Textbook of Addiction Treatment: International Perspectives
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Create Alert. Share This Paper. Topics from this paper. Published Comment. Citations Publications citing this paper. Yumayev , Olga Galtseva. References Publications referenced by this paper. Young , Christian Laier. Kuss , Mark D. Stars are assigned as follows:. Inventory on Biblio is continually updated, but because much of our booksellers' inventory is uncommon or even one-of-a-kind, stock-outs do happen from time to time.
If for any reason your order is not available to ship, you will not be charged. Your order is also backed by our In-Stock Guarantee! What makes Biblio different? Facebook Instagram Twitter. Sign In Register Help Cart. Cart items. Toggle navigation. Search Results Results 1 -2 of 2. Ships with Tracking Number! May not contain Access Codes or Supplements. Indeed, negative urgency has been related to poorer treatment outcomes including relapse in substance use disorder Furthermore, a meta-analysis examining changes in facets of impulsivity reported that sensation seeking and negative urgency were the only facets of impulsivity that significantly decreased during treatment Distress tolerance is a construct that is related to urgency in that it reflects perceived and actual capability to withstand negative emotional or physical states.
Lower distress tolerance, as assessed with simple behavioral tasks e. In addition, distress intolerance amplifies the distress-terminating effects of addictive behaviors Thus, the inability to tolerate negative emotions appears to be an important factor in the etiology and maintenance of both substance and behavioral addictions. Distress tolerance can be targeted in skills and exposure-based treatments, in which individuals practice cognitive and behavioral tolerance techniques in the context of negative affect.
Bornovalova et al. Furthermore, among smokers with a history of early relapses, people who were randomly assigned to a distress tolerance treatment were over six times more likely to be abstinent compared to a standard smoking cessation treatment, with the effects being maintained, albeit diminishing overtime More recently, Stein et al. At 3 months, Although not statistically significant, the distress tolerance intervention led to a small reduction in opioid use. In sum, the literature provides promising support for targeting distress tolerance in the treatment of addictive behaviors.
A recent advancement in the treatment of psychiatric disorders has been the emergence of a body of empirical literature supporting the use of mindfulness-based therapies in the treatment of psychiatric disorders including addictive disorders Mindfulness is broadly defined as attending to the present moment in a non-judgmental manner and reaching a state of awareness that can be cultivated through formal and informal practice Mindfulness is included as a component in dialectical behavior therapy and acceptance and commitment therapy as a technique to promote non-judgmental acceptance of internal physiological, cognitive, and emotional experiences Similarly, mindfulness-based cognitive therapy [MBCT; 79 ] is provided to reduce the likelihood of relapse into major depression by encouraging observation versus reaction to negative cognitions.
Recently, mindfulness based interventions have been developed in the treatment of addictive disorders e. A systematic review concluded that mindfulness-based interventions have demonstrated support for reducing severity of a wide variety of addictions, including behavioral addictions Interestingly, the authors found that combining mindfulness-based interventions with other active treatments led to the greatest efficacy, suggesting the importance of mindfulness as an intervention strategy in addictive behaviors.
In practice, mindfulness-based interventions help individuals become aware of their specific triggers and increase an individual's ability to stay in the moment with discomforting states In this way, cultivating mindfulness may help individuals become less behaviorally reactive when experiencing negative affect. Indeed, it has been found that a mechanism by which mindfulness helps improve mental health functioning is through lessening cognitive and emotional reactivity 91 , Although empirical studies testing the mechanisms by which mindfulness-based interventions lead to improved outcomes for addictive disorders are sparse, there is preliminary support that one potential mechanism is reduction of negative urgency.
A review of mindfulness-based interventions for substance use concluded that mindfulness meditation enhances peoples' emotion regulation skills, which is a component of urgency as well as reducing drug use Additionally, in a sample of smokers, Spears et al. Thus, there is increasing support for urgency as a potential intervention target in the treatment of addictive disorders.
Self-control refers to the ability to focus awareness beyond immediate stimuli It involves the ability to purposely direct one's actions toward a goal , which may involve short terms goals such as limiting the time spent playing video games, not stopping at the bar on the way home, as well as long terms goals such as abstaining from an addictive behavior.
