Relapse Prevention Strategies from a Neurocognitive Perspective
Automatic or implicit tendencies, specifically the acquisitive responses at the core of addiction, take time to develop but are slower to decay. Moreover, because of their capacity to operate without conscious awareness or insight, these action tendencies and cognitive biases can be latent vulnerability factors to the reinstatement of addictive behaviour months or years after cessation. In this chapter, I shall first explore the chronicity of addiction from a neurocognitive perspective. As will be seen, addiction casts a long shadow because of the enduring nature of changes to neural reward circuitry linked to a highly repetitious cycle of reward seeking. The following sections explore the implications for treatment planning in a context where on the one hand automatic processing of motivational cues is facilitated, and on the other executive—in particular inhibitory—control is compromised in the longer term.
The chronic nature of cognitive deficits
Clearly, in phases of active substance use, intoxication and withdrawal, inhibitory control is compromised. However, findings that changes to PFC connectivity and structure can endure for periods ranging from 6–9 months to 6 years in, for example, alcohol-dependent people who are largely abstinent have direct implications for the delivery of treatment. Thus, detoxified men with an average of over 26 weeks abstinence and with otherwise good psychosocial functioning can nonetheless register loss of grey matter in neural structures involved in higher cognitive function (Chanraud et al., 2007). Morphological changes were highest in the DLPFC (up to 20%), but were noted also in the temporal cortex, insula, thalamus and cerebellum. Makris et al. (2008) used a broadly similar approach, except that the alcohol-dependent cohort had been abstinent for almost 6 years. They noted volumetric reductions in neural regions associated with reward processing including the right DLPFC, right anterior insula, right nucleus accumbens and left amygdala. These correlated with performance on a working memory task (Wechsler, 1997), suggesting a functional deficit linked to observed structural changes, while amygdala volume correlated with general memory (Wechsler, 1997). Furthermore, nucleus accumbens and anterior insula volumes improved in alcoholic subjects with increasing length of abstinence, suggesting some potential recovery of structural deficits. This coheres with findings from one of the few studies that followed up a community sample of men, over a quarter of whom met the DSM-111 criteria for alcohol abuse at some point in their lives. Vaillant (1996) found that between 28 and 59% of these men, representing a lesser-educated ‘core-city’ and Harvard-educated cohort respectively, were still abusing alcohol at age 60 after up to 20 years biennial follow-up interviews. 11 and 30% of each group was abstinent. Notwithstanding the interesting finding that the ‘city men’ appeared to recover at a much higher rate than the ‘college men’, Vaillant noted that after abstinence had been maintained for five years relapse was rare. It seems plausible that, over several years, increasingly effective cognitive control was both supported by and in turn benefitted from recovering brain function.
Volumetric reductions in grey matter, in the region of 5–11%, have also been observed with other addictions such as cocaine (Franklin et al., 2002) and heroin (Yuan et al. 2009). These structural changes in temporal and cingulate cortical regions were observed, it should be noted, after several months of abstinence. The cohort of 30 long-term heroin users of Yuan et al. had been verifiably abstinent when the density of their grey matter was measured and compared with healthy controls. Moreover, the duration of heroin use inversely correlated with reductions in grey matter indicated by voxel-based morphometry. The ecological or ‘real-world’ impact of the subtle loss of function associated with these morphological changes is open to further investigation. However, given the need for executive control when habits are reversed, any loss of function does not bode well for recovery. In addition to the inhibitory mechanisms vital to overcoming addictive impulses, ‘prefrontal’ processes also include
- emotion regulation
- motivation, indexed by persistence and sustained effort
- insight and interoceptive awareness
- flexible deployment of attention
- decision making and encoding of value (including impaired reward devaluation)
- working memory and goal maintenance
- learning and memory processes such as stimulus–response learning and reward.
