill and efficiency and patient compliance in order to be delivered effectively.

Like the authors of some of the chapters in this book I have always been suspicious of that model, and our experiences in the UK Alcohol Treatment Trial (UKATT) confirmed my suspicions. When clients were asked at follow-up to what factors they attributed any positive changes they had made, the most popular attributions were characteristics of the therapist and of the client's relationship with the therapist, more so than social-type attributions for Social Behaviour and Network Therapy clients or motivational-type attributions for Motivational Enhancement Therapy clients (Orford et al., 2009).

I could go on listing the aspects of addiction which the conventional wisdom downplays or dismisses but which are not avoided in this highly thoughtful volume. The importance of narratives and story-telling, of personal and social identity, of one's life values, of the very meaning of life are among them. The experience of trauma and the high frequency of addiction problems combined with other mental health problems are recurring themes in the book.

However, clinical psychology faces a number of problems – although they are by no means confined to clinical psychology. One is the question of evidence. Like all professions, it is required to demonstrate that its treatments ‘work'. That can be problematic, not just because showing that something works can be costly, time-consuming and fraught with methodological and interpretive difficulties – research evidence is often so complex that it is difficult to draw clear conclusions – but also because what constitutes main outcomes may be debatable. Is the main aim symptom relief or adjustment to symptoms; abstinence or harm minimization? It is also problematic if a treatment method is comparatively new and innovative. Acceptance and Commitment Therapy (ACT) is an example, as McGrath and O'Ryan's Chapter 6 makes clear. Is ACT an example of running ahead of the evidence, they ask, or is it even, as they say one client put it, just ‘hocus-pocus'? Even if it can be demonstrated that a treatment works, there is the all-important question, addressed in the final chapter, of translating evidence into practice. This is a book about psychology being used to innovate, to push forward at the frontier of a subject that needs new thinking and fresh solutions. It therefore takes us well beyond the safe and secure domain of cognitive behaviour therapy (although the point is made a number of times in this volume that new treatments can complement rather than replace existing ones).

There is, finally, another problem for psychological applications to the addictions, and that is the need to develop methods that can be applied to large numbers. Psychology has often been criticized on this score in the past. If its methods remain specialized, requiring lengthy training or specialized institutional infrastructure, then good will be done for small numbers but the impact on the huge problem of addiction will be limited. I have always agreed with the principle that psychology must be ‘given away' if it is to be effective. We must think of training others who can deliver psychosocial treatments in non-specialized settings, or working remotely using modern communication technology. We must aim to make contact with hard-to-reach groups in our own countries, and the large numbers who might benefit from psychological methods in other countries, where specialized services and trained professionals are much thinner on the ground.

REFERENCES

Adams, P. (2008). Fragmented intimacy: Addiction in a social world. Sydney, Australia: Springer.

Levy, N. (2011). Addiction, responsibility, and ego depletion. In J. Poland & G. Graham (Eds.), Addiction and responsibility. Cambridge, MA: MIT Press.

Nussbaum, M. C. (2000). Women and human development: The capabilities approach. Cambridge: Cambridge University Press.

Orford, J. (2001). Excessive appetites: A psychological view of addictions (2nd ed.). Chichester: John Wiley & Sons, Ltd.

Orford, J. (2008). Asking the right questions in the right way: The need for a shift in research on psychological treatments for addiction. Addiction, 103, 875–885. doi:10.1111/j.1360-0443.2007.02092.x

Orford, J. (2013). Power, powerlessness and addiction. Cambridge: Cambridge University Press.

