st.onge paper

8/2/2019 St.onge Paper

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Neurocognitive underpinnings of denial and decision making 1

Neurocognitive underpinnings of denial and decision making

in treatment choice for drug addiction

Sarah St. Onge

Cognition

James Nelson, PhD, Professor

Derner Institute for Advanced Psychological Studies


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Neurocognitive underpinnings of denial and decision making

in treatment choice for drug addiction

Drug addiction is conceived as a cognitive disorder that shares similarities with

neuropsychiatric and psychiatric disorders (such as schizophrenia). One notable

similarity is impaired awareness. This impairment affects failure to recognize an

illness, denial of illness, compromised control of action, and unawareness of social

incompetence (p. 372). In addition, impaired self-awareness affects such basic daily

functions as decision making. According to the results of a 2006 national survey on

drug use and health (SAMHSA, 2007, as cited in Goldstein et al., 2009), 80% of

addicted individuals failed to seek treatment because they were unaware of the severity

of their illness. Added to these 21.1 million persons, are individuals who are aware of

their illness, in treatment or remission. This results in an astronomical percentage of

people in our nation suffering from substance abuse or struggling not to relapse. This

reason alone behooves us to study the neurocognitive underpinnings of this disorder so

that practitioners from related fields can work together to determine the most effective

way to support and aid such individuals.

NEUROCOGNITIVE FINDINGS


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Three neuro-scientific studies offer significant and overlapping findings about the

effect and interaction of denial among the affected brain regions of addiction.

Goldstein and her colleagues (2009) place emphasis on the insula, anterior cingulate,

and dorsal striatum regions found to be most related to interoception, insight and self-

awareness. Bechara (2005) considers the conflicting impact of the dual systems of the

amygdala and prefrontal cortex in affecting the cognitive resources needed to exercise

willpower and impulse control in decision making. Verdejo-Garcia and Perez-Garcia

suggest alterations in the frontostriatal systems, which play a critical role in self-

awareness and denial.

Goldstein et al. (2009)

Among the affected brain regions in addiction, the insula, anterior cingulate, and

dorsal striatum regions are most related to interoception, insight and self-awareness.

These concepts are needed to help us recognize and describe our own (and others)

behaviors, cognitions and mental states (p. 372). Damage to any of these neural

circuits affects other, related neural structures, resulting in dissociated, or dysfunctional

behavior. As such, drug addiction can be viewed as a compromised ability to

recognize external and internal drug-related cues (p. 373), resulting in excessive use,

dysregulated control of use, and compromised self-awareness, often mislabeled

denial.

Clinical psychologists looking to the DSM-IV to guide decisions about a diagnosis

of drug dependency, note that altered awareness is a major criterion. However, with

denial in question as a valid marker of altered awareness, neuroimaging offers another


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example of what such a state looks like. Also, given the importance of self-awareness

and interoception in understanding drug addiction and its treatment, practitioners need

to have a better grounding in the abnormalities in the insula and medial regions of the

prefrontal cortex (including the anterior cingulate and mesial orbitofrontal cortices) that

underscore interoception and behavioral control.

The insula

The posteria insula in all primates contains interoceptive representation of the

physiological condition of the body. The anterior insula in humans integrates emotional

activity from other forebrain regions for a re-representation of interoceptive responses,

and is also related to emotional awareness, empathic feelings, and to cooperative social

behavior.

In determining the role that the insula plays in drug addiction, an interesting study

on cigarette smoking was conducted by one of the authors (Bechara in Naqvi et al.,

2007, cited in Goldstein et al., 2009). 19 smokers with sustained damage in the insula

were compared with 50 smokers who sustained damage in other areas of the brain.

Consistent with other research findings on the crucial role of the middle insula in

cravings for food, cocaine and cigarettes, the insula-damaged smokers experienced a

disruption in nicotine addiction as indicated in neuroimaging studies.

