Psychological perspectives on alcohol addiction

Transcription

1 Psychological perspectives on alcohol addiction Stavanger

2 Aldous Huxley: «All human beings need a chemical substance in order to keep the doors of recognition open, bring about spiritual visions, and temporarily shut out the terrible nightmare of reality» Prof. Fanny Duckert, UiO

3 Why having a drink? Partly to revive, to relax, but it is also a convenient way of becoming a slightly different person from your daytime self, less methodical, less calculating somebody different, and the prospect of that has helped to make the day tolerable. The plain fact is that it makes other people, and indeed life itself, a good deal less boring Kingsley Amis: Everyday Drinking Prof. Fanny Duckert, UiO

4 Functions of intoxication - Alcohol makes you pretty, lady! - But I have not been drinking. - No, but I have.. Prof. Fanny Duckert, UiO

5 Responsibility Responsibility for the drinking behaviour Responsibility for acts performed while intoxicated Norwegian drinking culture Prof. Fanny Duckert, PSI, UiO

6 Alcohol enabling self instructions I want to drink as much as possible when it s possible!

7 Self permission I m entitled to a drink I need to drink Just this once It will be no fun without drinking I will be no fun without drinking I will not be able to endure without a drink

8 Basic knowledge of human Everyone engages in addictive behaviours to some extent Eating, drinking and sex is essential to survival States of changed consciousness have a unversal appeal There is a universal tendency to avoid doing the proper thing nature

9 Hot state Oldest, basic part of the brain (amygdala) Wired for survival Rapid, triggers immediate action Pleasure, craving, fright, aggression

10 Cold state Modern part of the brain (frontal lobes) Logical, reflective, planned decisions Calculates implications and consequences Able to postopone and to self control Slow Resource demanding

11 Processes leading up to drinking The actual drinking is just the final step in a process of cognitive decisions, (like forks in the road), which may or may not increase the likelyhood of drinking

12 Decsicion making

13 Expected benefits At a distance (predicted benefits) Close up (decision benefits - craving) When acting (consuming benefits) After consuming (experienced benefits)

14 Expected benefits buying a dishwasher 2,5 2 1,5 1 0,5 0 At a distance Close up Consuming Afterwards Series 1 Column1 Column2

15 Expected benefits of a cake 16 Diagramtittel At a distance Close up consuming afterwards Series 1 Column1 Column2

16 Activators of hot state Cravings and urges are internal or external signals which by conditional learning have been associated with drinking, or the after effects of drinking and which mobilize the want to drink again The intensity of cravings increase when selfregulation is under pressure (for instance, low blood sugar content in blood)

17 Internal craving signals Tiredness/stress Hunger/thirst Anxiety/insecurity Sleeplessness/pain Boredom/restlessness Anger/sadness Exitedness

18 External drinking signals External: Time Place Situation Who one is together with

19 A craving is like a wave; strong and intensive in the beginning, ebbing out after a while

20 Plasticity in drinking behaviour Substance use is highly responsive to contingent positive reinforcement. Even severely dependent substance users can and do abstain or modify their drinking in response to positive incentives to do so. Norms Obstacles Social contingencies

21 Important insights Alcohol use is chosen behaviour Alcohol problems emerge gadually and occur along a continum of severity Alcohol use responds to reinforcement Alcohol problems do not occur in isolation, but as part of behaviour clusters Alcohol problems occur within a family context Alcohol problems are affected by a larger social context Relationships matter Motivation is central to prevention and intervention

22 The nature of motivation Motivation for change is not unitary, but is comprised of multiple dimensions that are at best moderately intercorrelated Motivation for seeking help Motivation for remaining in treatment Motivation for change Motivation for long term change

23 Motivation The person s strength of motivation for change is strongly influenced by interpersonal factors. Motivation is a product of interpersonal and intrapersonal processes

24 Instigation of change Instigation of change occurs when a person perceives significant discrepancy between his/her present state and his/her desired goal or values. Motivation and instigation of change often emerge in the context of interpersonal communication

25 Commitment to change Deciscion or commitment is a final common pathway to change. Once instigation occurs, change may proceed without much additional support

26 Self-efficacy (Bandura) General efficacy (belief that there are effective ways to accomplish change) Self-efficacy (belief that oneself is able to make use of them)

27 Realtively brief interventions, including motivational interviewing are effective in intitating change

28 Therapist impact Outcomes vary widely across therapists. A positive therapist-client alliance is assosiated with better outcomes, and the therapist s empathic skills, in particular, predicts greater reduction in drinking.

29 How to translate knowledge of brain structures and processes into practical treatment?

30 Challenges for a problem Postponing gratification (planning forward) Dealing with impulses (impulse control) Keeping focus (be reflective) drinker

31 Challenges Situational abstinence Dealing with urges and cravings Moderation Slips Relapse

32 The Marshmallow Test (Walter Mischel) This Photo by Unknown Author is licensed under CC BY

33 What did not work? Focusing on the marshmallow on the table Focusing on the reward of getting two marshmallows Thinking of something sad

34 What worked? Hiding the marshmallow Distracting oneself Switching attention Reframing (thinking about the marshmallow as a cloud) Put a frame around it

35 How to postpone taking the mashmallow? The crucical factor in delaying gratification is the ability to change your perception of the object or action you want to resist All temptations have bot hot and cold attributes. Focusing on the cold attributes helps delaying consumption

36 Activating cold state in hot state situations General selfregulating instructions: «I will drink as little as possible!»

37 Strategies for dealing with cravings Self monitoring Analyzing the experience Alternative activities (distraction/postponing) Mental images (keep focus) Relaxation activities

38 Relapse prevention Identifying and avoiding high-risk situations «Fire drills» Self-regulation strategies Motivational strategies

39 What does not work? Once substance abuse has been established, education, persuasion, confrontation, punishment, and attention typically yield little or no beneficial effect or sometimes even excert a paradoxial effect.

40 Implications for intervention Intervention is not a specialist problem, but should be shared by many public and private sectors. The full range of alcohol problems should be addressed, and not just the most severe. Alcohol problems should be understood in a larger life context, and comprehensive care should be provided. Look beyond individual pathology. Enhancing motivation and commitment to change should be an early goal and key component of intervention Positive reinforcement for nonuse, and alternative resources of positive reinforcement should be enhanced

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