Orford, J., Hodgson, R., Copello, A., Wilton, S., & Slegg, G. on behalf of the UKATT Research Team (2009). To what factors do clients attribute change? Content analysis of follow-up interviews with clients of the UK Alcohol Treatment Trial. Journal of Substance Abuse Treatment, 36, 49–58. doi:10.1016/j.jsat.2008.04.005

Preface

Like many other complex health problems, addictions are probably best viewed within a biopsychosocial model (see, e.g. Ogden, 2012). It is, however, possibly a truism to say that the treatment of addiction is about changing behaviours, beliefs and feelings; something that psychology is likely to contribute to in a significant way. Understanding these processes from a psychological perspective, including using psychological approaches to recovery, is something academics and practitioners from all disciplines, professions and training backgrounds can benefit from. This book is intended to provide such an understanding and present an overview of the applications of psychology to addictive behaviours. The book is not written solely for psychologists, but rather is intended for all clinicians, practitioners and academics working in the addictions field, as well as those outside specialist services who may encounter addiction in their generic work. It brings together contributions from leading practitioners and academics in the addictions specialty, and provides in one volume a synthesis of psychological models and approaches used in this complex area.

Part 1 gives an overview of theories and models used to understand the aetiology and development of addictions and includes consideration of the psychological models used in the intervention approaches. Part 2 contains chapters on specific applications of psychology across selected addictive behaviour problems with a variety of service user groups, as well as practical guides to the implementation of addiction psychology in health and community care settings.

Many internationally recognized scientists, practitioners and experienced clinicians have contributed to this book, and we would like to thank them all. Gratitude is also expressed to the numerous service users who have informed the individual chapters; thank you.

REFERENCE

Ogden, J. (2012).

Health psychology: A textbook

. Maidenhead: Open University Press.

Notes on Contributors

EDITORS

Paul Davis is a Teaching Fellow in Clinical Psychology at the University of Surrey, Guildford, UK. He worked as a Consultant Clinical Psychologist and Specialist Lead for many years in several NHS mental health services in London, providing treatments for addiction problems and continues to practise as an independent consultant. His publications, research and academic work have focused on the psychology of addictions, and he provides training courses both in the United Kingdom and abroad on treatment interventions. He has held a number of national advisory roles within health and criminal justice bodies working on policy and guidelines development.

Sue Jackson is a chartered psychologist specializing in the psychosocial impact and treatment of chronic health conditions. In addition to managing an extensive research portfolio, she is a visiting lecturer at a number of UK universities. Dr Jackson supports a number of patient support charities, and is the first psychologist to serve on the Medical Advisory Committee for the Pituitary Foundation.

Robert Patton is a lecturer in Clinical Psychology based at the University of Surrey and a Visiting Research Fellow in Addiction at King's College London. He has run a research consultancy since 1993. During the 1990s he worked as a consultant for the Home Office Drugs Prevention Initiative and as research associate in health promotion for the University of Northumbria. Now based in London, he has worked for Royal Holloway, LSHTM, Imperial College, the Institute of Psychiatry and the Maudsley Hospital.

FOREWORD

Jim Orford. In his time as a clinical, and later clinical-cum-community, psychologist working in NHS and university settings in London, Exeter and for the last 20 years in Birmingham, Jim Orford has researched and written extensively about substance and gambling problems and particularly about their impact on the family. His best-known work is Excessive Appetites: A Psychological View of Addictions (2nd ed., 2001) and his most recent book is Power, Powerlessness and Addiction (2013).

CHAPTER AUTHORS

Jamie Brown is a Principal Research Fellow of the Society for Study of Addiction at University College London. He co-leads a programme of research to evaluate digital behaviour change interventions and runs the Smoking and Alcohol Toolkit Studies. In over 80 publications on a variety of topics, his focus has been on tobacco control, including e-cigarettes, harm reduction and the real-world effectiveness of smoking cessation treatments. He has been invited to present his work on e-cigarettes at international conferences, to the UK regulatory authorities for medicines, and has co-authored a briefing to the UK all-party parliamentary pharmacy group. He is a co-author of Theory of Addiction (2nd ed.) and ABC of Behaviour Change Theories, and is an Assistant Editor of the journal Addiction.

Alex Copello is Professor of Addiction Research at the School of Psychology, University of Birmingham, and Consultant Clinical Psychologist with the Birmingham and Solihull Mental Health NHS Foundation Trust addiction services, where he leads the addictions research and innovation programme. His career has combined clinical, service management and academic work. Alex has researched extensively on the impact of addictions upon families and family-based interventions and publishes regularly in scientific journals.

