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Contents for this page:

  1. Different theoretical views of addiction (see pages 36-42)

    1. Biomedical focus

    2. Environmental (learning) focus

    3. Focus on individual (personality; Psychodynamic)

    4. Interactive focus (social learning)

  2. Psychological aspects of alcohol use

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Approaches to treatment

  Practice Exam

One thing that determines use is the balance between perceived risks and benefits associated with a substance.  The rank- ordering exercise that we went over in class on the first day of this section was intended to illustrate one set of risk/benefit examples.

Looking at the qualities of many benefits and risks associated with drug use, the BENEFITS tend to be more *immediate* and *certain* whereas the RISKS tend to be more *distal* and *uncertain*.  As we did in class, take cigarette smoking for example.  Benefits can include positive feelings (relaxation AND stimulation), clear-headedness, taste, and social benefits.   For the addicted smoker, smoking will also lead to the elimination of withdrawal symptoms.  Risks or negative effects include risk of cancer and heart disease, other lung diseases, putting loved ones at greater risk for the same, bad breath, and a reduction in taste and smell sensitivity.  Clearly, the risks outweigh the benefits in severity.  Based only on that, we should assume that no one would ever smoke.

However, the benefits are certain to happen and happen immediately upon using the drug (note, elimination of withdrawal symptoms.)  The negative effects may or may NOT happen and have less control over current behavior because of the delays in their occurrence (note heart disease or cancer).  Principles of learning theories based on consequences note that sure and immediate consequences have significantly greater behavioral control than those that are uncertain and removed by time (ex.: would you more likely work hard on a job today if you expected payment today or if you expected payment 20 years from now?)

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It was noted in class that one can group theories regarding drug use in a number of ways.  Essentially, theories can be grouped thus:

  1. Biomedical focus:  As the name suggests, these theories focus on the pharmacological effects of substances on the body.  These include a focus on the drug itself (agent focused), or on aspects of the person's physiological make-up (e.g., genetics).
    1. Agent-Related Theories -- puts the focus on the pharmacological properties of the drugs and the ways in which those drugs alter physiological functioning.  Primarily, what kinds of  rewards will a drug offer?  

    2. Host-related theories (physiological susceptibility to addiction)--  These are biomedical models that look at individual differences, but again at a physiological level.  That is, are there people that are more susceptible to the effects of certain drugs than others?  Perhaps making them more likely to become addicted?      

      The theories tend to note ways in which people differ physiologically, thus explaining why not ALL people abuse substances, nor the SAME substances.

       -- Deficiencies-- either internally (genetically) brought about or externally (where early experience can shape development of nervous system leading to greater "need" for certain types of stimuli.) 

      -- Genes affect metabolism of drugs, responses to them, and vulnerability to dependence.  Clearly there is a genetic component to alcoholism.  However, a person doesn't have a gene that says, "You will drink a pint of Jack Daniels each day."  More likely, genes set up one person to respond to alcohol differently from another person.  

      • This may be in how they metabolize it (offspring of alcoholics seem to metabolize alcohol more efficiently); 

      • or how they respond to it (e.g., offspring of alcoholic parents report more positive responses to drinking alcohol than do others).

      These biomedical theories do not look at the behavioral side of initiating use-- how rewarding can a drug be if a person never tries it???  To do that, one needs to look at consequences and external pressures.  This involves the environment.

  2. Focus on the Environment:  These theories focus on the influences of people, events, or consequences outside the individual.  When discussing "peer pressure" or "rewards" and "punishments" associated with drug use, we're discussing environmental influences on behavior.  These views included operant and classical conditioning and make up the bulk of the book's discussion on psychopharmacology.  (Operant procedures regarding reinforcement/punishment were focused on more than classical conditioning.  Classical conditioning was discussed in relation to "Antabuse" and alcohol and in conditioned withdrawal symptoms triggering relapse). 

    Broadly, motivations for drug use can take two forms:

    • appetitive-- seeking the effects of the drug (e.g., drinking to get drunk)

    • escape-- escaping negative physical and/or psychological feelings (e.g., drinking to relieve withdrawal symptoms or to forget problems).  

    Both of these forms of motivation refer to consequences increasing the behavior-- appetitive motivations being influenced by gaining something; escape motivations being influenced by relieving something.

    ==> This also brings to the fore the differences between initiation and continuation of drug use.  In general, appetitive motivations are stronger at the start of drug use (that is, seeking out the effects of the drug), whereas escape motivations are stronger once addiction has set in (continuing use to avoid feeling bad from withdrawal symptoms).

    These consequences that influence behavior make up the core of behaviorist views. 

    Consequences can either lead to an increase in a behavior or a decrease.  

    • If it increases the behavior, it's referred to as a reinforcer

    • if the result is a decrease in behavior, it's referred to as a punisher.