The anterior cingulate cortex

Similarly, reduced activity in the anterior cingulate cortex was associated with

selective attention and inhibitory control for cocaine, heroin, alcohol, cannabis and other

drug users. For example, in a study that compared cannabis users and non-users on a

task of determining error awareness, imaging reported blunted rostral and dorsal


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anterior cingulate (and insula) response along with significant diminished awareness of

errors in cannabis users. These studies predict, It is most likely that abnormalities in

the insula contribute to intense drug cravings and compromised insight and awareness

of disease severity, whereas abnormalities in the cingulate cortices contribute to the

disadvantageous decision-making that precipitate relapse (p. 377).

Additionally, the anterior cingulate cortex is implicated in conscious and

subjective experiences (such as pain and pleasure). The anterior cingulate and bilateral

anterior insula work together for perceptual awareness of visual or auditory stimuli.

Damage in these regions correlate with decreased emotional self-awareness and self-

conscious behaviors, and affect decision-making abilities. Distinctive roles for the

anterior insula and anterior cingulate cortices affect control over ones behavior.

Together, the anterior insula and anterior cingulate cortices are conjointly activated in all

human emotions and behaviors.

The dorsal striatum

Neural imaging results indicate that there is a switch that occurs from voluntary to

automatic drug use involving movement from the prefrontal cortex to the dorsal striatum

region of the brain, the site of dopaminergic reactions. This affects both drug-seeking

and drug-taking behavior. In a study with rats (Miller & Cohen, 2001, cited in Goldstein

et al., 2009), it was found that disconnecting the ventral-dorsal striatal loop greatly and

selectively decreases habitual cocaine seeking (p. 377). This switch to an automatic

and habitual system adds to an already compromised insight into the severity of ones

addiction.


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Drug cues have been found to stimulate drug craving in the limbic reward

circuitry of the brain. Imaging results indicate that, both cocaine and sexual unseen

cues activated the ventral striatum/pallidum, amygdala, anterior insula, and caudo-

lateral orbitofrontal cortex, paralleling prior studies of reward circuitry in humans and

animals (Childress et al., 1999, cited in Goldstein et al., 2009). These findings suggest

that drug-related stimuli outside of awareness affect brain motivational circuits but also

point to possible treatment modalities that may rely on systematic desensitization

efforts.

Bechara (2005)

Bechara noted that there are similarities between substances abusers and

patients with damaged ventromedial prefrontal cortex (VMPC) areas of the brain. Both

have a tendency to deny, or are not aware that they have a problem. Specifically, it was

noted that when faced with a choice that could result in an immediate pleasure

response versus negative future consequences, the majority of both drug addicts and

VMPC patents chose the more immediate, pleasure-seeking reward. This finding was

substantiated in a study in which patients and addicts were taught the rules to a

gambling game: the Iowa Gambling Task. Subjects were asked to choose between four

decks of cards, each with a different potential payoff, to maximize their monetary gain.

63% of drug addicts performed within the range of patients with VMPC in choosing

cards with immediate financial rewards despite increasing losses associated with those

choices. Based on this finding, Bechara became interested in understanding the link

between substance abuse, denial and decision making.


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Bechara proposes that multiple brain mechanisms work together in addiction. He

believes that addiction is a condition in which the neural mechanisms that enable one

to choose according to long-term outcomes are weakened, thus leading to loss of

willpower to resist drugs (p. 1). In fact,

Bechara suggests that while we may see reduced decision-making as a result of

addiction, it may well be that a weakened decision-making ability underlies the initial

use and escalation of substance use leading to addiction.

Somatic marker theory

Bachara bases his research on a somatic marker hypothesis. Somatic markers

are emotion-related signals, both body- and brain-related, that assist cognitive

processes in implementing decisions. The somatic marker hypothesis is a systems-

level neuroanatomical and cognitive framework for choosing according to long-term,

rather than short-term, outcomes (p. 1). The amygdala and VMPC are critical for

triggering somatic states: The amygdala responds to events that occur in the

environment; whereas the VMPC responds to events in memory, knowledge and

cognition. Bacharas research indicates that willpower emerges from an interaction

between the two neural systems in which the amygdala and VMPC reside: the impulsive

system and the reflective system.