David Curran is a consultant clinical psychologist working for an Addiction Service in Northern Ireland, and Assistant Course Director with the Doctorate in Clinical Psychology training programme at Queens University Belfast. Areas of clinical and research interest include early adversity, attachment, trauma and co-morbid presenting problems.

Rudi Dallos is Professor of Clinical Psychology at Plymouth University, UK. Rudi is a clinical psychologist and systemic family therapist. Professors Vetere and Dallos have co-authored many articles and three books: Systemic Therapy and Attachment Narratives: Applications across a Range of Clinical Settings (2009, Routledge), is most relevant to their chapter in this book.

Lisa Dutheil trained as a clinical psychologist at the Institute of Psychiatry, Psychology and Neuroscience (King's College London). She has a long-standing interest in addictions, and worked for several years pre-qualification as a practitioner and manager within third sector substance misuse services. Since 2011, she has practised as a clinical psychologist in the alcohol services at Camden and Islington NHS Foundation Trust. She works with individuals and groups, primarily using CBT, Mindfulness Based Approaches and Motivational Interviewing.

Rebecca Fisher is a clinical psychologist who has worked with the National Problem Gambling Clinic. She has worked with problem gamblers in individual and group formats, assessing and treating them as part of the therapeutic programme at the clinic. She is now working in offender care in a London NHS Trust.

Alina Galis is a clinical psychologist who has worked in substance misuse services since 2007; in NHS Fife, in Camden & Islington Foundation Trust and in the South Westminster Drug & Alcohol Service, in partnership with the third sector. She completed her training as a clinical psychologist at the University of Edinburgh and has previously worked a part of a research group within the Centre for Addiction Research & Education Scotland, University of Dundee. Clinically, she works with individual and group interventions for substance misuse and dual diagnosis.

André Geel is a consultant clinical psychologist in Addictions for Central and North West London NHS Foundation Trust. He has considerable experience working in the NHS, specializing in community, general mental health and addictions. He has been a management and clinical lead for a number of services, as well as contributing to a variety of psychology training courses in London and the South-East of England. He has held Project Lead positions for Addictions for the British Psychological Society, has acted as Chair of Substance Misuse Management in General Practice and is on the Executive of the Skills Consortium. He was one of the psychology contributors to the NICE Guidelines on Substance Misuse Services.

Jennifer Harris is a clinical psychologist working in inpatient and community addictions services at South London and Maudsley NHS Foundation Trust. She has a particular interest in working with trauma and is also an EMDR Therapist. Prior to this, she worked as a researcher in the field of addictions and holds an MSc in Health Psychology.

Robert Hill is a consultant clinical psychologist. His area of speciality is addictive behaviours, along with co-morbid psychological difficulties and neuropsychological functioning. He has previously worked as a Senior Lecturer at Middlesex University, focusing on the reduction of stress and burnout among community and inpatient mental health staff. He has a particular interest in philosophy and holds an MA in Modern European Philosophy. His most recent publication is Principles and Practice of Group Work in Addictions, published by Routledge, with his colleague Dr Jennifer Harris.

Adam Huxley is a consultant clinical forensic psychologist. He is currently the national psychology lead for Crime Reduction Initiatives, a leading charity providing support to vulnerable people facing addiction, homelessness and domestic abuse. His research and clinical interests include the impact of substance misuse on marginalized groups.

Edward J. Khantzian is Clinical Professor of Psychiatry, Harvard Medical School, and a founding member of the Department of Psychiatry at The Cambridge Hospital, MA, USA. He has spent more than 40 years studying psychological factors associated with drug and alcohol abuse. Dr Khantzian is a practising psychiatrist and psychoanalyst, a participant in numerous clinical research studies on substance abuse, and a lecturer and writer on psychiatry, psychoanalysis, and substance abuse problems. His studies, publications, and teaching have gained him recognition for his contributions on self-medication factors and self-care deficits in substance use disorders and the importance of modified techniques in group therapy for substance abusers. He is a founding member of the American Academy of Addiction Psychiatry (AAAP) and is a Past-President of this national organization. AAAP honoured him in 2000 by making him the recipient of its Founders Award and Keynote speaker for the annual scientific meeting in recognition of his ‘courage in changing the ways we think of and understand addictions'.