     

    Be aware that behaviors can be reinforced (increased) either by presenting something or by taking something away.  (See the table below):

    Consequences that follow a response  

    Outcome

    Stimulus presented as a consequence   Stimulus removed as a consequence  
    Behavior increases   "positive reinforcement"   "negative reinforcement"  
    Behavior decreases   "punishment"   "response cost"  

     

    [Positive Reinforcement = something that increases the probability of a behavior occurring because of what was gained.  So, if a drug makes a person feel good, it will tend to increase the behavior of taking the drug.]

    [Negative Reinforcement-- The removal of something increases the probability of repeating a behavior-- For example, taking a Tylenol removes a headache, so when another headache occurs you'll be more likely to repeat the behavior (taking the Tylenol).  Likewise, withdrawal symptoms are removed by taking the drug again.  This leads to repeated drug use to avoid those bad feelings.]

    On the punishment side, behaviors can be reduced by giving something (a spanking, jail time, etc.), or by taking something away (loss of job or privileges), referred to as "response cost".

    Finally, behaviors can simply fade away because the consequences stop.  This is called extinction.  If a drug ceases having the desired effects (no longer get the thrill), a person won't feel compelled to keep using it.  This seems to be what happens with LSD-- people simply get bored with it.

    Test yourself on these ideas with this exercise:

    Click here to open the review exercise in a new window

  3. Focus on the individual:  Both the agent-related theories and the environmental theories suggest that we're all equally prone to addiction.  That doesn't appear to be the case-- so what's different between those that do end up using or abusing drugs and those that don't?  These theories focus on differences in personality and motivations.  We focused on Psychoanalytic theories here, but also noted other views.

    As useful as the behavioral theories are, they do not provide an understanding for why only some people begin using drugs or why others do not develop an abusive pattern of use when placed into similar environments.  The traditional operant and respondent theories do not attempt to explain how individuals differ.  Therefore they fall short in explaining why individuals differ and what pattern of differences will predict individuals' differing views.

                Psychodynamic perspective.  Psychodynamic, or psychoanalytic, theory of behavior originated with Sigmund Freud (1856-1939) through his interpretations of problems presented to him by patients, primarily middle to upper-class Austrian women suffering from anxiety, depression, or other pathologies.  Much debate continues about some of Freud's key assumptions and his focus on resolution of inner sexual conflicts as the source of personality and psychological health.  Despite the controversies, and even overt errors, in Freud's views, his impact on psychology and clinical practice has been profound.

    According to Freud, much of our motivations come from areas of our mind that we cannot readily access: our unconscious.  Freud assumed that a large proportion of who we are is beyond our awareness; other psychoanalytic theorists disagree with the extent of the unconscious.  One of the problematic aspects of psychodynamic views, from a scientific point-of-view, is the inability to directly measure unconscious activity.  Nevertheless, the idea of unconscious motivations remains a cornerstone of psychodynamic theory.

    With regard to drug addiction, the focus by psychodynamic theorists has been on the role of underlying conflicts, unconscious motivations, and early developmental events that would determine this form of behavior.  That means that there would be conflicts and drives that push people to engage in drug-abusing behaviors and the person may not even be aware of the reasons why they have chosen to do this.  One of the major differences between this and behavioral viewpoints is that, for the psychodynamic view, the motivations are generated within the person whereas, for the behaviorists, control over behavior is by the environment.

    Later views have focused on an inability to effectively develop a sense of self separate from others and to see self as an object that can be controlled and soothed by the person, leaving someone to addictive behaviors.  Addicts, according to this view, have an arrested development of self and tend to either see themselves in grandiose terms or in terms of being such an entity that needs and deserves total commitment and care from others with no reciprocation.  Because the self is weak and there is little self-esteem, drugs would become a crutch-- either to deal with the grandiose views differing from the dependent views, or to make up for the failings of others to nurture.  Characteristically, substance users are described as anti-social, impulsive, sensation-seekers that have difficulty tolerating strong emotions and delaying gratification (Lang, 1983). 

    But why drugs and not some other self-indulgent behaviors?  According to Brehm and Khantzian (1992), being able to achieve feelings of inner balance and comfort (homeostasis) is a "most crucial task" that an addict struggles with throughout their life.  In attempting to develop, maintain, or return to an internal (mental) level of comfort or balance, a person with poor ego strength will resort to drugs or other "easy" fixes (Pine, 1990).  That is, there is mental suffering if there is imbalance and a person might seek drugs to correct that imbalance if unaware or unable to find another means.  The focus, then, isn't so much to gain "reinforcing" kicks as it is to avoid or eliminate negative feelings (negative reinforcement in behaviorist language). 