This vulnerability has been examined in various research lines showing that addicted individuals have significant deficits, including shortened time perspective and self-control resource depletion. It has been suggested that people have a finite amount of self-control capacity, known as the resource depletion model, whereby if individuals use their self-control capacity for multiple tasks, less becomes available for other tasks A related construct to deficits in self-control is deficits in executive functioning. Executive functioning are cognitive functions that direct the ability to organize, plan, problem-solve, and coordinate thought and action toward goal-directed behavior, thus facilitating self-control It consists of several top-down cognitive processes such as inhibitory control and working memory It is now well established that deficits in executive functions measured by tasks such as the Iowa Gambling Task and Wisconsin Card Sorting Task have been implicated in a wide array of addictions including both substance use disorders 2 , and behavioral addictions , There are several intervention possibilities to increase individuals' self-control capacity, including working memory training to improve executive functions Several empirical studies support the use of working memory training in the treatment of addictions.
Houben et al. They found that participants who completed the working memory training showed improvements not only in working memory but reduced alcohol intake at 1 month follow up. Importantly, the reduction in problematic drinking was mediated through improvements in working memory. Additionally, preliminary evidence suggests that computerized tasks such as the Dual N-Back task can enhance executive functions and may show promise in the treatment of addictions Self-control training has also been shown to improve self-control and help with smoking cessation There are a variety of tasks to improve self-control ranging from strengthening one's hand grip to avoiding sweets and implementation intentions, which are if-then statements created to help with high-risk situations There is now empirical evidence to support that self-control capacity can be enhanced through deliberate practice Goal management training , designed to remediate executive dysfunction, has been shown to be effective in improving response inhibition and decision-making in individuals with alcohol problems Problem-solving therapy is another transdiagnostic approach to addressing deficits in self-control that impede effective problem resolution A central component of this approach is training individuals to use a structured process to identify possible solutions to well-defined problems to combat cognitive and emotional overload, biased cognitive processing of emotion-related information, and ineffective problem-solving strategies Although problem-solving therapy has demonstrated empirical support for the treatment of other psychiatric disorders, specifically depression and is included as a treatment intervention in some treatment manuals for addictive disorder 43 , to our knowledge, no studies have directly tested the potential of problem solving therapy in the treatment of addictions.
Cognitive expectancies for the effects of addictive behaviors have been found to be an etiological and maintaining factor of addictive disorders To this end, two types of dysfunctional beliefs have been identified: permissive beliefs and anticipatory beliefs CBT has been identified as the gold standard treatment for a variety of substance use disorders , , including behavioral addictions such as gambling A component of CBT is helping individuals identify and challenge maladaptive cognitions that are maintaining the addictive behavior Specific cognitive and behavioral substance use expectancy challenge interventions have also shown efficacy , For example, a meta-analysis involving 14 studies with 1, participants found that compared to control conditions, expectancy challenge interventions resulted in reducing positive expectancies in regard to alcohol.
Importantly, expectancy challenge interventions also resulted in improved treatment outcomes for problem drinking Restructuring of maladaptive cognitions have also demonstrated efficacy as a treatment target for gambling disorder Relatedly, motives for why people engage in addictive behaviors have been prospectively linked to problematic engagement in a variety of addictive disorders 57 , Generally, speaking, three primary motives for engaging in addictive disorders have been identified.
These motives include: i enhancement motives i. The empirical literature has consistently found that of all the motives, coping motives has been robustly associated with problematic engagement of addictive behaviors, including both behavioral and substance addictions 56 , Moreover, our recent work suggests that common motives underlie comorbid alcohol, gambling, and eating problems , Coping skills training is based on the premise that people engage in addictive behaviors to alleviate negative affect If an individual's only means of coping is to engage in addictive behaviors, then an effective treatment strategy would be to help individuals develop more adaptive ways of coping.
Adaptive coping skills can vary widely from practicing intrapersonal skills including relaxation training to interpersonal skills such as practicing refusal skills. Coping skills training has been shown to lead to greater treatment improvements as an adjunctive therapy , In a sample of marijuana users, Litt et al. The results found that longer term abstinence of marijuana was predicted most strongly by the use of coping skills.
Coping skills training has also been demonstrated to reduce problem drinking up to 12 months post treatment Moreover, in individuals addicted to gambling, Petry et al. Importantly, increased coping skills partially mediated improved treatment outcomes at 2-month post treatment. Deficits in social support have been consistently linked to the expression of addictive disorders, including alcohol 29 , cannabis , illicit drugs , as well as behavioral addictions such as gambling and video games Furthermore, lack of social support has been associated with poorer treatment outcomes , and increases the chance of relapse For instance, interpersonal conflicts may result in increases in negative affect, which then leads an individual to engage in addictive behaviors as a means of coping Enabling, that is, the well-intentioned but unhelpful behaviors of friends or family is another concept that has been shown to increase the use of addictive behaviors Interventions that enhance and reinforce social and family supports are well supported in the treatment of addictive disorders For example, a therapeutic benefit offered by step programs is social support such as access to a sponsor Additionally, family-based therapies and behavioral couples therapy have shown efficacy in the treatment of a variety of addictive disorders — An approach that has garnered increasing support in the treatment of addictions is the community reinforcement and family training CRAFT approach.
