Overview of Psychological Theories of Addiction and Recovery

28th January 2013Dr Jenny Maslin, Lambeth CDAT

Structure

•Today – How Psychology, as a discipline, plays a major role in understanding addiction recovery and treatment, via

– Some discussions– Some models– Introduction to rest of series

Discussion

What are the factors that influence people’s use of substances?

What factors?

• Situational factors (availability, price, environment/acceptability, encouragement, learning (family/friends, culture)

• Personal factors (to meet personal needs and dispositions, identity, meaning in relationships)

• Adaptational Factors (physical, belief or lifestyle adaptation)

• Bio/Psycho/Social Models

Edwards, G., Arif, A. & Hodgson, R. (1981). Nomenclature and classification of drug- and alcohol-related problems: A WHO memorandum. Bulletin of the WHO, 59 (2), 225-242. Memorandum Bulletin of the World Health Organization, 59 (2): 225-242 (1981)

Example of psychological processes integrated into general model

PRIME Theory and the structure of human motivation

West 2005 Theory of Addiction; West 2013 Models of Addiction

Psychological Theories of Addiction & Recovery

• Developmental theories of addiction (eg. Beck et al. (1993) Cog Therapy Model)

• Theories of motivation (eg. West (2006) Prime Theory)• Theories of change (eg. Prochaska, et al. (1992) Spiral of

Change; Miller and Rollnick (2002) Motivational Interviewing• Theories to explain relapse and desistance (Marlatt and

Gordon (2005)• Theory driven interventions to treat addiction and promote

recovery, ie. “psychosocial interventions” (mapping, structured advice, goal setting, problem solving)

Other lectures in module..

– Psychodynamic Approaches (Today)– Family Therapy (Today)– Motivational Interviewing (Today)– Relapse Prevention (29/1/2014)– CBT Overview & Interventions (29/1/2014)– Mindfulness (29/1/2014)– Contingency Management (30/1/2014)

www.skillsconsortium.org.uk

Recovery as an Organising Paradigm for the Addiction Treatment Field - Phases of treatment

Recovery: Recovery Capital

• Building recovery capital (White & Cloud, 2008) through self assessment and objective setting in various domains

• Domains may include: physical health, employment, finances, legal, family, social life, substance use, education and spiritual domains

• Best predictor of likelihood of sustained recovery is extent of ‘recovery capital’ (Granfield & Cloud, 2001)

Lambeth Access to Community Services Team

• Stand alone team, partnership between statutory and voluntary providers

• Aims and Objectives– To provide ‘Recovery’ support to service users throughout

their treatment journey– To provide ‘Aftercare’ support to clients in recovery

following a period of treatment either in prison or in the community

– To oversee a group programme

Lambeth Access to Community Services Team – Activities

• Facilitate a weekly Recovery Space for clients in treatment to discuss additional recovery support (eg. self help groups, access to residential treatment, groups etc)

• Dedicated Group Worker – developing and co-ordinating referrals to groups across the Borough

• One to one Aftercare support (employment advice, housing/benefit advocacy, psychological support, self care skills, leisure activities, RP support, training/education, voluntary placements)

• Weekly lunch event at local café– Service user led creative writing/drama and art workshops.– Tenancy Support workers operate a weekly benefits/housing advice surgery

• Service User involvement • Complementary therapies: reflexology, Indian head massage and auricular

acupuncture.• Psychological assessment to effect referrals to appropriate talking therapy• Financial support via Grants• Prison Link Worker• Family Engagement Worker

Psychological Processes in Recovery?Identity Shift Theory (Kearney & O’Sullivan, 2003)

Distressing accumulated evidence

Longstanding values, goals

Taking a hard look at self

Redefining self in situation as incongruent with values, goals

One small step

Taking tentative action toward change

Seeing self in new light

Increased self awareness

enables revision of ID toward

lasting change

Walking the walk, talking the

talk

New behaviour is solidified and

expanded over time

Identity Shift Theory - Constraints (Kearney & O’Sullivan, 2003)