    In sum, current psychodynamic views emphasize that substance use is a symptom of deeper disturbances and an inability to cope with those disturbances.  Although the original formulations by Freud focused heavily on child-parent (mother) interactions, the idea of deep-seated issues leading to poor coping skills and seeking external stimulation are still a part of the model and viewpoint.  It also suggests that long-term change will be affected only by including therapy for underlying issues and developing better coping skills.

    Criticisms of psychodynamic views of alcoholism and drug abuse abound.  The early overemphasis on sexual conflicts is a frequent source of criticism because of a lack of empirical backing (Cox, 1987; Thombs, 1994).  Beyond the role of sexual conflict, such key elements as unconscious mind and drives also lack empirical evidence or even a way to recognize and measure them.  More damaging for the more recent psychodynamic views of addiction is a lack of evidence for distress of the kinds proposed by Khantzian predisposing substance use (Cox, 1985; Schinka, Curtiss, & Mulloy, 1994). 

    Other personality theories:  Whatever the short-comings of psychodynamic views, the idea that certain, underlying characteristics will predict patterns of drug and alcohol use remain popular.  Much time and effort has been spent trying to identify the elusive "addictive personality."   

    Personality can be defined as a pattern of relatively enduring psychological and behavioral characteristics by which each person can be compared and contrasted with others.  A major assumption of any personality-based theory of substance abuse is that the personality characteristics were in place prior to any substance use and that this set of characteristics directly contributed to the uncontrolled use of the substance.  

    Interestingly, there may not be a one-to-one relationship between having a maladjusted personality and whether or not one uses drugs.  Shedler and Block (1990) studied the personality profiles of students from preschool through age 18 and found: 

    • Those that had at some point experimented with drugs (primarily marijuana) were the best adjusted.  

    • Those who reported frequent drug use in their adolescence were described as maladjusted, with a personality profile even at age 7 that showed an inability to form good relationships, insecurity, and emotionally distressed.  

    • Those that reported never trying marijuana or any other drug were found to be relatively tense, over-controlled, emotionally constricted, and lacking in interpersonal skills.

    The question then becomes one of whether these characteristics cause someone to begin abusing substances.  For example, we should also expect risk-takers and sensation seekers to engage in various sporting endeavors or be aggressive in fields of business.  

    The conclusion that personality characteristics directly lead to any one form of specific behaviors remains a sizable leap.  Accordingly, many have now begun referring to predisposing characteristics-- the idea that having certain personality characteristics can place one at greater risk for engaging in abusive behaviors given appropriate environmental demands, structures, and opportunities-- rather than there being some "addictive personality".  That places personality more into a role of being a possible ingredient in substance use, but not by itself a sufficient cause (maybe not even a necessary one).

  4. Interactions between the person and environment:  Realizing that all of these views have some merit, what view is correct?  The short answer is that they're all right (and all incomplete).  Interactionistic theories, such as social cognition (which focuses on how people interpret their environments) attempt to explain how these different pieces work together.  

    Albert Bandura's Social Learning Theory (Bandura, 1977; Bandura & Walters, 1963), sees human behavior as a continuous, reciprocal interaction among cognitive, behavioral, and environmental factors.  In this view, people are able to actively take a part in the determination of their destiny, but within limits set up by the environment.

    Accordingly, reinforcements and punishments will influence behavior, but the extent of that influence will be affected by cognitions (thoughts) that determine:

    1. which environmental influences someone pays attention to, 

    2. how they will be interpreted (e.g., good or bad), 

    3. whether they will be remembered, and 

    4. how they might affect future behavior.  

    Another difference between social learning and traditional behaviorist views is that one does not have to directly experience a reinforcement or punishment for a behavior to change in its likelihood.  Instead, as thinking beings, we're able to observe, interpret, and expect what kind of consequence will occur.  

    This last distinction is important for understanding why a person might begin to experiment with a drug in the first place and why, even with an initially negative experience (e.g., coughing on a cigarette, nausea with drinking alcohol), experimentation might continue. 

    Observational learning, or modeling, is a key part of social learning theory.  It can be defined as an acquisition of knowledge and behavior by observing other people and events without directly engaging in the behavior or personally experiencing consequences (Wilson, 1988).  Modeling, then, may result in

    • the discovery of new behaviors that the person was previously unfamiliar (e.g., freebasing cocaine); 

    • feeling disinhibited about trying a behavior because of either seeing an admired other (a "model") do it or see another person experience reinforcement (or lack of punishment) after doing the behavior; or 

    • simply may serve as a point of comparison (e.g., clapping when others clap; pacing one's drinking with others) 

    The role of modeling would seem to be illustrated in the common findings that people rarely use an unfamiliar drug for the first time alone and that the best predictor of smoking is parental use.

