Those who have been exposed, perhaps repeatedly, to adverse or uncontrollable life events are prone to developing emotional disorders consequentially. These experiences are often linked historically to parental or familial substance misuse or mental health issues. This subgroup will typically present for treatment to a specialist addiction or mental health treatment facility as adults reporting a range of emotional, behavioural and interpersonal in addition to substance-related problems. Weaver et al. (2003), for example, found that, in drug-using clients in treatment for their drug (nonalcohol; N = 216) misuse, 75% met criteria for one or more co-occurring mental-health conditions in the year prior as follows:

• 8% psychotic disorder
  
• 19% severe anxiety
  
• 26% severe depression
  
• 37% personality disorder
  
• 40% minor or mild depression.

For people in treatment for alcohol dependence and related alcohol problems (N = 62), 86% met the criteria for one or more comorbid mental-health problems as follows:

• 19% psychotic disorder
  
• 32% severe anxiety
  
• 34% severe depression
  
• 40% minor depression
  
• 53% personality disorder.

Conversely, 44% of attendees at Community Mental Health facilities who were also screened for psychiatric and substance-related problems reported problematic drug and alcohol use within the previous year. Coincidentally, this epidemiological study was carried out in part in a London clinic where I worked at the time. Consistent with this, my current caseload (in another London clinic) includes individuals with social anxiety disorders, generalized anxiety, sleep disorders, posttraumatic stress disorder, obsessive–compulsive disorder, anger management problems and a spectrum of depressive conditions ranging from acute clinical depression to dysthymia. In a recent clinical audit using the Personal Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001), 80% of 120 adults in local substance misuse clinics reported significant levels of anxiety and depression. 20% of these fell in the severe range as indicated by scores on the PHQ-9. These data from a locally recruited convenience sample are consistent with findings of the COSMIC study. Overall, the high level of concordance between mental-health problems and addictive disorders indicates that there is a need to offer empirically supported intervention to enable these patients to acquire emotional control strategies. The CHANGE model reflects the fact that these problems tend to become interdependent as part of a complex, self-perpetuating system. Accordingly, the care pathway needs to be integrated, with impulsivity and emotional distress addressed in sequence.

For example, I was recently referred Nigel, a 35-year-old man who had been sexually abused in childhood by an older sibling. His appraisal that he was complicit in this episode, which lasted over two years between the ages of 9 and 11, was associated with shame, guilt and self-loathing. As an adult in his 20s, Nigel formed a stable and loving relationship with another man who sadly died of natural causes. In the succeeding decade he did not become involved in any long-term relationships but on a weekly or near-weekly basis he engaged in brief sexual encounters with other men, invariably when he was intoxicated by alcohol and cocaine. This placed his health and personal safety at risk, as well as reactivating distorted beliefs associated with the historic sexual abuse. When intoxicated, he tended to engage in unhelpful reveries about his deceased partner, which led to depression and suicidal ideation. These problems occurred in the context of chronic insomnia. This contributed to an unhelpful dynamic whereby alcohol and cocaine were used as short-term palliatives. This led to continued mood disturbance and insomnia, but more worryingly contributed to Nigel engaging in risky sexual encounters. Nonetheless, Nigel’s career went from strength to strength and over this period he was promoted to marketing manager for a multimedia company. After about 12 face-to-face sessions marked by some success but also setbacks I summed up as follows:

I know that things have been particularly difficult for you over the past few weeks, even though you’re working hard to move things on. You’ve also taken on an exciting but challenging role at work. So, while there are many positives I do also appreciate how complex and sometimes frustrating your emotions are. That said, I believe that we need to prioritize and focus on just two things, your willpower in the face of alcohol and cocaine and the negative feelings that often set the scene for problems in this regard.

First, then, we need to look at ways to help you regain more control over your drinking. That really is the key because when the alcohol comes into the equation it sets the scene for more risky behaviour with cocaine and less control over the sexual impulses. It was concern about these risks that prompted you to seek out this referral a few months ago.

Second, we need to look again at how you can manage your daily negative feelings such as shame and depression. If we agree on these priorities I am confident that we will see improvements in your quality of life, especially with regard to improved sleep. Along these lines, as an agenda for today’s session I suggest we review the couple of situations you mentioned at the outset where you found yourself not really in control of your actions. I think one was your friend’s birthday party and the other was that Friday night when you when you went out with the crew from work and partied until 3am.

More detailed discussion of the antecedents of Nigel’s excessive use of alcohol and cocaine, which in turn were precursors to high-risk sexual behaviour, revealed the following:

• Nigel was very self-controlled for most of the week, exercising in the gym in the morning before work and meditating in the evening. Typically, he did not drink alcohol between Sunday and Thursday.
  
• He believed that he would be perceived as aloof or distant by his work colleagues if he did not participate in the Friday evening outings.
  