The CRAFT approach, involves including concerned significant others of addicted individuals in treatment to engage the addicted individual, as well as to teach social skills There now exists support for the use of CRAFT in the treatment of various addictive behaviors including alcohol, cocaine, and opioid dependence In a study of 31 concerned significant others of individuals addicted to gambling, those who received a manual based on CRAFT principles reported greater reduction of gambling in their loved ones.
Training in communication skills has been shown to result in increased relationship satisfaction and has demonstrated some support in the treatment of addictive disorders Providing support for the use of communication skills training in the treatment of addictions, Monti et al. Compulsivity refers to repetitive engagement in a behavior It is also termed impairment of control. Although, compulsivity shares overlap and is often confused with impulsivity, compulsivity is conceptualized to be a distinct construct from impulsivity Importantly, it has been proposed that whereas impulsivity plays a prominent role in the development of addictive behaviors, compulsivity emerges overtime and maintains addictions through a cycle of negative reinforcement In other words, compulsivity serves to maintain addictions through rigid patterns of coping strategies in response to negative affect.
The incentive-sensitization theory of addictions provides empirical support for the role of compulsivity in the manifestation of addictive disorders According to this theory, liking, i. In other words, engaging in addictive behaviors may become a compulsion that is cue-dependent, triggered by certain situations, people, places or internal states.
The incentive-sensitization theory has been applied to substance use disorders as well as with behavioral addictions Support for the incentive-sensitization theory comes from attentional bias research, in which problematic engagement with addictive behaviors is associated with a preferential view toward addiction-related stimulus to substances such as alcohol and behaviors such as gambling , video games , food , and shopping Stimulus control, attentional bias retraining, and contingency management may represent potential intervention possibilities for this component vulnerability.
These approaches may prevent the activation of the sensitized networks that mediate the motivation processes in compulsively engaging in the addictive behavior Stimulus control is based on the principle of classical and operant conditioning and helps individuals avoid or reduce the learned association between addiction-related cues and the desire to engage in the addictive behavior.
For example, stimulus control may involve avoiding certain places, people or things that have become associated with the addictive behavior. Stimulus control has been shown to be a very frequently used change strategy in recovery from addictions and case studies have demonstrated the potential for the use of stimulus control in the treatment of addictions Attentional bias retraining is also another potential treatment possibility.
Attentional bias refers to an unconscious process by which addicted individuals attend to addiction related cues, and subsequently have difficulties disengaging with the cues, which is thought to increase cravings and the risk of use There have now been several meta-analyses that support the use of attentional bias modification in the treatment of addictive behaviors, which have demonstrated significant improvements in reducing attentional bias Although the effects of attentional bias training on decreasing cravings remains unsupported, attentional bias training has demonstrated improved treatment related outcomes in problem drinkers including decreased length of stay in treatment as well as delaying the onset of relapse Contingency management is based on the principles of reinforcement and provides people tangible rewards e.
There now exists several treatment studies supporting the use of contingency management in the treatment of a wide variety of addictive disorders, including alcohol, gambling, stimulant use, cannabis, nicotine, and opioids The improved treatment outcomes not only include increased retention but also a reduction of addiction-related symptoms. The CMAT Figure 1 is a transdiagnostic treatment in that it can be used in the treatment of both behavioral and substance addictions.
It is pragmatic in that it targets component vulnerabilities that are common to both, and that has been demonstrated to be modifiable. Importantly, the CMAT is empirically grounded in that the component vulnerabilities have all been empirically shown to be important etiological and maintaining factors for addictive behaviors and can be targeted in treatment. It is a hybrid of the three broad categories of transdiagnostic treatments described by Sauer-Zavala et al. It draws upon treatment models that can be universally applied to addictive and mental health disorders, such as MET and ACT.
It is also modular in that remediation of any of the specific components can be emphasized based on the specific presenting needs and treatment progress of individual clients. Finally, the CMAT fits the third category of transdiagnostic treatments identified by Sauer-Zavala 47 in that the hypothesized components included in this treatment model have been found to be core mechanistic features of addictive disorders.
In our opinion, we believe that all the components below are necessary yet insufficient in and of themselves as an effective treatment for addictions. In other words, for effective treatment, all components would need to be addressed to varying degrees. The components and their related treatment interventions are also not conceptualized as independent, but rather are linked.
