Critically discuss the theoretical rationale for cue exposure treatment for addiction, and the factors that

might limit its effectiveness.

Dionne Angela Donnelly Module Code: PSYC335 Word Count: 2174

Addicts are more likely to relapse in environments associated with prior drug use (Carter & Tiffany, 1999, 328). It is thought that it is the presence of drug-related cues in the environment which leads to this increased risk (Conklin & Tiffany, 2002; Hogarth, Dickinson, Janowski, Nikitina & Duka, 2010; Shearer, 2007). Cue exposure treatment (CET) is based on the Pavlovian classical conditioning (CC) learning paradigm, and utilises the principle of extinction in order to reduce the risk of relapse in the long term. It does this by attempting to change the implicit associations that are generated during drug use. However, CET has been found to be of limited effectiveness (Thewisson, Snijders, van den Hout & Jansen, 2006) and it will be argued here that this is due to its foundations resting in CC, as the paradigm itself has inherent problems. This means that CET does not take into account other processes such as operant conditioning, and the effects human cognition on extinction (Lovibond & Shanks, 2002). This logically leads to the question of whether extinction learning is useful in the treatment of human addiction, as it is subject to problematic factors such as the renewal effect, reinstatement and spontaneous recovery (Conklin & Tiffany, 2002). A further, related, issue which will be considered is whether there is a causal relationship between cues, craving and drug relapse, as this is a fundamental presumption of the theoretical rationale (Carter & Tiffany, 1999). The outcome of this critical analysis will show that whilst CET can be beneficial, it also has many limitations, and should be combined with other treatment programs in order to boost its effectiveness (Conklin & Tiffany, 2002).

CET is based on the principles of the CC paradigm and extinction training (Cunningham, 1998; see also, Bouton, 1994; Shearer, 2007). For example in studies such as that by Hogarth et al. (2010), the drug is the unconditioned stimulus (US), and the drug response is the unconditioned 1

response (UR). The context (such as a bar) and/or situational cues (such as a syringe) become associated with the drug and therefore become conditioned stimuli (CS) which elicit drug seeking/use (i.e. a conditioned response - CR) when presented alone (Tomie, Grimes & Pohorecky, 2008; see also, Conklin & Tiffany, 2002). The treatment aims to use extinction: repeatedly presenting the CS in the absence of the reinforcing properties of the US, to replace the old CS-US association with the new learning that the CS is no longer associated with the US and subsequently the CR (Bouton, 1994, 2002; Shearer, 2007). The CR is usually defined as craving, withdrawal-like symptoms or drug-seeking behaviour (Carter & Tiffany, 1999; Conklin & Tiffany, 2002). Ideally, this new learning should prevent the recovering addict from relapsing (Conklin & Tiffany, 2002). Ultimately though, CETs rationale is based upon animal research, which makes it difficult to translate the findings to humans, as human learning is mediated by cognition and expectancies (as found in the study by Hogarth et al. 2010). Another problem is that humans may have participated in thousands of conditioning trials with a vast range of environmental cues and thus have an extremely reinforced association, whereas animals learn associations over a few trials in a very controlled environment and the response is then quickly extinguished (Conklin & Tiffany, 2002; Piasecki, 2006).

Despite the above limitations, research has shown CET to be effective across addictions. For example, OBrien, Childress, McLellan, and Ehrman (1990) concluded that the treatment did work in cocaine dependent subjects, as it significantly reduced craving. Similarly, Hogarth et al. (2010) found that CET reduced the subjective craving and number of cigarette puffs taken by smokers. Furthermore, Monti et al. (1993) found in a group of male alcoholics, those who received CET were more likely to be abstinent after 6 months. But, contrary to these positive 2

findings, a meta-analytic study of the area found that CETs effectiveness is limited as it has an extremely small, non-significant effect size (d = 0.087) (Conklin & Tiffany, 2002; for similar conclusions, see also Niaura et al, 1999). This shows that CET is not a very reliable treatment. This implies that the theoretical rationale behind CET appears to be deficient in some way. One possible reason for CETs lack of efficacy is the presumption that CET rests on, that craving leads to drug taking.