Existing cognitive and behavioural approaches to overcoming addiction do not acknowledge the likely negative impact of enduring cognitive impairment on the capacity of the client to process information within session and between sessions. Relapse prevention skills training and allied coping skills approaches proceed, no doubt with the best of intentions, to teach those aiming for abstinence or restraint a range of complex skills. In predominantly cognitive approaches, the person seeking help for addiction is expected to engage and collaborate in the complex process of change at the same level expected of an anxious or depressed individual. While anxiety and depression clearly interfere with cognitive processing, the affected individual does not have the possible pre-existing or consequential range of cognitive control deficits associated with addiction. Many of the procedures that form the basis of CBT are heavily reliant on executive functioning. Anticipating ‘high-risk’ situations and deploying problem-solving strategies require key ‘prefrontal’ competencies such as flexibility in response to changing task requirements, monitoring and updating progress in terms of goal pursuit and suppressing or inhibiting distractions. Granted, extant cognitive and behavioural approaches might compensate for possible cognitive deficiencies insofar as they embody a coaching or mentoring function. However, clients with more intensive or lifelong histories of substance use might struggle to acquire and apply new ways of thinking and behaving, particularly if this is not acknowledged by the therapist and remains unknown to the client.
Apart from directly affecting the ability to acquire and deploy new skills, underlying problems in the cognitive control domain could serve to undermine the therapeutic alliance. In common with implicit cognitive processes, it is the latency of these deficits that challenges the maintenance of change. The cohort of 31 detoxified alcohol-dependent men of Chanraud et al. (2007) were apparently functioning normally in the psychosocial domain. However, they displayed deficits on some neuropsychological tests and of course manifested volumetric reductions in grey matter primarily in the DLPFC and other cortical structures. It should also be recalled that pre-existing deficits in executive control could have been reflected in the anatomical or neuropsychological findings in this study, but the design does not allow for this to be revealed. In sum, maintaining change, here involving repeated suppression of impulses previously given free rein, is undermined by the perseverance of deficits in cognitive control. It appears that cognitive-control deficits that may have increased liability to addiction in the first instance do not simply go away once the treatment plan is signed.
The Importance of Goal Maintenance in the Long Term
In Chapters 3 and 4, I emphasized how exposure to drug-associated rewards can grossly distort the pursuit and valuation of normal rewards in two ways. First, the intensity and contingency of substance-derived gratification competes with, and often achieves ascendancy over, natural rewards such as eating, drinking, sex and social affiliation. However, recalling the experience of Gerald, when drugs such as cocaine become associated with sexual gratification the latter can become compulsive also. Second, even when the initial euphoria no longer ensues, strong stimulus–response learning ensures that the cue will still tend to elicit the response.
The more neurobiological emphasis here is based on evidence of the relatively enduring changes in neural processes as addiction becomes less outcome driven and more stimulus driven. In other words, choice and volition play less of a role as addiction becomes more established. A partial answer is revealed in the following anecdote recounted by one of my clients, Craig, the 37-year-old man with a history of addiction to cocaine and alcohol introduced on p. 120, who described the following episode that occurred after 20 months of abstinence from alcohol and cocaine: ‘I found myself on my bike like I was possessed, cycling along the road where the house I used to go to [to buy cocaine] was’. I asked Craig if he could recall anything else was going through his mind at the time. He recalled the following thoughts: ‘what am I doing’; ‘this is dangerous’; ‘this feels almost nostalgic’. One striking feature of these statements is the passive or observer-like status of the statements. It seemed as if Craig was watching himself carrying out a complex sequence of behaviours that he was unable to disrupt. Moreover, the rather dissociated sequence of thoughts did not seem to fulfil any functional role in mediating behaviour. For example, Craig did not recall thinking that he might feel better, worse or even differently if he used. Predictably, the episode of drug use that ensued left Craig impoverished financially and bereft emotionally. He had, as he saw it, left himself down after sustaining abstinence for almost two years. In an effort to reassure and empathize with him I responded as follows:
You have done really well with your recovery programme so far. What happened to the weekend is unfortunately a common occurrence when we try to overcome in addiction to a drug like cocaine. What seems to happen is that, while the rational and sensible part of you fully recognizes the need to abstain, another part of you, let’s say the more impulsive or emotional parts of your brain, still has not got the ‘quit’ message. This is not a particularly clever part of your brain but what it lacks in intellect it makes up for in persistence! If you’re feeling tired or stressed, which I know you were because of your forthcoming job interview, your impulsive brain can take advantage and get in the driving seat. What I suggest we do next in the session is a debrief about what was happening with you before you found yourself on the way to the crack house…
Craig engaged with the task of identifying the antecedents of his lapse and the session progressed well. He did not have any difficulty with the idea that impulsivity could be expressed behaviourally even though he was fully committed to overcoming his addiction. I believe that invoking a role for involuntary mental processes enabled me to provide a more nuanced version of the lapse reported by Craig. First, more accurate empathy was possible by acknowledging the existence of an impulsive system that remained influential despite his commitment to abstinence. Second, Craig was less likely to make the attributional error of blaming himself for the lapse. Finally, it is worth noting that Craig was reporting incidents of attentional bias, for example the ‘silver paper’ incident described in Chapter 7, even though he had been abstinent for 18 months at this point. As one of his between session tasks I asked Craig to read a copy of the Six Tips relapse prevention handout (see Appendix). The extent to which this cognitive bias subsequently contributed to the lapse into cocaine use remains a matter of speculation. However, it is consistent with the findings of Cox et al. (2002) that the strength of attentional bias following detoxification predicted liability to relapse.
