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Addictions: Tools for "Controlled" Drinking
6 CEUs Addictions: Tools for Controlled Drinking

Section 13
A Cognitive Processing Model of Alcohol Craving

Question 13 | Test | Table of Contents | Addictions CEU Courses
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Major features of automatic processing. Automatized performance can be characterized as having the following features. First, with practice, automatized actions speed up and become less variable. That is, automatized behaviors are increasingly fast and stereotyped. Secondly, automatized actions tend to be stimulus bound. The mere presentation of stimuli that have become associated with the performance of an action can trigger the execution of the automatized sequence. Thirdly, in the presence of the appropriate enabling stimuli, it may be difficult to inhibit an automatized action. Also, once initiated it may be exceedingly difficult to prevent the completion of an automatized sequence. Thus, automatized actions exhibit a lack of control. Fourthly, automatized actions are easy and non-demanding; they require relatively little cognitive effort. Moreover, automatized actions generally do not interfere with other automatized sequences or disrupt cognitive tasks that do require effort and attention. Finally, much of the cognitive regulation of automatized performance seems to occur outside of awareness.

Automatic processing and alcoholism. The cognitive processing model proposes that, over a long history of drinking, many of the actions required to acquire and consume alcohol become automatized for the alcoholic. That is, as with any other skill, over the course of repeated practice, alcohol consumption in the alcoholic can be seen as stimulus bound, stereotyped, effortless, difficult to control and largely regulated outside of awareness. Many of the actions of the highly practiced addict, both during regular use and during relapse, may be viewed, not as a consequence of craving, but as an example of the kinds of behaviors exhibited by any automatized skill (Tiffany & Carter, 1998). An excellent example of automatic drinking was captured by Ludwig (1988) in his consideration of the various ways that alcoholics can experience compulsions to drink: "Others essentially think instinctively, short circuiting both imagery and cognitions, and are inclined to act without knowing why. When alcohol becomes readily available, they drink before they think" (p. 92).

The cognitive processing model acknowledges that behavioral sequences as complex as alcohol seeking and alcohol consumption can rarely be regarded as being completely regulated by automatized functions. Skilled performance on complex tasks is likely to be controlled by an assembly of automatic and non-automatic processes (Tiffany, 1990). However, to the extent that components of those sequences are practiced repeatedly under consistent training conditions, elements may become increasingly automatized and integrated into higher-order automatized structures. Moreover, with repeated practice of fixed chains of behavior, even elements of behavior appearing early in the sequence may become increasingly regulated by automatized processes.

Major features of non-automatic processing. In direct contrast to automatic functioning, non-automatic processing can be characterized as slow, flexible, dependent upon intention, cognitively effortful and restricted by limited cognitive capacity. This kind of processing would be required under three kinds of circumstances. First, as described above, the acquisition of any skill typically requires, at the outset, some degree of non-automatic processing. However, with practice, regulation of the skill is transferred to automatized modes of control. Secondly, occasionally, even highly automatized sequences encounter unexpected obstacles that cannot be surmounted without the activation of non-automatic forms of processing. For example, imagine that you area highly practiced operator of a television remote control. As you sit in front of your television, mindlessly flipping through the channels, the remote control suddenly dies. You are now confronted with a problem that cannot be resolved through those automatized sequences you use to operate the remote control. This situation will demand the activation of non-automatic processing to manage the problem. Finally, it is widely accepted that it requires considerable non-automatic processing to impede or inhibit the execution of activated automatized sequences (Shiffrin & Schneider, 1977). This can be demonstrated fairly easily in the following way: turn to any page in this paper and try to count the number of periods and commas without reading any of the text. Clearly, it will be nearly impossible to keep from reading at least some of the words you see. Reading is such a highly automatized activity that it takes a great deal of concentration and effort to prevent your-self from doing it.