• He felt exhausted by the demands of his high-pressure job by the end of the week.

This exploration of the context and triggers of the problem behaviour led directly to an anticipatory coping strategy incorporating the following elements.

First, Nigel was encouraged to re-evaluate his somewhat austere lifestyle during the working week. Specifically, he identified opportunities for more social interaction during the week, for example agreeing to dine out with friends or simply go out alone to see a movie or a play in keeping with his well-developed cultural preferences.

Second, Nigel reappraised his beliefs about whether his absence from the Friday night sessions would be interpreted as some form of social exclusion. He considered that, if anything, his absence could be perceived as evidence of being socially engaged, but elsewhere! However, we agreed that occasionally, say once or twice a month, Nigel would join his colleagues for a drink. The goal was that he would only remain in the group and to have no more than two standard drinks. This was agreed in the form of an implementation intention as follows: ‘If I decide to join my colleagues for a drink on a Friday evening I will make my excuses and leave after an hour’. The collateral goal of consuming no more than two alcoholic drinks was deemed to be implicit in this plan. In the course of the following six months Nigel found it easier to regulate his drinking and subsequent sexual impulsivity was reduced. There were only two episodes of alcohol excess reported, one of which was associated with risk although no harm subsequently occurred.

In keeping with the sequencing of the CHANGE programme, the initial focus on the management and reversal of habits paved the way to address the underlying emotional issues. As referred to above, these were associated with protracted inappropriate sexual interaction with a sibling, who was three years older than him, when he was aged 9–11. Consequential feelings of shame were mediated by Nigel’s beliefs that he was complicit in this, together with guilt arising from the sensory pleasure he derived from the sexual activity. In turn, this appears to have made it more difficult for him to adjust the death of his partner, which occurred when Nigel was aged 27. Moreover, his single lifestyle created a more enabling context for the impulsive behaviour that ultimately proved to be the trigger for him to seek professional help. Nigel proved to be an excellent candidate for cognitive therapy designed to correct his faulty beliefs and attributions. For example, he re-evaluated his beliefs that assigned him culpability for what he now saw as unwanted sexual interaction that occurred in the absence of appropriate parenting or safeguarding. He recognized that this reflected a ‘hindsight bias’ based on the moral values of his adult persona rather than those he would have likely held as a child. The recurring episodes of sexual impulsivity served to reinforce Nigel’s view of himself as morally deficient, providing further justification for targeting this as a therapeutic objective.

Individuals without pre-existing genetic or neurobiological predisposition to negative affect can nonetheless develop a prevailing negative affective state due to the effects of repeated self-administration of drugs on key neurotransmitters such as dopamine and serotonin. In Chapter 4 this was aptly characterized as ‘the dark side of addiction’ (Koob and Le Moal, 1997). This includes loss of motivation, dysphoria and irritability, probably rooted in alteration of function in the neurochemical systems mentioned above. Symptomatically, individuals presenting with this syndrome might be comparable to those with more established emotional comorbidity. A different formulation and treatment plan is needed in this case, with less intensive treatment required. Third, in addition to more enduring negative affect, negative emotional states can be triggered by setbacks on the road to recovery, that is, resuming drug use or emergence of compulsive behaviours such as gambling. Marlatt and Gordon (1985) described this as the ‘abstinence violation affect’ or ‘rule violation affect’. Driven by negative attributions and cognitive errors such as labelling oneself as a failure, this negative emotional state containing elements of shame or guilt can motivate further addictive behaviour. A lapse or a slip, for example an abstinent smoker or drinker resuming smoking or drinking on one occasion, can thus spiral into a full-blown relapse. The following vignette illustrates the reciprocal relationship between affect and addiction.

Anthony is a 36-year-old man with a history of substance dependence dating back to his late teens. When I saw Anthony last month for initial assessment he was drinking alcohol episodically and excessively. He told me that two days prior to our meeting he had consumed the equivalent of 30 standard units of alcohol starting in a bar and continuing at home alone. As a child, Anthony recalled being regularly beaten by his father. He described feelings of dissociation whereby he felt ‘like a piece of meat’. He said he was feeling anxious and depressed and scored 21 and 19 on the GAD-7 and PHQ-9 respectively. We agreed that the priority was for Anthony to resume abstinence from alcohol. When Anthony was seen again two weeks later his scores had reduced dramatically to 5 and 4 on the respective mood rating scales. He told me that he had stopped drinking several days after our first meeting. We explored potential targets for therapeutic intervention. Increasing self-esteem emerged as a priority. For example, Anthony tended to discount his achievements such as successfully acquiring a university degree through part-time study despite a negative emotional legacy from childhood and chronic substance misuse. This problem could be addressed using standard techniques such as maintaining a diary of positive events and attainments and correcting attributional bias that appeared to minimize his own considerable contribution to his achievements. Note that if high levels of alcohol consumption had continued an entirely different therapeutic objective—emotional regulation—would probably have been agreed. The primary anhedonic effects of substance misuse should not therefore be overlooked. In the above example the underlying vulnerability was not a primary deficit in emotional regulation skills but deficits in self-esteem and self-worth. Without doubt, these originated in the invalidating experiences of parental abuse and contributed to vulnerability to subsequent addiction.