Indeed, treatment interventions likely impact multiple vulnerabilities. In addition, we advocate that the components listed below be individualized by modifying the varying degrees of focus on each of the components. For example, while urgency, social support, and maladaptive expectancies are all important treatment components, some individuals may require greater intervention in urgency, while others may require more focus on changing maladaptive cognitions.
In this way, the CMAT is flexible in nature, without changing the underlying protocol depending on the addictive behaviors. Furthermore, we believe that the CMAT can be delivered as an individual therapy and as a group treatment, specifically as part of a step-cared approach for the treatment of addictions. This is because the components do not have to be addressed sequentially in treatment. This allows the treatment to proceed by addressing each of the components delivered via a group format. Thereafter, referrals for individualized treatments can be made based on individual needs to target the specific components.
Thus, the CMAT will require clinicians to be skilled in the delivery of multiple therapeutic interventions. Clinicians will also need to be flexible in adapting the intervention possibilities based on client needs in order to address the component vulnerabilities that are maintaining the addictive behavior. The goals of treatment i. Indeed, there is currently no one agreed upon definition of recovery, and there are multiple pathways that an individual can take to overcome their addiction Furthermore, whether the goal of treatment is harm reduction or abstinence may depend on whether the addictive behavior is a behavioral or substance addiction.
This is because, whereas the traditional goal of treatment for substance use disorders has been abstinence based , such an approach may not be possible when it comes to primary rewards such as sex and food. This has led to traditional abstinence-based 12 step programs to make exceptions such as no extramarital sexual intercourse, opposed to all sexual intercourse in the case of Sexaholics Anonymous and the avoidance of certain food groups in the case of Overeaters Anonymous However, these approaches have led to concerns, for example restricting any sexual activity for individuals who are not married and the potential development of disordered eating caused by avoiding certain food groups.
Thus, in the case of certain behavioral addictions, harm-reduction approaches may be more appropriate. Harm-reduction approaches aim to reduce the negative consequences of addictions, as well as increase an individual's well-being. Importantly, harm-reduction has been shown to be effective in the treatment of both behavioral and substance addictions In line with Shaffer et al.
For example, there are differences regarding physical dependency between behavioral and substance addictions. While the presence of withdrawal symptoms are well-established for substance use disorders, it is disputable in the case of behavioral addictions A recent systematic review concluded that the evidence base for withdrawal symptoms in internet gaming disorder is underdeveloped Furthermore, withdrawal symptoms of behavioral addictions have largely manifest as psychological symptoms such as irritability and restlessness , rather than physiological symptoms, although physiological symptoms of withdrawal have been observed in gambling disorder , The debate regarding the presence of withdrawal symptoms is not limited to behavioral addictions.
Until recently, the presence of withdrawal symptoms in cannabis use disorder was debated, and was only included in the DSM-5 due to accumulating evidence 1.
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In a similar vein, more research is needed to demonstrate the concept of tolerance and withdrawal for behavioral addictions. The presence of withdrawal symptoms is an important factor that needs to be taken into account in the treatment of addictions as they are associated with increased risk of relapse As such, a greater emphasis on the management of withdrawal symptoms may be warranted for certain addictions. There are also differences in the physical dependency of addictions.
For example, heroin, cocaine and barbiturates have been identified as having the greatest physical dependency Additionally, different addictions are associated with varying degrees of both personal and interpersonal harms, with alcohol having been identified as the most harmful The differences in physical dependency between addictive behaviors have basic treatment implications.
For example, the risk of overdose is greater for substance use disorders, such as opioids whereas the risk of overdose does not apply to behavioral addictions. Physiological individual differences may also influence the development of certain addictions, including alcohol e. Although physical dependence has yet to be demonstrated in behavioral addictions, certain behaviors have greater potential to lead to the development of addictive behaviors.
Indeed, whereas there are countless behaviors, only a handful have been proposed to lead to addiction-related symptoms, suggesting certain compulsive behaviors have greater dependency potential than others Lastly, the negative consequences vary depending on the addictive behavior, which need to be taken into treatment considerations. For instance, the risk of sexually transmitted infections are greater for intravenous drug use 39 and compulsive sexual behaviors , whereas financial consequences may play a more prominent role in compulsive shopping and gambling disorder Individuals involved with illicit drugs, may face greater legal consequences and as such may require focus on the potential legal consequences associated with their illicit substance use.
It would be of benefit for clinicians to be cognizant of these important differences and tailor the treatment accordingly. Furthermore, studies are needed to determine whether the component vulnerabilities listed represent important mechanisms that account for treatment efficacy across a range of addictive disorders.