Aska Matsunaga completed her BSc Applied Psychology degree at the University of Kent as part of her career path to become a clinical psychologist, and has worked in London treatment services in addictions and adult mental health. She has delivered CBT in group settings and carried out research on methadone maintenance treatment as well as research into cross-cultural anger rumination and aggressive behaviour.

Liz McGrath qualified as a clinical psychologist from University College London, and has over 16 years experience of work in addiction services in Central London. She completed her training in clinical neuropsychology at the Institute of Psychiatry, London, before going on to train in mindfulness-based approaches at the Centre for Mindfulness Research and Practice in Bangor, Wales. Liz has applied mindfulness-based approaches at the individual, group, team and organizational levels in an inner-London NHS substance misuse service.

Mani Mehdikhani is a principal clinical psychologist and currently works for Greater Manchester West Trust's Specialist Services Network. Mani has worked as both a clinician and as a researcher in the field of addictions and substance misuse. He is a member of the British Psychological Society (BPS) and is also registered with the Health & Care Professions Council (HCPC). Mani regularly teaches on the Addiction modules at both Manchester and Liverpool Universities' Clinical Psychology training courses, and he has an interest in addiction, attachment, evolutionary psychology and personality disorders.

Luke Mitcheson, consultant clinical psychologist, is the Lead Psychologist for the addictions services in the South London and Maudsley NHS Foundation Trust and a consultant working in Lambeth community drug and alcohol services. He is also seconded as a clinical advisor to Public Health England in the Alcohol, Drugs and Tobacco Division.

Fraser Morrison is a clinical psychologist working in the field of Alcohol Related Brain Damage (ARBD). He has significant experience of substance misuse services and has specialized in the area of ARBD in recent years. He is currently completing the British Psychological Society Qualification in Clinical Neuropsychology and has published research specifically in this field of adapting existing therapeutic approaches and investigation of outcome.

Jo M. Nicholson completed her Doctorate of Clinical Psychology in 1997 and worked for 12 years in adult mental health services, mostly within acute psychiatric care settings. She currently specializes in working with people with Hepatitis C at Sheffield Teaching Hospitals. Dr Nicholson has an enduring interest in working with ‘hard to reach/hard to engage' groups, and she has a special interest in working with dual diagnosis, personality and substance misuse populations. In addition, she has an interest in service development and change process in NHS settings.

Dominic O'Ryan trained as a clinical psychologist at University College London and has worked as a practitioner and developer of clinical approaches in addiction services in Central London for over 15 years. In addition, he qualified in CBT from the Institute of Psychiatry, London, and in CBT Supervision from Royal Holloway University of London. Dominic has trained and practised in mindfulness-based cognitive therapy and offers mindfulness, acceptance and resilience-based approaches to service users and staff in an inner-London NHS substance misuse service.

Tony Rao is consultant old age psychiatrist at South London and Maudsley NHS Foundation Trust, working in an inner-city area of London with high rates of alcohol misuse in older people. As well as a Visiting Researcher at the Institute of Psychiatry, Tony is Chair of the Royal College of Psychiatrists Working Group on Older People and Substance Misuse. He is involved in policy change for older people with dual diagnosis and provides expertise to advisory bodies and voluntary organizations on substance misuse in older people.

Jenny Svanberg is a consultant clinical psychologist and Lead Psychologist for Substance Misuse in NHS Forth Valley. Her research and clinical interests include the prevention, assessment and treatment of complex difficulties relating to substance use and addiction.

Arlene Vetere is Professor of Family Therapy and Systemic Practice at VID Specialized University, Oslo, Norway. Arlene is a clinical psychologist and systemic family therapist. Professors Vetere and Dallos have co-authored many articles and three books: Systemic Therapy and Attachment Narratives: Applications across a Range of Clinical Settings (2009, Routledge), is most relevant to their chapter in this book.