Non-automatic processing and craving. The cognitive processing model hypothesizes that craving represents the activation of non-automatic processes that are activated in parallel with automatized drug-use sequences. These are activated either (1) in an attempt to overcome obstacles to the completion of automatized drug use or (2) in an attempt to prevent the execution of a mobilized automatized sequence. These kinds of situations generate, respectively, the craving we see in alcoholics who are not attempting to quit using drugs and the craving associated with alcoholics attempting abstinence.  Consider craving that comes about in alcoholics who are not trying to remain sober but who encounter some obstacle to their continued drinking. What about the alcoholic who goes to his local bar, the one where he does much of his drinking, only to discover that it is closed for remodeling? This obstacle will demand the activation of some measure of non-automatic cognitive processing to solve this unexpected problem. The non-automatic cognitive substrates of craving should be manifest in four domains. First, overt behavior will be characterized by actions to overcome the obstacles. For example, the alcoholic may have to hunt for another bar or find a store and purchase alcohol. Secondly, self-report should include expressions of desire for alcohol and intentions to find and consume alcohol. The alcoholic will also probably report frustration and anger at being thwarted in his attempt to drink. Thirdly, it is probable that the alcoholic will display elements of autonomic activation that reflect either the physical or cognitive demands of the craving situation. For example, the actions required to secure a new source of alcohol may require some physical exertion; if so, autonomic systems will be mobilized to support the metabolic demands of these actions. In addition, perhaps the solution to the alcoholic's dilemma is not immediately apparent. Consequently, the cognitive demands of the situation will also be associated with some degree of autonomic activation.  These first three kinds of variables (overt behavior, self-report and autonomic responses) represent the categories of reactions traditionally identified with craving activation. However, this model proposes that craving processes may be indexed by a fourth category of variables not typically associated with craving assessment; namely, indices of the cognitive demands of craving. The cognitive-processing model posits that craving represents the operation of capacity-limited non-automatic cognitive processes. These function at the cost of disruption of other activities that also demand non-automatic processing.

Implications of the cognitive processing model
The cognitive processing model presents an approach to craving distinctly different from the traditional view of the form and function of craving. Future research on alcohol craving and treatment may wish to consider some of the following issues suggested by this model:  A core proposition of this cognitive model is that alcohol use can operate independently of the processes that control self-reports of craving. As reviewed in this paper, this proposal certainly appears compatible with a considerable amount of research on alcohol craving and alcohol use. If craving is not necessary for alcohol consumption in the alcoholic, then measures of self-reported craving cannot be viewed as proxies for alcohol consumption or indices of general alcohol motivation.

Studies of autonomic responses generated in studies of alcohol craving are nearly always depicted as examples of classically conditioned responses. According to the cognitive processing model, many of the physiological changes that accompany craving reports represent reactions to the behavioral or cognitive demands of the situation and are secondarily, if at all, classically conditioned drug-withdrawal or drug-appetitive effects. The possibility that the autonomic physiology of craving is not limited to classically conditioned responses allows craving researchers to evaluate physiological data from the broader perspective offered by cognitive psychophysiology (e.g. Jennings & Coles, 1991).  The possibility that craving and consumption are, at best, only loosely coupled, has profound implications for the development of medications for the treatment of alcoholism. For example there may be no need to expect that effective anticraving medications should reduce alcohol consumption. Similarly, there may be no need to assume that effective anticonsumption medications should necessarily reduce craving or, even if they do, that their efficacy derives from their impact on craving.  The treatment approaches suggested by the cognitive processing model focus not on the alleviation of craving but, rather, on increasing the chances that the alcoholic would be able to successfully avoid or counteract automatized drug-use routines. According to this model, effective treatments should (a) target the stimuli that drive automatized drug-use routines, or (b) work to protect or enhance the processing resources required to impede the execution of activated automatized sequences. With regard to eliciting stimuli, any treatments that eliminate or degrade the cues that trigger automatized drug-use sequences should decrease the probably of alcohol use. For example, to the extent that elements of alcohol withdrawal reactions activate automatic alcohol-seeking behaviors, a treatment that reduces withdrawal should protect the alcoholic from relapse.

Although treatments might be fashioned to reduce an alcoholic's exposure to evocative cues, it is inconceivable that the abstinent alcoholic could be protected from all stimuli that might trigger automatic drug-use behaviors. Even under the best of circumstances, maintaining abstinence in the face of such stimuli would require considerable cognitive effort. Non-automatic processing has limited capacity, and anything that depletes processing resources will decrease the chances that the alcoholic will be able to successfully resist automatized drug use. It is not likely, for instance, that the alcoholic faced with the cognitive challenges of coping with intense stress or chronic negative affect would have the residual resources to successfully battle automatized drug-use behaviors. Any intervention that reduces ancillary demands on processing resources should promote continued abstinence. Similarly, any treatment that increases cognitive capacity should aid abstinence.
- Tiffany, Stephen T.; Conklin, Cynthia A.; A cognitive processing model of alcohol craving and compulsive alcohol use;  Addiction, Aug2000 Supplement 2, Vol. 95

Personal Reflection Exercise #6
The preceding section contained information about a cognitive processing model of alcohol craving.  Write three case study examples regarding how you might use the content of this section in your practice.

According to the cognitive processing model, what should effective treatments for alcohol abuse include? Record the letter of the correct answer the Test

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