The impulsive system

The somatic marker theory links the features of the stimulus to its

affective/emotional response. Physiological evidence suggests that powerful, short-

lived affective responses occur in the amygdala, such as viewing or encountering an

object of fear (e.g., a snake) or pleasure (e.g., money). Although money is not initially


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associated with affective properties, when its image is linked with drug use, it can

become a powerful reward trigger in the impulsive system. Research has been

conducted that suggests that drug cues, such as pictures of a needle, can also produce

strong, affective triggers in the amygdala-ventral striatum system. Like the Goldstein et

al. study, this ascribes a functional role to the striatum in the motivational and

behavioral aspects of drug seeking and addiction.

The reflective system

The VMPC is a critical substrate in the neural system necessary for triggering

affective states from recall or from imagination (Bechara, 2004, cited in Bechara, 2005).

In the reflective system, affective reactions can also be generated from recall of

personal or imagined affective/emotional events. One would think that recall of negative

consequences of drug use (i.e. trouble with the law, bodily damage, loss of finances,

family,job) would affect ones decision making process in future drug use; however,

dysfunction in the VMPC causes a state of obliviousness that may lead to escalating

use, and vulnerability to addiction.

Other systems within the VMPC are also linked to critical processes in decision

making. The dorsolateral sector of the prefrontal cortex and the hippocampus are

linked to memory. Maintaining an active representation of memory over a delay of time

involves the dorsolateral sector of the prefrontal cortex, and patients with damage to this

structure show compromised decision making. Thus, decision making depends on

memory as well as for emotion and affect.


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Cross-over effects

Bechara claims that addiction is the product of an imbalance between these two

separate, but interacting, neural systems that control decision-making. The control

between the two is not absolute; but evidence suggests that hyperactivity within the

impulsive system can override the reflective system. Drugs and drug cues can trigger

bottom-up, involuntary signals originating from the amygdala to take over the goal-

driven cognitive resources that are needed for the normal operation of the reflective

system and for exercising the willpower to resist drugs. However, there are also top-

down effects that mediate this finding.

Decision making deficits in addicts, and also in some of the normal controls in the

study, are not uniform across all individuals. As opposed to the 63% of addicts who

performed similarly to the VMPC patients, 27% did not. Bechara believes that there

may be more than one mechanism by which the reflective system exerts control over

the impulsive system. Besides decision making, there are other mechanisms of

inhibitory control to be examined, such as the ability to inhibit the intrusion of unwanted

information (such as thinking about drugs). Also, other neural regions of the prefrontal

cortex still need to be examined to determine the saliency of their effects on addiction.

Verdejo-Garcia & Perez-Garcia (2005)

In a study examining self-awareness of cognitive deficits in drug addicts,

Verdejo-Garcia & PerezGarcia state, Recent neuro-scientific evidence suggests that

denial of problems related to drug use can be associated with alterations in the

frontostriatal systems, which play a crucial role in executive functions and self-

awareness (p. 172). This area also affects emotional regulation and motivation.


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Specifically, poor awareness of cognitive deficits during rehabilitation can be

associated with reduced motivation towards reaching treatment goals, failure to use

recommended compensatory strategies, and a greater feeling of control over risky

behaviors, including those involving an actual encounter with the drug in the

environment. (Rinn, 2002, cited in Verdejo-Garcia et al., 2004, p. 174).

Study participants included a sample of 38 abstinent poly-substance abusers and

their self-appointed informants in Granada, Spain. Informants were required to know

the substance abusers well enough to report on their daily behavior patterns. All

abusers were abstinent for a minimum of 15 days and had ended rehabilitation at the

same time. No participant was taking any substance-related medication. Substance

abusers and their informants were asked to complete the Frontal Systems Behavior

Scale (FrSBe), a 46-item rating scale with 3 independent subscales for: apathy (poor

initiation, loss of energy and interest, blunted affective expression), disinhibition

(problems with inhibitory control, socially inappropriate behaviors, unmodulated or

excessive emotional expression), and executive function (deficits in planning, working

memory, mental flexibility). The FrSBe has high internal consistency and reliability,

especially in detection of frontostriatal deficits in substance abusers. The standard

version of the scale is intended to quantify behavioral change due to frontal lobe

lesions.