Clearly, compromised self-esteem can contribute to emotional dysregulation but the more dramatic impact of current substance use on emotional tone should never be underestimated. Addressing underlying vulnerability will therefore be necessary but usually insufficient in pursuit of a good outcome. Negative emotional states accentuate cue reactivity and increase the incentive value of appetitive cues. Deficits in self-image or self-esteem can also engender vulnerability to substance use and dependence. Negative affect is often a precursor of resumed drug use and can also serve to exacerbate episodes of drug use by transforming a lapse into a relapse. Negative emotional states compromise cognitive control and increase competition for access to scarce resources such as working memory. Thus, an anxious individual will either perform less efficiently on a given task or have to apply more compensatory effort to obtain an outcome equivalent to that of the nonanxious performer. According to Eysenck et al. (2007; p. 336), ‘anxiety impairs efficient functioning of the goal-directed attentional system and increases the extent to which processing is influenced by the stimulus-driven attentional system’. The cognitive-control perspective espoused here assumes that craving has a similarly compromising effect on cognitive control. Consequently, therapeutic intervention needs to reverse this, that is, increase the efficient functioning of the goal-directed attentional system and decrease the influence of the stimulus-driven system. In a word, negative emotions, and states such as craving, are taxing. In addition, craving can impair cognitive efficiency by capturing cognitive control systems such as working memory (Madden and Zwaan, 2001).

There is thus a strong case to be made for providing addicted people with an opportunity to learn emotional control strategies if they are aiming to overcome addiction. As a guide to terminology, the term ‘mood’ is used in the CHANGE model to signify a range of common mental-health problems where emotional distress combined with poor coping mechanisms is in evidence. While addiction is, of course, associated with a spectrum of co-morbid psychological and psychiatric disorders, anxiety and depression are either primary or secondary components in many cases. Accordingly, while the main focus of this chapter is on these common examples of negative affect, other emotions such as anger, shame or guilt are also implicated. In the following sections I shall outline a stepped-care framework for addressing emotional disorders and other mental-health problems. The rationale is that only a subset of clinic attendees will need formal or intensive psychological therapy such as CBT. Further, the decision on the level and intensity of any intervention can only be made once substance misuse has been addressed, as this is often accompanied by a significant reduction in dysphoria. Negative emotions interact dynamically with addictive behaviour.

For people recovering from addiction sudden or unexpected negative emotions can also increase liability to relapse. Anecdotally, I can think of several incidents where a parent who had made excellent progress during supervised treatment for an addictive disorder lapsed or relapsed immediately prior to a decision been made as to the suitability to resume parenting. Apprehension at facing a formal hearing about one’s future as a parent is surely a candidate for triggering stress that made a lapse or relapse more likely at a critical time. Recall the study by Shiffman and Waters (2004), cited in Chapter 1, that indicated abstinent cigarette smokers were more likely to relapse after sudden upsetting incidents such as an argument with a partner rather than more enduring negative affect prevailing in the days prior.

Stuart, a 35-year-old man with a history of intensive alcohol use to the point of dependence who sustained abstinence for 10 weeks following detoxification in an inpatient unit is a case in point. He was also on extended leave from work in order to address his alcohol problems and appeared highly motivated and committed to remaining abstinent. Stuart did not report any adverse or traumatic events in childhood, adolescence and adulthood. He said he had enjoyed childhood and loved sports. There was no evidence of concurrent emotional or psychiatric disorder. He had separated from his girlfriend by mutual agreement because of his drinking. They met to discuss their future and an argument ensued. Joe thought that it was too early for them to resume the relationship and he felt pressured. He became angry and reported thoughts such as ‘I’ll show her’ (Stuart explained that this meant he thought she did not realize how much of a struggle it was for him to remain abstinent and how vulnerable to relapse he was) and within the hour had purchased 24 cans of lager and proceeded to drink.

