From: Chapter One, "Theories of Addiction and Implications for Counselling" by Alan C. Ogborne, in Susan Harrison and Virginia Carver eds., Alcohol & Drug Problems: A Practical Guide for Counsellors (© 2004 CAMH)
Three types of psychological factors will be discussed: (1) personality traits, (2) psychodynamic processes and (3) learned cognitions and behaviours.
Hundreds of studies have searched for differences between people who have substance use problems and other people. In general, these studies do not support the notion that people with substance use problems have different personalities than others and, in the early 1970s, one expert called for an end to this type of research, at least in the alcohol field (Keller, 1972). He also proposed “Keller’s Law,” which states that whatever trait was considered, the results would show that alcoholics have either more or less of it!
Personality research has, however, continued, and several studies have sought to identify personality characteristics associated with the onset of heavy drinking and other drug use in adolescence. The results suggest that such use is more common among adolescents who show pre–drug use signs of one or more of the following: rebelliousness, other adjustment problems, depression, sensation seeking (Kandel & Yamaguchi, 1985; Stein et al., 1987; Shedler & Block, 1990).
However, no specific pre–drug use traits or clusters of traits have been shown to fully account for the onset or maintenance of drug use in adolescents or others.
There is evidence for common pre-drinking personality traits in one type of problem drinker (Allen, 1996; Molina et al., 2002). These are people who have alcohol problems from an early age (late teens or early 20s) and strong antisocial tendencies. Evidence also suggests that such people have a genetically determined brain disorder involving the prefrontal lobes (Tarter et al., 1988). The relevant neurological disturbances may involve the brain’s “executive” functions of planning and goal formulation, persistence, self-monitoring and self-evaluation. These disturbances manifest in:
- attention-deficit disorders
- childhood hyperactivity
- pre-alcoholic essential tremor (a neurological movement disorder that most commonly affects the hands)
- low academic achievement
- lack of inhibition
- emotional instability
- antisocial and psychopathic tendencies.
These traits can find expression through heavy drinking and a preference for companions who drink heavily. Although there is less relevant research on people who use drugs other than alcohol, similar neurological disturbances may occur in some people who use heroin and cocaine. Users of alcohol and other drugs with these personality traits may benefit from training in coping skills, self-control and relapse prevention (Ball, 1996).
The relationship between substance use problems and various types of mental illness has been considered in a number of studies (Miller, 1994; Health Canada, 2002). One U.S. study (Reiger et al., 1990) of 20,291 people living in the community found that over 50 per cent of those who qualified for a diagnosis of drug abuse also had one or more mental disorders at some point during their lifetime. Most common were anxiety disorders (28 per cent), depression and other mood disorders (26 per cent), antisocial personality disorder (18 per cent) and schizophrenia (7 per cent). Some had multiple disorders. The prevalence of mental disorders among people with drug use problems varied depending on the drug, from 50 per cent of people who met criteria for a diagnosis of marijuana abuse to 76 per cent of those who met criteria for a diagnosis of cocaine abuse. Almost half the people with such drug use problems also had drinking problems during their lifetime.
However, the relationships between mental health and substance use are complex and difficult to disentangle. Some people with serious mental disturbances (e.g., phobias, rage, anxiety, depression, mania, paranoid delusions) appear to use alcohol and other drugs to self-medicate for mental distress. For others, mental health problems are caused or exacerbated by substance use, and these problems tend to decrease with abstinence. (See Chapter 26 for further discussion of the etiology of concurrent mental health and substance use disorders). While clients with concurrent disorders are generally considered hard to treat, integrated mental health and addiction treatment services seem to be quite successful (Health Canada, 2002).
A psychodynamic approach to understanding human behaviour emphasizes psychological forces, structures and functions as they develop and change over time. There is a special interest in childhood experiences and conflicts and their influences in later life. Psychodynamic perspectives on substance use problems focus on unconscious motivation, emotions, self-esteem, self-regulation and interpersonal relationships.