Sarah Wadd is programme director of the Substance Misuse and Ageing Research Team (SMART) at the University of Bedfordshire and is one of the UK's leading experts on substance misuse in older people. Her seminal ‘Working with Older Drinkers Study' identified best practice in this area, based on interviews with alcohol practitioners who specialize in working with older people and older people receiving alcohol treatment. She is an expert advisor on substance misuse in older people for the Welsh Government and the UK's Advisory Council on Drug Misuse. Sarah is the academic lead for the £25m Big Lottery-funded ‘Drink Wise Age Well' Programme which aims to reduce alcohol-related harm in people aged 50 and over. Her other research studies have included alcohol misuse that co-exists with cognitive impairment in older people and illicit drug and medication misuse in older people, and she has contributed to studies on alcohol-related elder abuse and sight loss. Sarah is a cofounder of the Coalition of Older Adults Affected by Substance Misuse (COAASM), whose members work to reduce discrimination and improve prevention, services and treatment for older adults and families affected by substance misuse.

Kathryn Walsh is currently pursuing clinical psychology doctoral training at the University of Birmingham. Kathryn previously worked as a Research Associate at the School of Psychology, University of Birmingham, in a Brief Intervention National Institute of Health Research funded randomized controlled trial for people with addictions and severe mental health problems. She has published in the area of addictions and mental health and was awarded the first prize in the mental-health and substance-use essay competition 2012 by the Mental Health and Substance Use academic journal, where the essay was subsequently published.

Martin Weegmann is a consultant clinical psychologist and group analyst, with 20 years experience in the field of substance misuse. He is a well-known trainer, having delivered workshops and keynote lectures to a range of organizations through the United Kingdom, including organizing seven annual conferences on the theme ‘Psychotherapy of Addiction'. Martin has co-edited two books, Psychodynamics of Addiction (2002, Wiley) and Group Psychotherapy and Addiction (2004, Wiley) and published many chapters and papers. His latest book, The World within the Group: Developing Theory for Group Analysis (London, Karnac) was published in 2014. In 2011, he joined the General Services Board of Alcoholics Anonymous, as a ‘non-alcoholic trustee'.

Robert West is Professor of Health Psychology and Director of Tobacco Studies at the Cancer Research UK Health Behaviour Research Centre, University College London, UK. Professor West is also Editor-in-Chief of the journal Addiction. He has authored more than 500 scientific articles, books and book chapters. He was co-founder of the NHS stop-smoking services. His research includes evaluations of methods of helping smokers to stop and population surveys of smoking and smoking cessation patterns. He is author of The SmokeFreeFormula (Orion), which aims to bring the science of stopping to smokers. For more information, see www.rjwest.co.uk.

Christopher Whiteley, consultant clinical psychologist, is the Trust Deputy Head of Psychology for South London and Maudsley NHS Foundation Trust. His clinical work is with the Trust's specialist HIV Mental Health Team. He previously worked for over 10 years in drug and alcohol treatment services and more recently as a seconded clinical advisor to Public Health England in the Alcohol, Drugs and Tobacco Division.

Part 1Understanding the Psychology and Treatment of Addictions

1Addiction: A Comprehensive Approach

JAMIE BROWN AND ROBERT WEST

Cancer Research UK Health Behaviour Research Centre, University College London, UK

CHAPTER OUTLINE

1.1 INTRODUCTION

1.2 EXISTING THEORIES

1.3 THE HUMAN MOTIVATIONAL SYSTEM

1.4 INTERNAL AND EXTERNAL SOURCES OF INFLUENCE

1.5 THE DYNAMICS OF THE SYSTEM

1.6 CHANGING DISPOSITIONS

1.7 TESTING THE THEORY

SUGGESTIONS FOR FURTHER READING

REFERENCES

1.1 INTRODUCTION

‘Addiction’ is a social construct which can be usefully defined as a chronic condition in which there is a repeated powerful motivation to engage in a rewarding behaviour, acquired as a result of engaging in that behaviour, that has significant potential for unintended harm. From this perspective, a broad conception of motivation is at the heart of addiction and requires any theory of addiction to be based on a comprehensive theory of motivation. This approach understands addiction can be driven by many different factors – physiological, psychological, environmental and social – and that it is not useful to focus on one particular factor to the exclusion of all others. PRIME theory aims to provide a conceptual framework within which the major insights provided by more specific theories of choice, self-control, habits, emotions and drives can be integrated.