    Modeling, however, will not lead one to automatically copy what they observe another do.  Remember that social learning stresses that there is a continual interrelationship between environment, the person, and the behavior.  Accordingly, a person doesn't just blindly follow what others do.  Therefore, social learning theory includes the concept of self-regulation which refers to the ways in which people incorporate observed information and decide to act on it, even in the absence of external environmental rewards (Abrams & Niaura, 1987).  

    One's particular self-regulation, then, may explain why they can go out with friends and be the only one not drinking.  

    On the other hand, another's self-regulation may explain why, after experiencing repeated DWI arrests, they continue to drink and drive when there seems to be little external reward for doing so.  

    So--- how does one decide which course of action to take, especially when one's own concepts seem to differ from those exhibited or expected by others?  An underlying principle in social learning theory is self-efficacy.  Self-efficacy can be defined as a perception or judgment of one's ability to carry out a particular course of action in order to deal effectively with a situation (Abrams & Niaura, 1987).  

    This is in part a judgment of one's own ability to carry out a behavior to its intended conclusion and in part a judgment of whether the conclusion is a desirable one. 

    As was discussed in approaches to therapy, one's self-efficacy is also thought to have particularly important effects on continued drug abstinence when leaving treatment and returning to the community.


Alcohol:

As noted in class, the same drug is used for everything from ceremonial occasions (e.g., weddings, celebrations) to other social events such as parties and sporting events to more intimate settings to drinking alone.  The same drug, then, is being used as an anti-anxiety drug or "social lubricant" to liven things up; as a source for relaxation or as a source for angry arousal being associated with assaultive crimes.

How can one single, simple, depressant drug have such varied effects?  A large number of alcohol's supposed effects come from what people believe alcohol will do to them.  These expectations have a strong effect on how people act and feel when "drunk."  How, then, do we tell the difference between what alcohol, as a pharmacological agent, actually does to a person and what effects occur simply because someone expects them to happen?  

One technique used to separate expectations from pharmacological effects is the balanced placebo design.   This technique involves measuring how people act and feel when they think they've had alcohol (but really haven't) and comparing that to actions and feelings when a person has actually consumed alcohol, but didn't think that they were.  In sum, the balanced-placebo design looks like this:

 

BEVERAGE ACTUALLY RECEIVED BY SUBJECT

WHAT SUBJECT TOLD DRINK IS

ALCOHOL

ALCOHOL

TONIC WATER

(1) This is the typical drinking condition-- person orders alcohol and gets alcohol.

(2) This is the placebo condition.  Person thinks they're drinking alcohol, but there's no alcohol in the drink.  This condition measures expectation effects.

TONIC WATER

(3) This condition measures the pharmacological effects of alcohol because the person thinks they're drinking tonic, but there's enough alcohol in the drink to get them legally drunk.

(4) This is the control condition where the person neither expects alcohol nor gets any.

By comparing cells 2 and 3, one can get an idea of what alcohol does as a drug (3) v. how people respond to alcohol because that's what they expect (2).  Over the years that this has been done, it's been found that nearly all the effects one thinks of in relation to alcohol-- increased violence, stress reduction, decreased inhibitions, etc.-- are primarily expectation effects.  Based on these studies, only one pharmacological effect of alcohol comes out clearly and consistently-- alcohol decreases your ability to process complex cognitions (i.e., it makes it harder to think clearly).

So how does that translate into all the behaviors and feelings we see related to alcohol?  Claude Steele (1990) has developed a theory about alcohol myopia which seems to explain this quite well (introduced briefly in your textbook on p. 216).  Consider the situation introduced in class:

Stan's landlord is truly a crook.  He makes shoddy repairs and overcharges Stan and then charges him again when things fall apart.  He comes into Stan's apartment whenever he pleases and Stan suspects the landlord goes through his stuff.  So far, Stan has kept his cool around him because he realizes he'll lose his security deposit if he gets kicked out and other apartments aren't available.  One night, however, Stan's been drinking at the local tavern, complaining about the landlord, when he comes in.  Already worked up, Stan picks a fight with the landlord and gets clobbered.

Why did he choose to fight the landlord when drunk, but not when sober?  ("Because he was drunk" is not an answer, by the way.)  Claude Steele would say that the alcohol affected Stan's ability to think about the consequences of his actions (which he was able to do when sober).  Instead, Stan pays attention to the clearest thing in his immediate environment-- the landlord whom he hates.  That focused attention without the restraint of the consequences leads to an amplified response.

For those that prefer graphic representations, click on the images below:

How Stan sees things when sober:   or after drinking:

 

Similarly, alcohol can act as an anti-anxiety agent (for the short term) if the environment that one is drinking in is distracting enough to push the anxiety-producing thoughts out of mind.  However, alcohol can often have the effect of making someone feel more miserable about their troubles because they're unable to think of other things and put their problems into perspective when drunk.

 


Approaches to treatment   Practice Exam

 

 

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