The next day, he awoke from an alcohol induced sleep on his sofa feeling physically and emotionally devastated. His thoughts on this occasion focused on failure: ‘I’ve blown it; despite all my hard work I screwed things up again’. He described his mood as depressed, ashamed, angry (at himself) and anxious that he might have a neurological seizure of the type he had previously experienced. He felt too ashamed to contact the Treatment Centre to speak to me or his key-worker. He went to the refrigerator and retrieved one of the few remaining cans of beer and drank it. He then bought more lager and drank it but then stopped the following day. He continued to be negative and despairing and resumed drinking the following weekend. He became very fearful that he would have an alcohol withdrawal seizure. He contacted the emergency services claiming he was suicidal, although his main concern was acute alcohol withdrawal problems. He was admitted to hospital, where he received medical attention. He subsequently re-engaged with the Treatment Centre and the opportunity to reflect on the course of events arose. Clearly, a range of negative emotions influenced the course of events at critical stages. Anger was instrumental in the first lapse, with more negative affect such as depression, shame and anxiety being subsequently implicated.

So, bearing in mind that resources are always constrained, what is the best way to respond to the somewhat diverse needs of the community of treatment-seeking people with addictions? On the one hand, perhaps the majority of clinic attendees will have more transient emotional distress possibly linked to recent substance misuse and associated psychological and social problems. On the other hand, a significant minority will have more established and probably chronic emotional disorders that need more intensive psychological or pharmacological treatment. This will include individuals characterized as having personality disorders. In a substance-misuse setting, common problems that I have encountered include high levels of impulsivity or dissocial behaviour and chronic emotional instability, often accompanied by a propensity to self-harm and expression of suicidal impulses and actions. Here, I do not intend to focus particularly on these complex presenting problems. I would, however, point out that acquiring the emotional regulation skills profiled as part of the CHANGE programme is likely to confer some benefit on people with these more enduring difficulties.

In the UK, albeit in more general health and mental-health rather than substance misuse settings, the answer to this question has been to instigate a system of ‘stepped care’, which essentially attempts to calibrate the level and intensity of therapeutic intervention to the chronicity and severity of the presenting problem. A graduated response such as this will be familiar to many in the addiction-treatment community, as addictive disorders vary considerably in chronicity and intensity. As the CHANGE framework is designed for those with more severe addictive disorders but variable degrees of associated emotional or mental-health problems, the stepped-care approach is more relevant to the latter.

Stepped care is a cost-effective and parsimonious system that calibrates the level and intensity of intervention to the severity of the presenting problem. In the context of substance misuse, where emotional tone fluctuates widely, it is important to have a measured response, usually beginning with a less intensive intervention. Because of the dysphoria associated with excessive use of alcohol and other drugs, it is also important to assess emotional functioning longitudinally. This is of course one of the tenets of the CHANGE approach, which invariably addresses substance use in advance of emotional disorder. So when can an authentic judgement be made regarding an individual’s mental health or emotional status? There is no simple cut-off point, but clinical judgement would suggest that, at the very earliest, any medication used for detoxification (such as benzodiazepines) should have been discontinued. In most cases however clinical judgement will inform the decision based on factors such as the personal history, for instance exploring vulnerability factors or a possible history of mental-health problems preceding any current substance issues. If it seems clear that substance misuse is the primary problem relatively little intervention is required to augment emotional control. For example, if there is a clear link between the experience of anger and alcohol use, anger management strategies need to be identified and implemented. What needs to be borne in mind however is that the primary therapeutic objective is to regulate the impulsive alcohol use in the first instance. Viewing the anger as the primary focus of therapy can detract from this.

Interventions aimed at improving emotional regulation should be routinely offered to those aiming to overcome addiction. The CHANGE model ensures that this is delivered as part of a formulated treatment plan, and consequential to tackling addictive impulses. A ‘stepped-care’ approach is proposed, in keeping with recent developments in the United Kingdom aimed at improving access to psychological therapies to the general population. The aim of stepped care is to apply the principle of optimal intervention. This means that the individual gets no less and indeed no more therapeutic intervention than required. In practice, this usually means that briefer, less intense interventions such as guided self-help procedures are deployed in the first instance. In the event of a good therapeutic response, this could be sufficient, but in many cases intervention would need to be ‘stepped up’, say to a more formal cognitive therapy protocol, or other approaches such as pharmacotherapy.

A guiding principle of the CHANGE approach is that restraint or stability needs to be attained in relation to substance misuse in advance of engaging in therapeutic intervention to address pre-existing or co-morbid mental-health problems. Some years ago, a 35-year-old woman had developed posttraumatic stress disorder (PTSD) stemming from experiences of being sexually abused as a child. She was also a daily excessive drinker with features of alcohol dependence. She was attending my clinic to address her alcohol problems but was seeing a clinical psychologist in a neighbouring mental-health team to address the psychological problems such as PTSD. It emerged from her weekly ‘drink diaries’ detailing alcohol consumption that her heaviest drinking days occurred following therapy for her PTSD. Her way of coping with the upsetting emotions evoked by revisiting her traumatic past in therapy was to drink excessively. While this perhaps illustrates uncoordinated care planning as much as anything else, it does serve to emphasize the importance of achieving stability or abstinence in the face of unregulated substance misuse before embarking on more intensive therapeutic intervention.