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Indeed, while we found generally strong support for the intervention possibilities listed in the CMAT model for substance use disorders, more empirical evidence is needed in the treatment of behavioral addictions, specifically other than gambling disorder. It is our hope that the model inspires both basic and applied research on these issues. Furthermore, there are likely other component vulnerabilities that have yet to be elucidated and may represent important mechanisms which can be targeted in treatment.
To this end, we are currently engaging in a program of research that aims to identify and provide further empirical support for the components in the CMAT model through a multi-method approach with diverse populations. For example, we are currently conducting a quantitative study using a lay-epidemiological approach to identify the most important symptoms for 10 addictive behaviors e.
Furthermore, we are assessing common clinical processes e. In regard to the CMAT, we are in the midst of developing a treatment protocol and will be testing the effectiveness of the treatment model and whether improvements are mediated by the component vulnerabilities on an individual basis, as well as a treatment protocol that will be delivered in a group format in Canada. Furthermore, we will be piloting the treatment protocol in Brazil to test whether the treatment model can be applied across diverse cultures. Future directions will involve creating an assessment tool that will have clinical validity in helping treatment providers determine which component vulnerabilities are the most important to target in treatment.
Additionally, we have begun a program of research that also aims to address the treatment needs of co-occurring addictions and mental health concerns. Indeed, concurrent disorders tend to be the rule rather than the exception in addictions treatment 6.
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Importantly, similar component vulnerabilities have been implicated in the etiology and maintenance of mental health disorders including negative urgency 56 and impulsivity To this end, we have assessed whether similar component vulnerabilities represent common factors that exacerbate the severity of mental health and addictive disorders.
For example, we have found that heightened levels of impulsivity mediate the relationship between dual diagnosis of gambling and psychosis, and increased gambling severity Relatedly, we have found that maladaptive expectancies mediate the relationship between co-morbid gambling and depression, and increased gambling severity. We are extending this line of work with non-treatment seeking samples as well as examining component vulnerabilities that are important in the co-morbid expression of mental health disorders and other behavioral and substance use addictions.
While we remain cautiously optimistic about the potential benefits of the CMAT, we would like to note where alternate treatment approaches may be more appropriate. First, is in the treatment of opioid dependence, which often involve the use of pharmacological treatments such as opioid agonists. In a review assessing the effectiveness of the addition of psychosocial intervention along with opioid agonists, the inclusion of psychosocial interventions did not lead to improved treatment outcomes including treatment retention, adherence to treatment or abstinence from opioid use Further, the authors found that these null-results held regardless of the type of therapy intervention.
In our review of the literature on the component vulnerabilities, we also found some evidence to suggest that the use of psychosocial interventions such as cue-exposure may have deleterious effects on the treatment of opioid dependence Secondly, one of the hypothesized benefits of the CMAT is in the treatment of co-morbid addictions. However, we should note that both behavioral and substance use addictions are also highly co-morbid with other mental health disorders, with high prevalence rates of co-morbid mood and anxiety disorders 54 , While we believe that several of the components listed in our CMAT model may be applicable to co-occurring substance use and mental health concerns, our literature review was limited to component vulnerabilities implicated across addictive disorders, as opposed to component vulnerabilities in co-occurring mental health and addictions.
Thus, caution is warranted in applying our model to co-occurring addictions and mental health concerns, and we advise the use of concurrent disorder treatments in these instances. The current and future directions noted above are only the start of an ongoing program of research. To the extent that new evidence emerges identifying new component vulnerabilities, and advancements are made in the treatment of addictive disorders, the CMAT will be revised to reflect the latest evidence base in the treatment of addictive disorders. Indeed, it is our hope through an ongoing process that the CMAT will represent an evidenced-based treatment for both behavioral and substance addictions, including addictive disorders that are well recognized, as well as emerging addictive disorders.
Addictive disorders represent one of the most common psychiatric disorders in the general population and are associated with significant degradation in psychological, physical, and social impairments The treatment of addictions has advanced significantly in the past several decades, with the development of evidence-based treatments However, the recent proliferation of behavioral addictions has created the need for the development of a unified treatment for addictive disorders, which may help to increase the efficiency, effectiveness, and accessibility of addictions treatment for traditional and emerging addictions.
The CMAT represents to our knowledge, the first attempt in developing a unified treatment approach to addictions.
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It is our hope that the presentation of the CMAT will generate further research in transdiagnostic mechanisms across addictive disorders and in turn, facilitate the creation of a unified treatment of addictions that may help people live a life free from their addiction. HK wrote the first draft of the manuscript. DH wrote parts of the manuscript and edited subsequent versions.
Funding for work was supported by a salary award to DH and graduate scholarship to HK.
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