About the Author ix
Preface xi
1 The Tenacity of Addiction 1
Introduction and Overview 1
Discovering Cognition 5
Implicit Cognition and Addiction 6
Neuropsychological Findings 9
Addictive Behaviour is Primary, Not Compensatory 11
Changing Habits is the Priority 14
Diagnostic Criteria 15
Towards Integration 15
Equivocal Findings from Research Trials 16
Time for CHANGE 16
Evolution, Not Revolution 17
Something Old, Something New 18
2 Existing Cognitive Behavioural Accounts of Addiction and Substance Misuse 21
The Evidential Basis of CBT for Addiction 23
Meta-analytic Findings 23
Behavioural Approaches 24
Diverse Treatments Mostly Deliver Equivalent Outcomes 25
What are the Mechanisms of Change? 26
The Missing Variable? 27
A Dual-Processing Framework 28
3 Core Motivational Processes in Addiction 33
Is Addiction About Avoiding Pain or Seeking Reward? 33
How Formulation Can Go Astray 34
Incentive Theories of Addiction 35
Learning Mechanisms in Addiction 36
Distorted Motivation and Aberrant Learning: the Emergence of Compulsion 41
'Wanting and Liking' in the Clinic 41
The Role of Secondary Reinforcers 43
Beyond Pleasure and Pain: a Psychoanalytic Perspective 43
Conclusion 44
4 A Cognitive Approach to Understanding the Compulsive Nature of Addiction 45
Theories of Attention 46
Top-Down Influences Can Be Automatic 47
Automatic Processes Can Be Practically Limitless 48
Motivationally Relevant Cues are Prioritized 48
Biased Competition 50
Attention and Volition 51
Appetitive Cues Usually Win 52
Purposeful Behaviour Can Occur in the Absence of Consciousness 53
Attentional Bias and Craving 54
Cognitive Cycle of Preoccupation 56
5 Vulnerability Factors In Addiction 63
Individual Differences in Addiction Liability 63
Personality Traits 63
The 'Big Five' Personality Factors 65
Personality Disorders 66
Affective Vulnerability Factors 67
Brain-Derived Neurotrophic Factors 69
Neurocognitive Vulnerability 70
Findings from the Addiction Clinic 71
From Research to Practice 72
6 Motivation and Engagement 75
Impaired Insight and the Therapeutic Relationship 75
The Sad Case of Julia 80
Conflicted Motivation is the Key 81
Goal Setting and Maintenance 82
The Importance of Between-Session Change 83
Neurocognitive Perspectives on Motivation 83
Motivational Interviewing in Practice 84
Formulating and Planning the Intervention 88
Attributional Biases: the Blame Game 90
Case Formulation 91
Summary 97
7 Managing Impulses 99
Introduction and Overview 99
Structuring the Session 99
Building Resilience 100
Impulse Control 102
Craving and Urge Report 103
Cognitive Processing and Craving 104
Cognitive Bias Modification 105
Attentional Bias in the Context of Addiction 106
The Alcohol Attention-Control Training Programme 108
Modifying Implicit Approach Tendencies 110
Reversing the Bias: Conclusion 112
Brain Training and Neurocognitive Rehabilitation Approaches 112
Clinical Implications of Delayed Reward Discounting 117
Tried and Tested Techniques 119
The Road to Recovery is Paved with Good Implementation Intentions! 125
Neurophysiological Techniques 129
Neuropsychopharmacological Approaches 130
8 Managing Mood 135
The Reciprocal Relationship Between Mood and Addiction 135
Pre-existing Vulnerability to Emotional Distress 137
Negative Affect Due To Drug Effects 141
Stepped Care for Addiction 145
An Integrated Approach to Addressing Negative Emotion 147
9 Maintaining Change 155
Relapse Prevention Strategies from a Neurocognitive Perspective 155
The Importance of Goal Maintenance in the Long Term 158
A Neurocognitive Perspective on Relapse 159
Twelve-Step Facilitation Therapy 161
Implicit Denial 162
10 Future Directions 171
Neurocognitive Therapy 171
Increasing Cognitive Control is the Goal 172
Do We Know Anything New? 173
Appendix Self-Help Guide Six Tips - a Pocket Guide to Preventing Relapse 179
Introduction: Why Six Tips? 179
1. Don't Always Trust Your Memory! 180
2. Beware of the 'Booze Bias'! 180
3. Separate Thoughts from Actions 181
4. Learn How to Distract Yourself 181
5. Willpower is Sometimes Not Enough 182
6. Beware of the Dog that Doesn't Bark. . . 182
References 185
Index 201