A Neurocognitive Perspective on Relapse
Steve, a 37-year-old builder, was one of my clients who had sustained abstinence from alcohol for five months when attending a day programme and individual sessions of cognitive therapy, recently returned to work after an absence of six months. In the week prior to his return to work he reported only one episode of craving or compulsion. Two weeks following his return to work he attended for the scheduled follow-up session. He described experiencing high levels of craving and compulsion on his return from work each evening. Steve lived alone, having agreed on a temporary separation from his partner while he addressed his alcohol and related problems. He described the recurring compulsions as ‘exhausting’. His coping strategy was to retire to bed about 9 p.m., shortly after eating his evening meal. Prior to returning to work he was maintaining a good daily routine involving exercise such as swimming, running and attending a local gym. Steve also enjoyed cooking and watching DVDs, especially at weekends. After a day at work he believed that he did not have the energy for this, hence the early bedtime. Steve was also heavily indebted due to his alcohol problems.
As his recovery progressed he duly returned to work. His creditors increased their demands for payment and Steve was particularly angry about one demand for rapid payment from a utility company. He described being preoccupied with this, especially when he returned home and opened his mail. Looking at Figure 4.3, Steve appears to be in the top right quadrant with low working-memory capacity and low perceptual load. This is because he was ruminating about his debts (thus absorbing available working-memory capacity) and not engaging in any pursuits that might be stimulating (approximating to a low perceptual load). This provides a formulation for the resurgence of craving and compulsion in the absence of any available triggers or cues in his workplace or in his apartment, which was devoid of alcohol. It also provides a rationale for agreeing on a coping strategy. In the session, we agreed that Steve could accept a ride home from work with a colleague, thus avoiding a 40-minute walk that was his normal routine. This meant that he would be at home earlier, feel less tired and thus be able to either attend the gym or go jogging. The combined effect of these activities would be to free working-memory capacity and increase perceptual loading, in effect moving Steve to the top left quadrant. At a recent six-month review I was delighted to learn that Steve had been abstinent from alcohol since this episode, apart from a relatively minor lapse. He also told me that he had left his job as a building worker and was getting help with longstanding literacy difficulties and planning a career in the personal-fitness industry. Clearly, it is impossible to attribute his progress to any particular factor, but the example illustrates that successful recovery needs to proceed on a number of fronts and at different levels. And it takes time.
Any competent therapist would doubtless derive a similar or comparable strategy. However, the cognitive, formulation-based approach outlined here provides a rationale not immediately apparent from existing CBT or other approaches. More generally, working-memory function could be facilitated by strategies such as goal maintenance or goal rehearsal and implementation intentions. Perceptual loading can be augmented by identifying activities, for example computer games; reading; creative pursuits, that ‘soak up’ attentional capacity that might otherwise be diverted to process addictive cues. But what if there are constraints such as being at work or sitting on a train? Mindfulness meditation appears to be a plausible option insofar as it presumably increases perceptual load. For example, consider this segment from the Awareness of Seeing mindfulness exercise from Bowen et al. (2011; p. 102) and derived from Segal et al. (2002):
Sit or stand in a way that you can comfortably see out the window. Take a few moments to look outside, noticing all the different sites. The colours, the different textures, the shapes. For the next few minutes just see if you can let go of trying to make sense of things in the way that we usually do instead, see if you can see them as merely patterns, shapes, and movement.