CET relies on the assumption that cues reliably lead to craving and that this craving results in drug approach/consumption/relapse (examples can be seen in the majority of studies in the field, including but not limited to Cunningam, 1998; Havermans & Jansen, 2003; Hogarth et al., 2008; Winkler et al., 2010). Cues used in CET are personally relevant to the addict (Cunningham, 1998) and can include stimuli such as videos, in vivo and imaginal cues (Conklin & Tiffany, 2002) which are assumed to elicit a response of craving, drug approach and drug consumption (Tomie, Grimes & Pohorecky, 2008). When faced with drug-related cues craving is the most reliable and sensitive response channel (Carter & Tiffany, 1999, cited in Piasecki, 2006, 207). For example, LaRowe, Saladin, Carpenter and Upadhyaya (2007) found that exposure to smoking cues led to significant increases in craving as opposed to neutral cues (see also, Erblich, Montgomery & Bovbjerg, 2009; Hogarth et al., 2010). Whilst the evidence clearly shows that cue exposure leads to increased craving, what is not clear is whether craving does in fact lead to drug approach and consumption. The concept that craving does this is based upon the idea of negative reinforcement, in that withdrawal leads to craving which in turn leads to consumption and relapse (Tiffany, 1998). However, this appears to be a faulty assumption (which may therefore lead to CETs theoretical rationale being flawed). Tiffany (1998) argued that drug 3

craving does not necessarily lead to drug taking, the association between craving and drug use is a poor correlation and not a fact (which leads us to question whether the research cited above does actually substantiate CET). Also, in studies using self-report, addicts rarely cite craving as a reason for relapse, they usually quote external factors, such as a stressful life event (which accounts for up to 29% of reasons given) (Marlatt, 1996), negative affect due to by frustration at not being able to use drugs (Baker et al., 1984, cited in Carter & Tiffany, 1999) and even positive mood (Marlatt, 1996). In Marlatts (1996) study, only 21% cited intrapersonal temptation (which may be interpreted as craving) as a reason for relapse. Such reasons point to a role for more explicit, cognitive based reasons for relapse, and thus other treatments such as cognitive behavioural therapy (CBT) with a focus on helping improve coping strategies and to change outcome expectancies may be more effective in helping treat addiction (Larimer, 1999).

Further evidence that craving may not play as important a role in relapse than previously thought comes from research on priming. Stewart, de Wit & Eikelboom (1984) stated that there is a drug priming effect, which means that actual ingestion of the drug is more likely to cause craving (and is when craving is reported to be at its height), not a lack of the drug (during abstinence). Therefore it would seem that the theoretical rationale and the research that is based on it operates on a flawed premise, cues may lead to craving, but it is debatable whether this is actually what leads to relapse. This could mean that CET is limited in its effectiveness because cues do not directly lead to drug consumption. Despite this, Piasecki (2006) states that increased craving during cue exposure sessions does in fact predict better clinical outcomes. Also, Havermans and Jansen (2003) state that the above criticism does not prevent CET from being a useful treatment. This means that whilst at the moment, research which supports the theoretical rationale of CET is 4

based on a tenuous link between craving and consumption, there is a correlation between the two (although there may be a factor that coincides with craving or is masked by it) which may be better understood as research progresses.