Psychodynamic theories can be traced to the writings of Sigmund Freud and his followers and revisionists. There are perhaps as many variants of a psychodynamic approach to substance use as there are psychodynamic theorists. Freud originally proposed that “alcoholics” were “orally fixated” (i.e., stuck at an early developmental stage) and thus unable to cope with the demands of adult life. Thus they used alcohol to “escape from reality” (a Freudian concept). Later, Freud proposed that “alcoholism” was an expression of repressed homosexuality. He reasoned that male homosexuals turned to drink because they were disappointed with relationships with women and because drinking gave them an excuse to be with other men. Other psychodynamic theorists have proposed that alcoholism is a reflection of unresolved dependency conflicts, a striving for power or a form of self-destruction. “Fixations” at Freud’s anal and phallic stages have also been proposed as explanations for alcoholism (Barry, 1988).
Psychodynamic theory does not feature prominently in the mainstream of current substance use research, and it has not been expanded to accommodate recent research on biological factors. Psychodynamic formulations of human behaviour have not led to testable assumptions and, in general, they have little clear empirical support. Purely psychodynamic treatments designed to increase the client’s insight have not proven effective (Health Canada, 1999) and have generally been abandoned. However, various forms of non-psychodynamic, client-centred psychotherapy are often used in conjunction with other types of treatment in specialized addiction treatment programs.
The relationship between psychodynamic and learning theories (discussed below) is problematic. Although both theories of substance use emphasize the role of experience (including childhood experiences), learning theorists typically challenge the utility of the concept of “repressed” memories or impulses. Nonetheless, some overviews of the psychodynamic approach (e.g., Khantzian, 1995) seem quite compatible with social learning theory.
Learned cognitions and behaviours
Use of alcohol and other drugs activates two basic learning mechanisms. The first, called classical conditioning, occurs when an initially neutral stimulus eventually produces the same responses as an existing stimulus with which it has been paired. The best-known example is the experiments of Ivan Pavlov, in which he rang a bell every time he fed his dogs. Initially, the dogs salivated (an unconditioned response) only at the sight of food (an unconditioned stimulus). However, in time the dogs began to salivate at the sound of the bell. The bell thus became a conditioned stimulus and salivation a conditioned response.
Another example of a classically conditioned response is the onset of cravings and withdrawal symptoms in response to stimuli associated with substance use. These stimuli, or cues, may be internal to the person (e.g., feelings of depression or anxiety) or may be found in the external environment (e.g., advertisements, social situations or the sight of a syringe). Through classical conditioning, alcohol- or other drug-related stimuli may also invoke mild drug effects that whet the person’s appetite for more.
The importance of cues in conditioning craving for a drug is illustrated by the very low rates of heroin use among American veterans who had previously used heroin in Vietnam. This phenomenon may be explained partly by the relative lack of external cues for heroin use in the veterans’ home situations (Robins, 1974). For most returning veterans, the main external stimuli for heroin use were not associated with the United States but with Vietnam and the war. In addition, policies were established to reduce the likelihood of internal cues (e.g., coming down from heroin intoxication) occurring in the United States. Thus, no soldier was allowed to board a plane for home without passing a urine screening test.
Classical conditioning has been used to account for increased tolerance of the effects of alcohol and other drugs. Tolerance is typically greater in situations or locations where alcohol or other drugs have previously been used. One theory proposes that these familiar situations become classically conditioned stimuli that evoke unconscious, compensatory physical responses whenever alcohol or other drugs are used. These tolerance responses reflect the body’s need to re-establish biological equilibrium disrupted by substance use. By being frequently paired with substance use, the (now conditioned) tolerance responses become stronger, and more of the substance is needed to produce intoxication (Sherman, 1998). This theory has been used to explain why people addicted to heroin sometimes overdose after taking a dose of heroin that is usually well tolerated. It has been found that often, this happens when the person took the dose in an unfamiliar environment, and so the usual conditioned tolerance response did not occur (Siegel et al., 1982).
“Cue exposure” treatments have been used to eliminate classically conditioned substance-related responses through the process of extinction. Clients are presented with, or asked to imagine, situations in which they typically used their preferred substance. They are then asked to imagine themselves resisting urges to use the substance. The assumption is that classically conditioned responses to these situations (withdrawal symptoms or drug effects) become “extinguished” through lack of reinforcement. However, studies of this type of intervention have produced mixed results (Health Canada, 1999).