PRIME theory describes the motivational system as the set of brain processes that energize and direct our actions. The system can be usefully divided into five interacting but distinct sub-systems: (1) response execution; (2) impulses/inhibition; (3) motives (wants and needs); (4) evaluations (beliefs about what is good or bad); and (5) plans (self-conscious intentions). The response execution system co-ordinates what is happening at any given moment. The proximal influences on this are the impulses and inhibitions to perform particular responses. Motives can influence behaviour only through impulses and inhibitions, evaluations can do so only through motives, and plans must operate on either motives or evaluations. These can also each be influenced by the immediate internal or external environment. Important internal sources of influence include identity, self-control, drives and emotional states.

A core proposition is that all the subsystems compete with one another and we simply act in response to the strongest influence at any given moment. In terms of deliberate action, this means that from one moment to the next we will always act in pursuit of what we most want or need at that moment. These motives vary according to the current strength of evaluations and plans, but also in response to the internal and external environment. For example, if an intention or belief is not currently generating a sufficiently strong motive for performing (or inhibiting) a particular action, then the system may produce an apparently contradictory action in response to a strong internal drive or external stimulus. The operation of this dynamic, complex system is inherently unstable – reflecting the variety in patterns of addictive behaviour – and requires constant balancing to avoid heading into maladaptive ‘chreods’. The motivational system can be changed over time by a range of processes including habituation, associative learning, imitation and explicit memory.

This chapter provide a brief background to the origins of PRIME theory, before describing in more detail the proposed structure of the motivational system, important internal and external sources of influence, the dynamics of the system, and how motivational dispositions change over time. The chapter will finish by summarizing addiction research that has been inspired and informed by PRIME theory.

1.2 EXISTING THEORIES

There is no shortage of theories about addiction. The book Theory of Addiction (West & Brown, 2013), in which PRIME theory was first proposed, was originally intended to provide a convenient overview of available theories. During the course of the research for the book, however, it became apparent that theories of addiction tend to focus on one aspect of addiction or rely upon just one level of explanation. In a problem as manifestly complex as addiction, these approaches are unable to provide a sufficiently coherent and nuanced account of the phenomenon. Existing theories span a range of approaches from those that emphasize choice to those that focus on neuropharmacology. We now summarize some important categories of addiction theory and explain in each case why we believe more comprehensive theories are required. For a fuller account, see Chapters 3–7 in West and Brown (2013).

1.2.1 Choice Theories

Examples of theories that focus on addiction as the exercise of choice based on desires are Becker’s Rational Addiction Theory (Becker & Murphy, 1988) and Skog’s Unstable Preference Theory (Skog, 2000; 2003). Others focus on addicts’ ‘expectancies’ (for a review, see Jones, Corbin & Fromme, 2001). Slovic et al. (2002; 2007) have developed a theory of judgement relating feelings to analytical judgements (an ‘affect heuristic’) and applied this to smoking. There are theories that focus on attentional, or other cognitive, biases (e.g. McCusker, 2001; Mogg, Field & Bradley, 2005; Field & Cox, 2008). A raft of theories argue that the behaviour of addiction can be understood in terms of concepts derived from economic theory, such as temporal discounting (e.g. Bickel, DeGrandpre & Higgins, 1995; Bickel, Miller Kowal, Lindquist & Pitcock, 2007).