According to the theoretical account proposed here, one way in which mindfulness can increase focus and reduce distraction is by increasing the vibrancy and texture of the perceptual world by simply paying attention. Mindfulness training can help individuals become more aware of these processes. The acronym RAIN (recognize, accept, investigate and note) can be applied to foster detached mindfulness of cravings, and as a way to encourage individuals to disengage from habitual or automatic responding. Meditation techniques are addressed in more detail on p.168.
Twelve-Step Facilitation Therapy
The defining feature of the Twelve-Step doctrine must surely be the repetition of the same message followed by sequential recovery steps. Commonly, an individual participating in the 12 steps would attend a meeting with perhaps 20 or more individuals attempting to manage their addiction on a daily basis. Some attend more than one meeting each day. Pursuit of this recovery pathway can begin with 90 meetings in 90 days and continue, on a daily or near daily basis, for many years. Throughout, participants acknowledge the chronicity of their addiction and the requirement to address this on a daily basis or, in the terminology of the Fellowship, ‘one day at a time’. Viewed through a cognitive-control prism, one is again struck by the repetitious nature of the message. This robust goal maintenance, reinforced by rehearsal, is likely to guide cognitive processing and behavioural governance.
Implicit Denial
Consider the following anecdote from a recent clinical encounter. The client was Simon, a 46-year-old man with a 20-year history of intensive alcohol consumption. Simon was a highly educated man with a PhD in history. Unfortunately, his successful academic career was undermined by his escalating alcohol consumption over the years. This had also had a negative effect on his health and interpersonal relationships. He had, somewhat reluctantly, accepted that abstinence from alcohol was the best option for him. In the course of our fourth session he announced that he had been invited to spend a week with some friends in France. The following section illustrates how Simon had rationalized his addiction to alcohol as a matter of choice, negating the implicit assumptions that guided his decision making. At this stage he had maintained abstinence from alcohol for over nine weeks following the completion of an inpatient detoxification. My aim was to encourage him to select goals other than alcohol consumption. This is what he said next:
Simon: I think it’s going to be very difficult for me not to drink when I’m in France. I keep thinking of a cold glass of Chardonnay. Ultimately, despite what they say in AA, I think it is a matter of free choice. I have chosen not to drink for over two months therefore I should be able to choose to have a drink when I go to France. I then intend to choose not to drink when I return to London.
Therapist: I am glad that you brought this issue to today’s session. You’ve done very well not drinking for the past couple of months or so. We agreed last week that there had been significant improvements in your mood, health and general wellbeing. But I can well understand that thoughts about drinking are never too far away, especially when you are reminded of times when maybe drinking seemed more like fun. Can you tell me a little bit more about your dilemma about drinking?
S: Well, when I received the invitation to spend some time in France, I started thinking about wine. You see, I don’t really buy into the idea that alcohol, or any other addiction for that matter, is a disease involving loss of willpower. I chose not to drink a while ago and I fully accept that I needed to, but equally I feel I should be able to choose to have a drink, especially when I am in a different environment, and with friends who drink sensibly.
T: I see. Your point is that you have chosen not to do something so by the same token you should be able to choose freely to do it again.
S: Yeah, something like that.
T: My view is that in general we can exercise free choice in many areas, for example deciding what to wear or where to go to lunch. The picture with addictive drugs such as alcohol is more complicated. It appears that once we’ve been overexposed to alcohol, as we know you have in the past, it seems to bias or distort how we view the world. This can alter the way we make decisions, specifically guiding us back to further drinking.
S: In what way?
T: What actually happened here is that you were invited to spend a week in France with some old friends. Your response, or what seems to be the most obvious response, was to reflect on the remembered pleasures of alcohol and re-evaluate your decision to quit drinking. I know that in the minds of many France is associated with fine wines but there is much more to France than wine! For the sake of argument, can you mention something else about France?
S: Of course, France is the home of haute cuisine and a centre of culture and the arts. It is a large country with beautiful cities and landscapes. It also has a range of climate—which helps make such good wine! Seriously, I think I’m beginning to see what you’re getting at. I’m also meeting up with old friends who I haven’t seen for years, so perhaps there is more to this trip than just wine after all.