The second learning process activated by drug use is called operant conditioning. This occurs when behaviours are shaped by their consequences. Through operant conditioning, positive reinforcements (rewards) are used to increase the frequency of specific behaviours in specific situations, and negative reinforcement (withholding of rewards) or punishments are used to decrease or eliminate behaviours. Behaviours come to be evoked in response to the various stimuli associated with the conditioning process. Depending on the schedules of reinforcement used (e.g., continuous, intermittent, response-dependent or time-dependent), behaviours may be very persistent if the appropriate cues are present.
All drugs used for pleasure can act as positive reinforcers. This is clear from studies showing that animals will learn to perform tasks when drugs are used as rewards. Alcohol and other drugs are, of course, positive reinforcers for drinking and other drug use, and through experience can become associated with a variety of internal and external cues. For many people, these cues may be rather limited (e.g., only at family meal times and never more than once a week). For others, drinking cues can become highly generalized (e.g., when they are happy, sad, alone, with others, and at any time of the day).
One apparent problem with this view of substance use is that many people continue to use alcohol and other drugs despite negative consequences such as hangovers, ill health, and social and legal problems. This appears to be contrary to an operant conditioning analysis. However, this is not the case because these negative consequences do not occur immediately after alcohol or other drug consumption. The immediate effects (the effects of the substance and the relief of withdrawal symptoms) continue to be positive and reinforcing. A person with substance use problems may acknowledge and regret the social and other problems caused by his or her substance use and vow, quite sincerely, to abstain in the future. But without some sort of help, such as relapse prevention treatment, he or she may continue to be overwhelmed by stimuli that evoke substance use (e.g., the sight of old friends, anxiety or arguments with a spouse).
It is widely believed that the use of alcohol and other drugs can relieve stress, which may motivate and sustain a person’s consumption. Retrospective and prospective studies with humans lend some support to this stress-reduction theory, but other relationships between stressful events and substance use are not as strong as the theory suggests. A likely explanation is that stress relief from alcohol or other drug use is influenced by expectations that relief will occur (Cohen and Baum, 1995).
Expectations of the effects of alcohol or other drugs are cognitions and, like other cognitions, they both influence and are influenced by classical and operant conditioning. Through conditioning, expectations and other cognitions not only arise from stimuli and rewards, but they also influence reactions to stimuli, behaviours and consequences. This is a basic premise of social learning theory (Bandura, 1977), which recognizes the behaving and self-aware individual as an active participant in the learning process rather than as a passive victim of circumstances. The theory also emphasizes that learning takes place through modelling, and is shaped by consequences under the control of the individual. Moreover, reactions to stimuli, rewards and punishments are mediated and modified by changes in cognitions. Thus, an “overwhelming desire to drink” can come to be viewed as a passing “crest of a wave” (Marlatt & Gordon, 1985). Similarly, one lapse after treatment can be seen as either a sign that all is lost or as a positive learning experience.
Social learning theory also recognizes the influence on behaviour of self-monitoring and self-evaluation, self-reward and self-punishment, perception of responsibility and control, and expectancy effects. The theory has also given rise to the notions of learned helplessness (belief in loss of control) and abstinence violation effects (“I have relapsed and so all is lost”).
There is strong experimental and clinical support for a social learning analysis of substance use (Wilson, 1988). In addition, alcohol use treatments based on this theory have more support from experimental studies than do other types of treatment for alcohol use (Health Canada, 1999). Treatment methods based directly or indirectly on social learning theory are:
- aversion therapy (including covert sensitization)
- cue-exposure training
- social skills training
- self-control training
- relapse prevention.
Social learning theory, along with theories of client-centred counselling, also influenced the development of motivational interviewing (Miller, 1996). Most of the chapters in this book reflect the influence of both these types of theories.
Social learning theory can explain why other forms of treatment can work for some people. For example, 12- step programs can be seen as creating drug-free environments, providing social reinforcements for abstinence and for related verbal statements, and providing an appealing explanation for problems. Social learning theory does not support the concept of alcoholism as a distinctive entity and regards “loss of control” as a modifiable experience, not as an inevitable, objective consequence of alcohol use. Nonetheless, the theory does not deny that, for some people, acceptance of the label “alcoholic” and the concept of “powerlessness” over alcohol can become the cornerstones of their recovery.
In Alcohol and Drug Problems: A Practical Guide For Counsellors