A synthesis of these theories describes an individual who chooses in some sense to engage or not engage in the behaviour. The choice involves a cost-benefit analysis: the costs are weighed against the benefits of the behaviour which change over time and the appreciation of which changes over time. The costs and benefits, and indeed aspects of the analysis, may involve mental representations to which one does not have full conscious access. The choice does not need to be rational; it can be influenced by pharmacological and non-pharmacological factors, including one’s sense of self and what one wants to be, and possibly by biases in attention to and memory for stimuli related to the addictive behaviour. In this view, the idea that addictive behaviour is driven by a damagingly powerful and repeated motivation is an illusion based on a failure to appreciate that the expressed desire to stop doing something at one time does not reflect the preferences operating at a later time after the attempt at restraint has begun.

An important problem with this view is that it does not accord with the experience of many addicts. At the point where they find themselves about to relapse back to their old ways, they frequently report feeling compulsion that is distinct from simple desire. It is not even that it is a ‘strong desire’; it is an urge that is often accompanied by a sincere attempt to resist. Successful restraint does not simply depend upon on analysis leading to a decision to refrain; the implementation of the choice requires self-control and expends mental effort. By focusing on the choice, the approach neglects the panoply of observational and research evidence for the importance of a failure of impulse control in the development and maintenance of addiction.

1.2.2 Compulsion and Self-Control Theories

The so-called ‘disease model’ of addiction takes the view that addiction involves powerful and overpowering compulsions that are experienced as ‘cravings’ (e.g. Jellinek, 1960; Gelkopf, Levitt & Bleich, 2002). Examples of theories concerning the failure of impulse control include those that focus on either the dysfunction of inhibitory brain circuitry (Lubman, Yucel & Pantelis, 2004; Dalley, Everitt & Robbins, 2011), or the dysfunction of the prefrontal cortex (Goldstein & Volkow, 2011). A cognitive model of craving has also been proposed (Tiffany & Drobes, 1991). A more general view of addiction as a failure of self-regulation has been proposed by Baumeister (Baumeister et al., 1994; Baumeister & Vohs, 2007; Vohs & Baumeister, 2011). Self-regulation extends beyond impulse control, or the adequate functioning of basic associated mechanisms; instead, it recognizes that failure to self-regulate may also involve a lack of reflective strategies, skills and capacity for self-control. Other examples of theories emphasizing the role of self-regulation in addiction are cognitive control theory (Miller & Cohen, 2001), executive dysfunction theory (Hester & Garavan, 2004; Fernández-Serrano, Pérez-García, Perales & Verdejo-García, 2010; Madoz-Gurpide, Blasco-Fontecilla, Baca-Garcia & Ochoa-Mangado, 2011), and self-determination theory (Deci, Eghrari, Patrick & Leone, 1994; Ryan & Deci, 2000; Deci & Ryan, 2012).

By incorporating theorizing about compulsion and self-control into ideas about choice, many important aspects of addiction are explicable. An addict may be someone for whom the desire to engage in an activity is abnormally strong, or the ability to resist the desire is abnormally weak, or some combination of both. Invoking both avoids the philosophical problem of addicts having ‘no choice’, which is implied by relying only on regulatory failure, and can explain a great deal about addiction. However, a model relying on choice (even if it acknowledges failures in self-control can sometimes be undermined), still has anomalies. A reliance on choice means that behaviour is still fundamentally centred on analyses of costs and benefits (however irrational), whereas, in reality, sometimes behaviour is simply not related to such analysis; instead it is habitual or automatic (i.e., the behaviour itself is automatic, not just the processes by which choices form). Another difficulty for choice models is that sometimes the priority given to certain behaviours can be out of all proportion to any apparent analysis, even allowing for certain biases or unstable preferences. The field of behavioural pharmacology can address this weakness.

