How can addiction be treated in therapy?
Firstly it is probably best to decide what the term ‘addiction’ actually means as there is disagreement, even within those professions that deal with addictions. The word addiction is commonly employed to refer to the compulsive use of psychoactive drugs(drugs that exert a psychological effect). Apart from illegal drugs such as heroin, cocaine and cannabis; psychoactive drugs also include legal drugs such as prescription drugs, alcohol, nicotine and caffeine. Addiction is generally signified through the excessive amounts of time and effort devoted to the pursuit of a drug by the addict, even when this appears to be to the overall detriment of the person. However, the term ‘addiction’ is also commonly applied to describe other activities where the individual feels compelled to take part in an activity, such as shopping, gambling or sex addictions. For the term addiction to be used there is usually an element of irrationality in the activity in terms of its negative effects on health and well-being, its intensity or the length of time spent on it, or some combination of these. Thus, one criterion is that the addiction creates a problem that is in need of resolution.
Clearly, addiction is an example of motivation taking an abnormal direction; however, understanding this motivation can be somewhat difficult to define. The classic way of defining addiction is through the behaviour shown towards drugs such as heroin. However, there are certain other drugs that are also taken for their psychoactive effects, but which are not addictive such as ecstasy and LSD and others that only some people become addicted to like alcohol and marijuana. Furthermore, some non-drug-related activities can take on serious addictive properties, as exemplified by gambling.
A possible definition of addiction is when someone reports an excessive craving for something when it is absent. This can apply to addiction to drugs and such non-drug addictions as shopping, gambling or sex. However, although it would be difficult to imagine an addiction that was not associated with excessive craving, some people commonly report cravings for particular foods, as exemplified by women during pregnancy, which would be hard to describe as addiction.
Another approach to a definition of addiction is based on objective evidence of withdrawal. Withdrawal symptoms are uncomfortable and disrupt behaviour. If they are triggered when the person suddenly ceases to engage in their behaviour, then they might be used as a pointer to addiction. Another term in common use and meaning much the same as ‘addicted’ is to say that withdrawal symptoms are indicative of a person’s ‘dependence’ upon a drug. For such drugs as heroin, withdrawal symptoms consist of, for example, sweating, nausea, cramps and convulsions. According to the traditional account, the pleasure caused by heroin is at first intense but then declines and the frequency and strength of aversive withdrawal symptoms increase. There is no set of identical symptoms following cessation of any addictive drug. Each has peculiar features but all are described as unpleasant and undesired, indeed with some drugs such as alcohol sudden withdrawal can be fatal and, in the chronically addicted, should not be attempted without medical supervision. However, it must be noted that only a small percentage of addicts that have returned to hard drugs give withdrawal symptoms as their reason for relapse. Somewhat surprisingly, times of the most potent cravings do not correlate strongly with times of withdrawal. Detoxification programmes fail to cure a significant percentage of those attending. Similarly, in the case of nicotine, there is no strong relationship between withdrawal symptoms and relapse of smoking. Nicotine replacement, which reduces the withdrawal symptoms following cessation of smoking, is of only very limited help in giving up. The criterion of withdrawal in defining addiction would appear to be applicable only to certain drugs and thereby preclude, say, Internet addiction or compulsive shopping. However, even a drug such as cocaine might not qualify as being addictive in that there is relatively little in terms of observable withdrawal symptoms, and yet by the criterion of craving and disruption to life, it can be highly addictive.
Another way of defining addiction that seems to encompass addictive behaviour is one that is based in terms of the excessiveness of the activity (e.g. in terms of money spent) and the disruption to the life of the addict and others. This can be applied across a spectrum of activities, both drug related and drug unrelated, however, when is excessive, ‘excessive’. The notion of the activity being excessive according to what the person desires would seem to be a crucial feature of addiction. If the person wants to give up the activity and tries to resist but without success, this would seem to be a useful indicator of the presence of an addiction. It offers the possibility of a theoretical integration across diverse addictions such as to drugs, gambling and sex.