Abusers were assessed during drug use (they were asked to retrospectively

rate their behavior during lifetime drug use) and during abstinence. Results indicated

that informants scores were significantly higher than substance abusers scores on

apathy and executive function during drug use, indicating poor awareness of deficits.


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No significant discrepancies between abusersand informants scores were noted

during abstinence. Severity of alcohol and cocaine abuse significantly predicted poorer

self-awareness during drug abuse, but not during abstinence.

Based on the findings of this small study, researchers concluded that the

frontostriatal systems play a critical role in supervisory and self-awareness processes

in drug addiction. This is supported by previous observations about the similarities

between substance abusers and patients with lesions in the orbitofrontal cortex, who

also tend to present with poor awareness of their cognitive deficits. These results are

also consistent with the previous studies of Goldstein et al. and Bechara whot have

reported incidental and direct evidence of the relationship between cognitive deficits and

denial or poor awareness in drug addicts.

Although substance abusers reported relatively high levels of behavioral

symptoms (especially of executive dysfunction) during drug use, discrepancy with

informants scores may have relevant clinical implications. For example, reduced

awareness about the actual degree of deficits might be closely associated with poor

judgment and a variety of ill-considered choices during drug abuse, including sharing

needles, risky sexual behavior, driving under the influence of drugs, and higher

incidence of antisocial behavior. Furthermore, neurocognitive skills seem to modulate

the response of high-risk populations to prevention materials. Thus, the findings could

have important implications for prevention strategies, which should highlight the impact

of drug abuse on self-awareness. These findings may also have important implications

for motivational attitudes towards treatment, since substance abusers presenting poor


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awareness may be reluctant to acknowledge their addiction and to seek treatment (Rinn

et al., 2002, cited in Verdejo-Garcia & Perez-Garcia, 2005).

TREATMENT

The particular construct of denial is one that has various meanings within the

field of psychology. Understanding its function with substance abusers and determining

answers to essential questions is vital in determining effective treatment plans. For

example, given that there is impairment in substance abusers self-awareness, to what

extent can insight-oriented therapies be effective? With drug addiction seen as a

cognitive disorder, which cognitive therapies may be most effective? Similarly, with our

greater understanding of the neurological circuitry in addiction, how can

psychopharmacological interventions best improve neuropsychological functioning?

Also, if improved self-awareness is the goal, how can treatments be devised without

running the risk of incurring greater negative affect leading to greater substance use?

Some research offers hope and direction in designing effective treatment. For

example, studies involving activation of the anterior cingulate cortex (Grusser et al.,

2004; Paulus et al., 2005; Garavan et al., 2008, cited in Goldstein et al., 2009), indicate

positive outcome in alcoholics, methamphetamine and cocaine users. The well-

established role of the orbitofrontal cortex (Rolls, 2000, as cited in Goldstein et al.,

2009) in reversing stimulus-reinforcement associations also suggests a positive role in

insight and awareness. However, most current treatment for drug addiction falls within

more traditional approaches, ignoring the wisdom of neuroscience.


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The treatment-as-usual for alcohol or other substance abuse in the United States

is based almost exclusively on the 12-step, Hazelden, or Minnesota model. This

treatment modality is based on the premise that addiction is a disease, most likely

genetic, and not controllable unless one is completely abstinent. Furthermore, addiction

is considered incurable and irreversible. Unfortunately, there have been a number of

research studies that indicate that the disease model is not very effective in treating

addiction. Empirical evidence now points to the fact that substance use is a

continuously distributed phenomenon, ranging from problem use to dependence, and

not a discrete entity in which one diagnosis fits all. Thus, people who may be problem

drinkers but are not alcoholics, for instance, are not getting the help they need. Also,

the fear of labeling and stigma (i.e., I am an alcoholic), and the negatively-tinged moral

stance directed towards abusers is a major barrier to treatment entry. Empirically-

based treatments, on the other hand, have personalized, non-judgmental approaches

that lower resistance and increase awareness of ones abuse and engagement in

treatment.