T: I fully agree. My point is how quickly you interpreted this invitation as an opportunity to resume drinking. By planting that thought or goal in your mind, the likelihood of you drinking again is increased. Going back to the issue of free will I would say that, while you are still a free agent, the range of options you have arrived at has at the very least restricted your free will. Instead of a wide range of options it seems to have narrowed down to a question of ‘to drink or not to drink’. I would suggest that, paradoxically, choosing to drink when you visit France demonstrates a lack of free will rather than the expression of free choice.
S: You mean that I reduced my options and my room for manoeuvre. But what should I do now?
T: First, you need to recognize that you have not made a mistake or done anything wrong: it’s just your mind doing what it is trained to do, or what you have become used to doing! For many years seeking out alcohol was the thing to do, so that is the ‘default’. The best way to manage the situation now is to identify other goals, especially ones that you will find engaging or rewarding. Any ideas?
S: Well, I’ve never been to the top of the Eiffel tower, and I will be only a hour away from Paris by train. I also want to see some modern art in Paris, and of course check out some restaurants.
COMET: continuous outcome monitoring while engaged in treatment
In the CHANGE model, outcome is continuously monitored (i.e. session by session) across two central domains: addiction and emotional wellbeing or absence of distress. The latter domain is clearly the more diverse and likely to encompass numerous specific indicators of therapeutic gain such as improved quality and quantity of sleep, less anger or more harmonious relationships. For the most part these issues are linked to, or indeed index, emotional dysregulation. For example, recall Kevin, the 47-year-old man introduced in Chapter 6, who reported chronic problems with low mood, worrying and insomnia. He initially progressed with a significant decrease in frequency and intensity of excessive alcohol binges. From a baseline of 20–30 units two to three times a week, with examples of more restrained drinking in evidence also, Kevin constrained himself to about 3–5 units daily with one or two days alcohol free. Sleep and mood improved (anxiety ratings reduced to ‘mild’ from ‘severe’ and depression reduced to ‘moderate’ from ‘severe’), although Kevin did not meet the criteria for major depressive disorder in any event. Sleep had also improved insofar as Kevin reported two or three good nights’ sleep each week and less worrying about the perceived negative consequences of insomnia. After 20 sessions spread over 14 months it was agreed to pause, and a follow-up date agreed for three months hence. The continuous monitoring served two purposes. First, and most obviously, it enabled both Kevin and I to evaluate progress and be better able to adjust the intensity and focus of therapy. Second, and perhaps more subtly, it fostered goal maintenance in working memory (in fact for both parties!). By anticipating that he would be asked about his drinking, in particular, Kevin had a rationale for maintaining his goal of moderation.
Rationale for continuous feedback
Consider this statement and the ensuing discussion with a client who I saw recently:
Client: I failed again, I simply was not able to stop drinking. Of course when I was drinking last weekend I phoned my dealer and got 2 g of cocaine. That took care of the weekend and I had to phone in sick to work on Monday.
Therapist: I’m glad to see you in the clinic today. It’s important that you make it along to these appointments whether things have gone well or not so well between sessions. It sounds like you have had problems at least some of the days in keeping to the goal we talked about earlier on. Was that the time that you used?
Client: I shared a bottle of wine with my partner at home on Wednesday, but it was last Friday when I went out after work that I drank more heavily.
T: Okay. So, including the weekend scene that you just mentioned, on how many days did you have any alcohol or cocaine in the past week?
C: Let me think—on Friday I had four or five beers and then I phoned Gary because I knew he would have some coke. We met in the bar, had a few lines [of cocaine] and carried on drinking until about midnight. We then went to a club, had some more coke and a few shots of vodka. I think I got back home about 5 a.m. I stayed in bed most of Saturday but when I got up I drank some wine and had some more cocaine. I then went out to the bar and had some more beers. This wasn’t such a late night but I was due to pick up Jason, my little boy, from my ex-girlfriend’s on Sunday and spend the day with him. I really didn’t feel able to do that. Joanne, my ex, has warned me that she does not want me looking after Jason if I’ve been partying at the weekend. So I had to phone her and say I wasn’t feeling well enough on Sunday to look after Jason. I’m sure she knows that it was all self-inflicted, although she didn’t accuse me directly of using.