The major theoretical issue above is compounded by the practical issue that even when extinction training seems to work to extinguish the cue-relapse association, under certain circumstances the extinguished response recovers, increasing the likelihood of relapse (Conklin & Tiffany, 2002; Tomie, Grimes & Pohorecky, 2008). One example of this is reinstatement (Bouton, 1994). This occurs when the addict is exposed to the original US in the conditioning context (i.e. they experience a lapse), this then reinstates responding to the CS when it is presented alone (Bouton, 1994; Conklin & Tiffany, 2002). This can be reversed by continued exposure to the context without the US present (Bouton, 1994). This is extremely difficult for the addict but it is also shows that CET has a positive effect on relapse, as re-exposure to the US does not automatically lead to re-addiction (Conklin & Tiffany, 2002). However, a factor which affects how the effectiveness of CET is perceived is that CSs which have not been extinguished are actually less prone to such contextual effects (Bouton, 1984, cited in Bouton, 1994).

A similar problem facing the persistence of extinction is spontaneous recovery. This is a temporal problem, in which the original CS-CR association returns over time (Conklin & Tiffany, 2002). This affects CET as often the rationale consists of one long exposure to a cue in order to extinguish it, whereas optimal extinction occurs following several short exposures spread across trials, spaced around the time recovery is most likely to occur (Conklin & Tiffany,

2002). This is an issue because using these findings to order to improve the efficacy of CET will make it costly, time consuming and also, may increase likelihood of people dropping out.

The final problem with the persistence of extinction is context. Extinction critically depends on the context it occurs in; a move from the extinction context usually leads to the loss of extinction performance (Bouton, 1994; Bouton, Westbroook, Corcoran & Maren, 2006). Bouton (1994; 2002) argues that the CR assumes the quality of an ambiguous word, which relies on the context for disambiguation. This lack of generalistion is a factor which limits the effectiveness of CET, and it leads to the renewal effect (Conklin & Tiffany, 2002). The renewal effect is the reemergence of the original conditioned response due to the extinguished cues being presented outside the extinction context (Conklin & Tiffany, 2002; see also, Bouton, 1994). Therefore, in accordance with the findings of Chelonis, Calton, Hart and Schachtman (1999) CET needs to include multiple contexts, and a variety of cues in order to aid generalisation, to reduce the context specificity of extinction. However, Conklin and Tiffany (2002) argue that research points to there needing to be more extinction contexts than the number of conditioning contexts. This is seemingly impossible with human subjects as there are a vast number of possible cues and contexts in which conditioning may have occurred. Furthermore, the number of extinction contexts/trials needed may differ across various types of drugs (Conklin & Tiffany, 2002).

A potential way of dealing with renewal is to condition an extinction reminder (Conklin & Tiffany, 2002). This is because it is thought that the renewal effect occurs because extinction is forgotten in new contexts (Bouton, 1994; 2002). Bouton and Brooks (1993) found that renewal was decreased when a novel cue was also paired with extinction and subsequently presented in 6

the original conditioning context. Taylor et al. (2008) also advocate mnemonic agents in improving the efficacy of CET.

However, it is possible that forgetting is not the only reason for reinstatement. As CET operates on the basis of CC, it assumes that relapse is triggered by cues which elicit an automatic CR of craving and/or drug-seeking. But, it is possible that some cues, such as a vodka bottle, have not only been reinforced via classical conditioning but also operant conditioning (OC). Conklin and Tiffany (2002) argue that the vodka bottle may act almost like the lever in animal studies of OC, and thus even if the CC associations are removed, drinking will still remain intact (p. 163). They use the example of a conditioned rat, where if the lever is taken away and then returned, the rat will continue to press it as before in order to receive its reward. CET may benefit from this added concept as it could also try to then extinguish operant cues by presenting the cue/lever/vodka bottle without any reinforcement/pleasurable effects of alcohol. Thus, it would seem that CETs theoretical rationale could be improved by the introduction of some concepts from the operant conditioning paradigm.

In conclusion, despite the fact that CETs theoretical rationale is subject to a wide range of limitations, such as the problems with extinction discussed above, it also appears to have potential as a useful treatment for addiction. It is possible that combining CET with other treatments, such as CBT, and using concepts from other conditioning paradigms, may help broaden the scope of CET and help it to overcome the factors that limit its effectiveness.

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