Evidence-based treatments

In determining what constitutes as evidence-based treatment, Miller et al. (2005),

examined the conclusions of 10 reviews of evidence-based treatments from seven

research groups. The studies more than a thousand controlled clinical trials in the

literature for alcohol, tobacco, and illicit drugs - ranged from randomized clinical trials,

the gold-standard research design of the U.S. Food and Drug Administration (FDA) for

approving pharmacotherapies, to quasi-experimental and correlational studies. In

addition, anecdotal case reports, professional opinion and best practice guidelines


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developed by clinician consensus, such as was used to develop the Treatment

Improvement Protocols published by the U.S. Center for Substance Abuse Treatment,

were considered. Among the meta-analysis, 12-step programs fared 13th from a list of

29 treatment modalities. Topping the chart were motivational interviewing, cognitive-

behavioral treatments, and community reinforcement approaches. Thus, these are the

treatments that I will now discuss.

Motivational interviewing

For addicts, the notion of hitting bottom was often thought to be necessary for a

person to admit he or she had a problem and to accept help. Those who did not reach

that stage were thought not to be sufficiently motivated, Over the past three decades,

however, there has been a gradual yet dramatic shift in thinking about motivation for

change (Miller, 2005). With theoretical underpinning from self-determination theory, a

transtheoretical model for change emerged, in which people are thought to pass

through four discrete stages: precontemplation, contemplation, preparation, and

action/maintenance. The transition between each stage is dependent upon various

motivational tasks. Also, there was new thinking about the addictive personality. After

considerable numbers of research studies on alcoholism, it was evident that people with

alcoholism appeared to be as variable in personality as the general population.

Motivation was seen as a result of an interaction between the drinker and those around

him or her. Motivation was no longer something one has, but rather something that

one does. It involves the recognizing of a problem, searching for a way to change, and

then beginning and sticking with that change strategy (p. 134).


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Motivational interviewing consists of four strategies: expressing empathy for the

patients problems, developing discrepancy between how the patient is acting and how

that behavior interferes with other life goals, rolling with the patients resistance, and

supporting self-efficacy. Within the developing discrepancy strategy there is room for

the therapist to assist the substance user with feedback on areas in which the lack of

self awareness and denial is playing into repeated patterns of use and abuse. The

FRAMES model is currently seen as a major form of motivational enhancement which

includes these strategic elements. The six key elements upon which the FRAMES

acronym is based: offering non-jugmental Feedback on risks; stressing personal

Responsibility for changing; offering Advice to change when appropriate; providing a

Menu of alternative strategies for change; communicating Empathy for the patient; and

facilitating a sense of Self-efficacy. Organizations, such as The Center for Motivation

and Change in Manhattan, utilizing motivational interviewing techniques among other

cognitive-behavioral and psychodynamic approaches, are reporting excellent results

(from personal training at the Center, summer 2009).

Cognitive-behavioral approaches

Behavioral theories view psychoactive substance use disorders (PSUDs) as

resulting from a combination of factors presumed to interact in different ways to produce

PSUDs depending on each individuals unique characteristics and environment. Basic

assumptions of cognitive-behavioral treatments (CBT) include the following: behavior is

largely learned, rather than determined by genetic factors; the same learning process

that creates problem behaviors can be used to change them; behavior is largely

determined by contextual and environmental factors; and covert behaviors (thoughts,


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feelings) can change with the application of learning principles (Rotgers, 1996).