T: In the circumstances, you didn’t really have much choice but to cancel Sunday, although I know this would not have made you feel good about yourself. But just staying with the substance issue for the moment, it seems that you used only three days of the past seven. I appreciate that things didn’t go well at the weekend but you’re getting it right more days than you’re getting it wrong.
C: It just doesn’t feel like I’m getting it right most of the time! I seem to have no control when it matters the most.
T: I agree that it does seem in particular situations you seem to reach a stage where there is no going back. I think it would be helpful to go back over the lead-up to last Friday’s episode. The aim here would be to help you to anticipate and be more prepared to cope if you find yourself in a similar situation again. One simple technique that has been proved useful in research trials and in practice is to plan in advance precisely what to do if you are in a situation where there is a risk of using, based on past experience. For example if someone often drank too much wine before dinner, they would come up with something like: ‘If I really want a drink then I will prepare dinner a bit earlier and have a glass of wine with the meal’.
Providing feedback in a neurocognitive framework
In a situation where the client has been unable to maintain the goal of abstinence or restraint it is helpful to restate that addiction is essentially a disorder of impulse control, for example
Therapist: In one sense, what happened to you at the weekend was almost inevitable: in a particular situation, such as being in a bar and consuming alcohol, wanting to have cocaine is bound to happen. It’s a bit like seeing the red stop signal too late to give yourself a chance to stop. That is why your treatment programme here emphasizes looking ahead or forward planning. This means that there is little point in playing the blame game but that doesn’t mean you are ‘completely off the hook’! What I’m saying here is that once there was a real prospect of getting your hands on some cocaine it would have taken more willpower than you, or most other people for that matter, would be able to summon up. But that makes it all the more important for you to scan the horizon well in advance so you have more time to avoid situations like this altogether, or cope with them when they occur. With the benefit of hindsight, is there anything you could have done differently to maintain your agreed goal: not using cocaine?
Client: Going to that particular bar and drinking that amount of beer was a big mistake. I actually did a deal with myself, telling myself that I somehow ‘deserved’ a few drinks because I worked hard all week and I was staying away from the coke. But after four or five beers I really felt like a line or two.
T: It sounds as if at that stage you had forgotten your earlier resolve and your goal of not using cocaine. As I said a moment ago, it would have been especially difficult to put the brakes on at that stage. But the question is what can you do that’s different when, say, you finish work next Friday?
C: Well, it’s a no-brainer, I could go straight home! But that would make me miserable, I mean going back to an empty apartment. Since I separated from Joanne it seems quite lonely and of course I miss Jason a lot although he would usually be in bed by the time I get home.
T: I know. That must be one of those times when you feel that you have lost a lot over the past few months. But I remember when Joanne came to one of the sessions early on she seemed be keeping an open mind about your future together. She said that the main problem in the relationship was your drug-using lifestyle, which I suppose is a reminder that we have work to do. As we agreed last week the best way forward is for you to gain more control over your drug use. So, looking ahead to Friday are there any options other than a possibly lonely night in or a night out in the pub where you might be made an offer you can’t refuse?
C: I got an e-mail out of the blue from an old school friend the day before yesterday and he suggested that it would be good to meet up and maybe go for something to eat.
T: It sounds like a good idea. Might I ask whether your friend was part of your cocaine using network or was that before you started using?
C: You’re right, Steve was never into any of the clubbing party scene.
T: Right. So what did you say in your reply to Steve’s e-mail?
C: He e-mailed me his number and I said I would phone him.
Meditation techniques
Meditation techniques aim to enhance the regulation and monitoring of attention. In this text, with its emphasis on cognitive control, I have attempted to create a coherent framework within which meditation can be practised. Lutz et al. (2008) outlined a neuroscientific framework for the practice of meditation, which they conceptualized as ‘a family of complex emotional and attentional regulatory strategies developed for various ends, including the cultivation of well-being and emotional balance’ (Lutz et al., 2008, p. 163). They proposed two broad styles of meditation, focused attention (FA) and open monitoring (OM). These styles, found in several meditation traditions such as Zen and Vipassana, are often combined either within a given session or perhaps in the course of a practitioner’s learning processes. FA meditation techniques include
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