Distressing accumulating evidence

Longstanding values, goals

Taking a hard look at self

One small step

Seeing self in new light

Walking the walk, talking the talk

Constraints to redefinition•Need for stability•Perceptual impairment•Accommodating personal norms•Chaotic life•Social isolation•Threats from others•Social rewards for status quo

Constraints to ID change•Incongruity of behavioural results with desired self•Low importance of new ID•Lack of confidence in new ID•Social pressure for new ID•Lack of associates congruent with new ID

Constraints to behaviour change•Burden of new behaviours•Presence of temptations•Lack of alternatives•Lack of knowledge/experience•Lack of satisfactory results•Stressful events, need for solace•Social pressure

Identity Shift Research• “Even quite profound changes in evaluations of the addictive

behaviour will not lead to sustained change unless they propagate to other core beliefs including sense of identity as well as habitual thought patterns, feelings and impulses” (West 2006, p. 187)

• Natural change literature (Best et al., 2006) discusses ‘Addict Identity’ (Stall and Biernacki, 1986)

• Kellogg (1993) – Common features in ID change across 3 types of treatment

• McIntosh and Mckegany (2000) Importance of constructing and defending a new “non addict” identity by creating a gap between selves and past and fill with rewarding role and relationships which stiffens resolve

• IPA Study of Alcohol and the Self/Identity (Shinebourne and Smith, 2009)

Conclusion

Psychology is at the cornerstone of understanding and treating substance use

problems from specific behavioural concepts (which are not necessarily amenable to

conscious awareness) to broader concepts of identity and beyond…

Matching Treatment to Stage of Recovery (Wanigaratne and Keaney, 2002)

Psychotherapy Drug free/maintained

CBT (Relapse Prevention) and counselling Reducing use/maintenance

CBT (Motivational Interviewing) Stable/continuing to use

Behavioural Approaches Chaotic/severe problems

References • Beck, A.T., Wright, F.D., Newman, C.F. and Liese, B.S. (1993). Cognitive Therapy of

Substance Misuse. New York: Guilford.• Best, D., Day., E and Morgan, B. (2006). Addiction Careers and the Natural History of

Change. Research Briefing: 20, London: NTA.• Granfield, R. and Cloud, W. (2001). Social context and “natural recovery”: The role of

social capital in the resolution of drug-associated problems. Substance Use and Misuse, 36, 1543-1570.

• Kearney, M.H. and O’Sullivan, J. (2003). Identity shifts as turning points in health behaviour change. Western Journal of Nursing research, 25, 134-52.

• Kellogg, S (1993). Identity and Recovery. Psychotherapy, 30 (2), 235-244.• Marlatt, G.A. and Donovan, D.M. (2005). Relapse Prevention: Maintenance

strategies in the treatment of addictive behaviours. New York, Guilford Press. • McIntosh, J. and McKeganey, N. (2000). The recovery from dependent drug use:

addicts’ strategies for reducing the risk of relapse. Drugs: Education, Prevention and Policy, 7 (2), 179-192.

• Miller W.R. and Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd Ed). New York: Guilford Press.

References cont…• Prochaska,J.O, DiClemente, C.C. and Norcross, A.C. (1992). In search of how

people change: Applications to addictive behaviours. American Psychologist, 47, 1102-14.

• Shinebourne, P. and Smith, J. (2009). Alcohol and the self: An interpretative phenomenological analysis of the experience of addiction and its impact on the sense of identity and the self. Addiction Research and Theory, 17 (2), pp 152-167.

• Stall., R and Biernacki, P. (1986) Spontaneous remission from the problematic use of substances: An inductive model derived from a comparative analysis of the alcohol, opiate, tobacco and food/obesity literatures. The International Journal of the Addictions, 21, 1-23. West, R. (2006). PRIME Theory of Addiction. Oxford: Blackwell Publishing.

• Wanigaratne, S. (2006) Psychology of Addiction. Psychiatry, 5:12, pp 455-460.• Wanigaratne, F.S. and Keaney, F. (2002). Psychodynamic aspects of relapse

prevention. In M. Weegmann and R. Cohen (Eds), The Psychodynamic of Addiction. London: Whurr Publishers.

• White, W. and Cloud, W. (2008). Recovery capital: A primer for addictions professionals. Counselor, 9(5), 22-27.