Additionally, actually engaging in new behaviors in the contexts in which they are to be

performed is a critical part of change. Like motivational interviewing, a critical task of

CBT is to foster motivation, but it also teaches or re-teaches important coping skills,

such as craving management and works to enhance interpersonal functioning,

communication skills and social support. These goals that can target many of the

cognitive deficits that remain out of awareness in the denying user. Amongst the many

forms of CBT, The Community Reinforcement Approach (CRA) is seen as most

effective, but other approaches include behavioral marital therapy, contingency

management, and dialectical behavior therapy. Systematic desensitization and cue

exposure therapy are two especially useful CBT strategies that can aid in relapse

prevention by bringing into awareness the stimulating effect of drug cues on the

amygdala system.

CRA and Community Reinforcement Approach and Family Training (CRAFT)

The CRA is a comprehensive behavioral intervention for substance-abuse

problems that focuses on multiple problem areas in an individuals life. It utilizes social,

recreational, familial, and vocational reinforcers to aid in the recovery process. The

reinforcing community includes family, friends, work/school, church, and social

activities. This operant program attempts to rearrange environmental contingencies

such that sober behavior is more rewarding than drinking or drugging, and

accomplishes this through positive reinforcement and specifically avoids the use of

confrontation (Smith et al., 2003). The CRA was the first of two treatments developed.

However, since it is common for individuals with substance use disorders to be


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uninterested in (due to lack of self-awareness and denial) and even opposed to

treatment, CRA was modified so that it could work through concerned family members

and friends of the addict as part of a programmatic effort to get the individual to seek

treatment. Central clinical components include sobriety sampling, developing a

treatment plan that may include optional use of disulfiram or antabuse, behavioral skills

training (such as improving impulse control and decision making skills), social and

recreational counseling, CRA marital therapy, CRA relapse prevention, and other

strategies (such as job counseling).

Psychopharmacological interventions

Abusable substances affect the limbic system of the brain. When dopamine is

released, neurotransmitters attach to specific receptors in the brain which cause a

pleasure response or high. Repeated stimulation of these receptors creates tolerance,

as well as withdrawal. In addiction, there is a decrease in the dopamine receptors

which reduces sensitivity to anything rewarding; the high is decreased, while the craving

is increased. Substance abuse treatment programs refer to the repeated attempts to

replicate the first high as chasing the dragon. The purpose of most

pharmacotherapies is to target the brain receptors or

neurotransmitters/neuromodulators that are dysregulated in addiction to a particular

drug of abuse (Miller & Carroll, 2006, p. 241).

Psychopharmacological interventions for substance abuse tend to fall within four

categories: agonists, indirect agonists, partial agonists, and antagonists. Robust

principles from drug-based research suggest that agonist replacement therapies have

the most efficacy for some drugs, such as methadone for heroin. Agonist therapies


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have advantages in that they do not require detoxification, they can prevent withdrawal,

and at adequate doses, they can reduce the reinforcing effects of the abused drug by

blocking the involved brain receptor. Partial agonists, such as buprenorphine for

opiates, which have milder agonist properties, less abuse liability, and greater safety,

can be very useful for office-based practice. Antagonists of specific receptors have

generally been found to be ineffective due to problems with adherence, the need for

detoxification, and side effects. Antagonists may be more beneficial with alcohol abuse,

because the antagonist blocks only a subset of the drugs actions and are less likely to

precipitate a withdrawal syndrome or result in discontinuation of the medication.

Indirect methods of inhibiting a drugs reinforcing potential (either positive or negative

reinforcement) that appear promising include medications that enhance the function of

the GABA (a major inhibitory neurotransmitter) system (e.g., topiramate for alcoholism)

or increase tonic levels of dopamine (e.g., disulfiram for cocaine)(from a lecture by Rita

Goldstein at the Stony Brook University Counseling Center where I work as an Extern).

Drugs that primarily make the drug of choice aversive (e.g., disulfiram for alcoholism),

are likely to be associated with compliance problems.