Perhaps addiction is best explained when it is considered at the synaptic level. Neurotransmitters such as dopamine, sometimes called the pleasure neurotransmitter, or perhaps more accurately described as the reward neurotransmitter appear to play a role in all activities that are described as addictive. Dopamine occurs in pathways essential for sensory and motor performance. Many psychoactive drugs interfere directly with this process such as ‘opiates’ (heroin and morphine), which are similar to the endorphins produced naturally by the body and lock onto the opioid receptors located on the dopaminergic neurons; alcohol, which increases activity on dopaminergic neural pathways; caffeine (thought to be the world’s most widely taken psychoactive drug) has a similar structure to the neurotransmitter adenosine, which suppress the release of neurotransmitters from, among others, dopaminergic neurons. Interestingly neither LSD nor ecstasy, although both being psychoactive drugs but considered by many as non-addictive, impact on dopaminergic processes, instead affecting other areas of the brain.
Using a PET scan, researchers looked at the dopaminergic activity of the brain not only with chemically addicted subjects, but also those said to be addicted to non-drug activities such as playing of a video game and found causal link between level of dopamine release and successful negotiation of a task. With those subjects with chemical addiction, dopamine activity increased, not only when taking the drug, but simply in the presence of the drug. This would seem to suggest a single process for addiction being the conditioned response to a stimulus, be it a drug or an activity, so that addiction could be considered as not the drug or activity, but its anticipation. This would seem to be born out through observation where the culture of drug taking and its associated activities are strongly paired with the drug itself, such as the nicotine addict, craving a cigarette in a pub and where heroin addicted GI’s returning from Vietnam who with the change of environment simply gave up their drug without withdrawal. This would also seem to provide an explanation for how addictions can be transferred from one addiction to another, as the brain finds other activities that supply it with its dopamine fix. What these studies seems to reveal is that drugs interact with brain processes that evolved to serve conventional motivations. It is surely not coincidence that dopaminergic neurotransmission feature in conventional motivations such as feeding and sex, as well as drug taking.
Addiction then seems best described in terms of brain chemistry, this would provide an explanation for why addictions, be it drug or non-drug related are so hard to break. Long after the withdrawal phase has past, an addict can relapse, perhaps years after withdrawing from their addiction. Alcoholics in recovery will normally refer to themselves as alcoholics in recognition of the enduring nature of their addiction. However, it is the essence of psychotherapy that change is possible and that there is hope for even the most seriously addicted.
If addiction can be described then in a single model, then it stands to reason that therapy would be similar in the chemically addicted client to the behaviour addicted client and that all therapy will involve changing the clients thinking towards their particular addiction, or at least making them consciously aware of their motivations surrounding the addiction so that they can choose to behave differently and override the motivations of their addiction. It may well be that they will need to always consider themselves to be an addict, but instead choose not to give in to their addiction because the rewards of not giving in are greater than giving in to the addiction. Therapies such as CBT that focuses on their actual behaviours, motivations and thinking would most likely prove affective and psychoanalytic approaches may be useful in helping to uncover, why the client has embarked on a self-defeating behaviour.
Indeed almost any self-defeating behaviour could be regarded as addiction and conversely addiction viewed as a self-defeating behaviour. Therapy could then be based on many of the principles of those clients presenting with self-defeating behaviour whether it be with clients presenting with chemical or non-chemical addictions.
However, it is important to stress that for those clients where the case would not be considered as chronic. Such chronic symptoms would be signified by any client that as a result of their addiction was snuffing from psychological problems such as psychosis, schizophrenia, paranoia, were hearing voices, were delusional etc, apart from the fact that they would probably not be in a position to make an informed choice about the therapy they were seeking, in which case it would be unethical to treat them, but also psychotherapeutic treatment would be unlikely to be successful. Such seriously distressed clients should only be treated using the medical model of psychiatry. Any such clients should be referred to their doctor as they would require expert medical supervision and specialist psychiatric counselling.
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