Neurocognitive Therapy

It is 9.30 a.m. and your first client has arrived. In the light of the foregoing, what could be done differently in terms of formulation ad treatment now than, say, a decade ago? In an effort to elaborate on this issue I shall highlight key reference points on a typical treatment journey consistent with the Four M structure. The chapter will conclude with a scan of the horizon in an effort to identify key areas for research and how this might be translated into practice. To recap, the key theme in applying the model thus far is that addiction endures because cognitive control is compromised by repeated drug seeking and taking or the pursuit of overvalued rewards associated with gambling. This contributes to the enduring nature of addiction because cognitive control is vital when the challenge is to overcome these highly motivated habits. Executive control is weakened and impulsivity is given free rein, more or less.

This emphasis on cognitive control has important implications for how addictive disorders and associated mental health problems are conceptualized, formulated and managed. For instance, in Chapter 1, I described how cognitive therapy has, in effect, ascribed addiction a rather utilitarian role insofar as the goal is to manage or compensate for unbearable emotions linked to extreme or distorted beliefs. Further, cognitive therapy has historically addressed addiction by encouraging the client to either supplant irrational beliefs about addiction such as ‘I need cocaine to be sociable; people find me boring unless I have a few drinks; I can’t cope without a tranquilizer’; or discover and modify core beliefs about self, others and the world. Targeting these cognitions is, I propose, often necessary but rarely sufficient in combating addiction. This is because, in addition to the accessible thoughts and beliefs cited above, cognitive processes that evade introspection, operating in parallel with or in advance of deliberation, can lead to the recurrence of addictive behaviour by default. Of course, targeting implicit cognitive and behavioural processes requires considerable ingenuity. However, ignoring their existence and influence is not an option for empirically supported therapy such as cognitive therapy.

Increasing Cognitive Control is the Goal

This serves to create a rather different therapeutic dynamic than specified or implied by the extant accounts referred to in Chapter 1. It is less about core beliefs, schemata or spirituality and more about engaging with competing neural systems that generate a ‘valuation malfunction’, in computational parlance (Rangel et al., 2008). This provides a focus for therapeutic intervention along these lines: components that enhance cognitive control are good; those that do not are less good, or perhaps a waste of time. In the earlier chapters I explored the implications of this idea across the phases of typical therapeutic encounters. The balancing act that was required was to maintain the robust, proven format of cognitive therapy while at the same time incorporating innovations such as WM training or cognitive-bias modification. I surmised that, while explicit or specified, these elements of therapeutic intervention are usually embedded in otherwise diverse approaches such as Twelve-Step or CBT. Goal setting or regular attendance at Twelve-Step meetings directly act on WM, the engine of executive control. However, no intervention is ‘process pure’ with regard to cognitive enhancement, so the therapist has to accentuate these particular levers of change.

My hope is that this text provides a rationale and a guide to translate cognitive-neuroscience concepts and applications to the addiction clinic. Targeting cognitive control by the diverse techniques outlined in this text offers both patient and therapist a coherent and accepting, if prototypical, framework to understanding and modifying harmful habits. The components of CHANGE are all individually supported by experimental findings, preclinical or clinical outcome studies. However, the package per se has not yet been subject to formal evaluation. In due course, innovative techniques such as cognitive-bias modification, modifying behavioural approach tendencies and more explicit neurocognitive interventions such as WM enhancement might well feature prominently in the addiction-therapist’s toolkit. Researchers and clinicians are currently refining and evaluating these interventions. In one treatment centre where I worked clients readily took advantage of internet access, spending much time on social networking sites! Steering these computer-literate individuals, or encouraging those less computer literate, towards programmes aimed at reversing cognitive and behavioural biases seems entirely plausible. Pending the likely wider dispersal of these interventions, the question is how to apply the findings detailed in the foregoing chapters. In this concluding chapter I shall briefly revisit the major phases of the therapeutic journey, cycling through the Four Ms.

Do We Know Anything New?

Converging findings with both community and clinic-based populations have accorded cognitive control a key role in the persistence, cessation and resumption of addictive behaviour. Further, insights into the component processes of cognitive control of addictive impulses have also been gleaned from a diverse range of methodologies employed by a wide range of research teams. The task I embraced in the foregoing chapters was to create a psychotherapeutic framework that could accommodate these findings and perhaps create a platform for evaluation and refinement. Throughout, I have endeavoured to remain focused on the therapeutic alliance, the importance of case formulation and the scope this provides for addressing the more dysfunctional component processes of cognitive control.