1.2.3 Theories Focusing on the Neural Basis of Reward and Punishment

There are theories that focus on addiction as the development of a habit through instrumental learning (O’Brien, Childress, McLellan & Ehrman, 1992), or through both instrumental and Pavlovian processes (Everitt, Dickinson & Robbins, 2001; Everitt & Robbins, 2005; Everitt et al., 2008). Others, such as the Opponent Process theory, seek to explain the development of pharmacological tolerance and withdrawal symptoms (Solomon & Corbit, 1973; 1974; Solomon, 1980), which may lead to dose escalation and maintenance of drug use to avoid the aversive consequences of abstinence (e.g. Lewis, 1990; Schulteis & Koob, 1996; Koob, Sanna & Bloom, 1998). There are theories that focus on the neural basis of rewards that underpin addiction (e.g. Wise & Bozarth, 1987; Koob & Nestler, 1997; Koob & Le Moal, 2001; Weiss & Koob, 2001; Hyman, Malenka & Nestler, 2006). There are also theories that focus on Pavlovian conditioning in the development of cravings and dependence (e.g. Melchior & Tabakoff, 1984).

Theories focusing on the neural bases of addiction have become more complex over the years. White (1996) has proposed a theory involving multiple learning pathways. A particularly popular theory differentiates the hedonic effects of addictive drugs from their effects on pathways involved in habit learning in the context of cues (Robinson & Berridge, 2003; Berridge & Robinson, 2011). In that theory, it is claimed that tolerance to the hedonic effects of some drugs occurs while the mechanism underpinning the effect of cues on wanting a drug actually sensitize as a result of drug exposure. Instrumental learning and classical conditioning models have been combined in a theory that differentiates the effects of addictive drugs on different parts of the brain’s reward system (e.g. Balfour, 2004). More recently, attempts have been made to integrate how the neural bases of learning in addiction ultimately relate to dysfunction in inhibitory circuits (Koob & Volkow, 2010).

The addition of associative learning and response mechanisms, and their neural bases which can be affected directly by drugs, improves the explanatory power of a model of addiction. The synthesis of models previously described already recognized that an individual often chooses to engage in addictive behaviour as a result of a cost-benefit analysis of the alternatives, which may be influenced by biases and changing preferences. The concepts of compulsion and self-control account for the phenomenon whereby addicts sometimes sincerely choose to refrain from a behaviour but fail to enact their choice. Learning mechanisms help explain that sometimes behaviour results from a habit with little conscious decision-making, and also why certain behaviours come to be valued out of proportion to the benefits they confer, even after controlling for processing biases or preferences changing over time according to emerging needs or drives.

1.2.4 Integrated Theories

There are few theories that have attempted to span many of the areas considered above, but two that are important to mention are Orford’s Excessive Appetites theory (Orford, 2001) and Blaszczynski’s model of pathological gambling (Blaszczynski & Nower, 2002). These two theories are able to capture the experience of addiction and they do so by recognizing the diversity of patterns, feelings and routes to addiction. This diversity presents a major challenge to theory development. A synthetic theory must account for the big observations but also needs to be more than a listing of influences and factors; it must synthesize and add value with a unifying construct that itself generates new ideas.

1.2.5 The Need for a Synthetic Theory

A theory is needed that provides a parsimonious, synthetic and useful description of the nature of addiction that explains the major observations relating to the phenomenon and incorporates the insights of the range of theories that have been proposed to date.

PRIME theory is an attempt to synthesize the insights contained in more specific theories into a coherent account that is set within a general theory of motivation. This chapter provides an outline of the theory. For the sake of conciseness, it is just an exposition – it delves only a little into the evidence and inferences that led to the development of the theory, or the theory’s relationship with others in the literature. It is recognized that the ideas need to be expanded, developed, defended and related to other intellectual contributions on which it has drawn. This is attempted in the book, Theory of Addiction (West & Brown, 2013).

The theory is pitched at the psychological level of analysis but with a view to providing a ‘pegboard’ into which can be plugged theories at other levels (including economic theories and neurophysiological theories). When giving a psychological account of motivation, it is impossible to avoid making statements that just sound like common sense. The advance on common sense that is being offered here is bringing these ideas together in a coherent framework, together with non-common-sense ideas that have been developed through formal study and critical observation.

It is painted with a broad brush and does not attempt to capture what is known about the details of drug actions, social forces, and so on. However, it does seek to provide a coherent framework within which existing knowledge and future findings can be integrated.

1.3 THE HUMAN MOTIVATIONAL SYSTEM