Pharmacotherapy can play a role at different stages of the recovery cycle

including initial abstinence and relapse prevention. The type of pharmacotherapy

needed at each stage may vary. All studies of pharmacological treatments have

incorporated some kind of counseling, from basic education about how to use the

medication to comprehensive behavioral approaches. The intensity and nature of the

behavioral treatment component can influence the overall outcome of treatment for an

individual patient. Combining therapies, such as cognitive-behavioral approaches with


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psychopharmacological interventions, offers the greatest support in adhering to

treatment.

Psychodynamic approaches

Although psychodynamic therapy is considered one of the less effective

treatments for addiction, I believe it should be considered, at least as an adjunctive

therapy. The one-on-one nature of the therapeutic setting is conducive to

understanding the nature, prognosis and possible treatment of addiction for the

individual person. Winnicott (1960) wrote, Changes come in an analysis when

traumatic factors enter the psychoanalytic material in the patients own way, and within

the patients omnipotence. (p. 37).

Lisa Director, a psychoanalyst who has worked successfully in the field of

substance abuse for many years, claims, Psychoanalysis has much to offer the chronic

substance user: while most drug treatment seeks to end substance-abusing behavior,

the psychoanalytic effort would encompass this goal and extend beyond it to explore

the omnipotent state that finds fruition in drug use and in other patterns of behavior in

his or her life. In effect, the analytic tack would be to treat the patients drug use but

seek to disengage such a symptomatic outbreak from the underlying self-state, which

has needed to be preserved for its history and meaning to the person, and for that

reason, warrants understanding (p. 569).

Director believes that the reason many users devotion to their habit outlasts its

delivery of pleasure is suggestive of unresolved relational dynamics. Drugs, drug

paraphernalia and the various effects on varying mood states and methods of

administration service a wide a range of relational needs. From this perspective, the


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therapeutic aim is to find the relational bind partly embedded in a persons drug use,

formulate it as conflict in symbolic terms, and revisit it in the transference, alongside

new connections. Meaning though by no means always or solely effective works to

dismantle addiction, by serving to transpose dynamics into terms of expression and

forms of object relationship that are more accessible to exploration and change (p.

571). Director adds: . . .one more reason why psychoanalysts trained in treating

addiction are uniquely suited to be of help to substance users, as compared with other

treatment professionals: We promote the choice of sobriety, of health overall, but

recognize the complexity of the choice, which lends essential pathos to the human

struggle (p. 582)

Regina Pally (2007) offers a technique that helps to bridge neuroscience and

psychotherapy. In her own therapeutic work, she explains neuroscience concepts to

patients to help them understand the link between past relational issues and the

repeated attempts to replicate those patterns in current behavior. She writes,

Unfortunately, some children receive far less than is optimal [in childhood] and must

erect defenses against powerful negative affect states early in life. These defenses

lead to repetitions, which tenaciously resist conscious awareness and change. What

neuroscience adds is that, in addition to defenses, repetition resists awareness and

change because of deeply encoded non-consciously operating predictions (p. 863).

Helping patients to recognize these patterns brings self-awareness to the surface so

that it can be used to inform change.


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Conclusion

Although I had hoped to learn more about the intersection between the

neurocognitive underpinnings of drug addiction and treatment, what has become

apparent, is that traditional treatment has been slow to integrate or even interface with

findings from the neuroscientific field. Pharmacotherapies address some of the neural

dysfunction and symptomatology of addiction, motivational strategies and CBT

treatments address behavioral issues in drug abuse, and psychotherapy addresses

underlying emotional issues, but much more needs to be done in this area. With

greater understanding of the neuro-structures that most deeply relate to the processes

of decision-making and self-awareness throughout the addiction cycle, including

relapse, treatments need to be devised to support the substance users ability to affect

change. While there may be no exclusively correct answer to which treatment may be

best suited to addiction for substance users, new links combining neuroscience and

psychotherapy should highlight the future direction. In addition, having a neural basis of

insight and self-awareness will enable everyone in the field to work with addicted

individuals with increased understanding, empathy and effectiveness.


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