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ADDICTION AND ITS SCIENCES doi:10.1111/j.1360-0443.2006.01706.

The psychological science of addiction

Elizabeth Gifford & Keith Humphreys


Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA, USA

ABSTRACT

Aim To discuss the contributions and future course of the psychological science of addiction. Background The
psychology of addiction includes a tremendous range of scientific activity, from the basic experimental laboratory
through increasingly broad relational contexts, including patient–practitioner interactions, families, social networks,
institutional settings, economics and culture. Some of the contributions discussed here include applications of behav-
ioral principles, cognitive and behavioral neuroscience and the development and evaluation of addiction treatment.
Psychology has at times been guilty of proliferating theories with relatively little pruning, and of overemphasizing
intrapersonal explanations for human behavior. However, at its best, defined as the science of the individual in context,
psychology is an integrated discipline using diverse methods well-suited to capture the multi-dimensional nature of
addictive behavior. Conclusions Psychology has a unique ability to integrate basic experimental and applied clinical
science and to apply the knowledge gained from multiple levels of analysis to the pragmatic goal of reducing the
prevalence of addiction.

Keywords Addiction, behavior, psychology, substance use disorder intervention.

Correspondence to: Elizabeth Gifford, Program Evaluation and Resource Center (152-MPD), 795 Willow Road, Menlo Park, CA 94025, USA.
E-mail: elizabeth.gifford@va.gov
Submitted 7 July 2006; initial review completed 20 September 2006; final version accepted 16 October 2006

INTRODUCTION defined in the traditional sense as a ‘a rule or law con-


cerning the functioning of natural phenomena [emphasis
Psychology is the study of the individual in context, and added]’ [1]. We emphasize how a functional approach
as such is fundamental to the clinical and research aspi- provides a useful means of orienting scientific efforts,
rations of the addiction field. ‘Addiction’ is a hypothesis, integrating basic and applied domains and leading trans-
namely that a cluster of correlated phenomena are linked disciplinary or interdisciplinary research efforts. We close
by an underlying process (or as Gertrude Stein might by illustrating how the functional principles derived from
have put it, that there ‘really is a there, there’). Without this knowledge base contribute to a progressive, incre-
the behavior of persistent, destructive substance use, the mental science of addiction.
environmental availability of the substance itself, and the Before proceeding to our review of psychology’s sub-
environmental effects on the behavior, it would be diffi- stantive and conceptual contributions to the field, we
cult from a scientific viewpoint (and meaningless from a would acknowledge all too briefly psychology’s far-
clinical viewpoint) to verify the hypothesis that addiction reaching contributions to methods. Graduate psychology
really exists. This does not limit addiction to observable training programs typically place substantial emphasis
behaviors but does identify behavior–environment inter- on measure development and assessment. One dividend
action as the central concern. from this investment is many widely used instruments
Throughout this paper we argue for attending to the designed by psychologists to assess individuals, families,
dynamic multi-dimensional adaptations involved in treatment programs and environments; for example,
person–environment interactions. We describe several Moos’ coping responses inventory [2] and social ecology
domains in which psychology, as a focused and flexible scales [3], Halstead & Reitan’s neuropsychological test
science, is making contributions to understanding the battery [4] and McLellan and colleagues’ [5] Addiction
development, maintenance and recovery from addiction. Severity Index. Psychologists have also been leaders in
From this knowledge base we derive some principles the development and application of quantitative

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
Psychology of addiction 353

methods, including accounting for regression to the occur without thinking (a combination of the effects of
mean [6], establishing construct validation [7,8] and drugs on the brain’s reward systems, particularly dopam-
improving quasi-experimental and experimental treat- ine signaling in the nucleus accumbens, respondent con-
ment evaluations using mediational modeling [9] and ditioning and incentive sensitization [16–18]) and
meta-analysis [10]. Indeed, experimental studies with because of other cognitive processes (e.g. expectancies,
human participants in addiction are almost entirely the beliefs, mental representations, self-efficacy and coping
province of psychologists, including but not limited to [19]. More recent models synthesize these various
many of the methods used to evaluate learning. All these dynamic motivations [13,20]). Notably, all the above
methodological contributions made possible the models are concerned with understanding how and why
advances on which we focus in this essay, as well as innu- addicted individuals persistently respond to certain
merable advances that space limitations will prevent us immediate rewards [13].
from discussing here.
SOCIAL CONTEXT
ADDICTION AND MOTIVATION
Addictive behavior occurs within a social context,
The best scientific evidence for addiction is provided which can serve as a risk or protective factor. Social
by persistent substance use in the face of cumulative contexts and individuals influence one another.
costs, such as psychological distress, social conflict
What are the contexts that influence the above-
and physical harm to health.
described motivations? Psychology has led the field in
Addiction is not simply a physiological process, but the identifying the importance of social connection in
action of multi-dimensional individuals behaving in a addiction, including the conceptualization and measure-
particular fashion in certain contexts. Although many ment of the social ecology in which addicted people
professional and lay individuals speak of addiction as if receive care and in which they live [21,22]. Social
it were synonymous with tolerance and withdrawal, context serves as both a risk factor and protective factor
both of these phenomena can occur without addictive for substance use, playing an important role in addic-
behavior [11]. Indeed, even if we developed a blood test tion’s initiation, escalation, maintenance and relapse;
that could measure precisely the degree of an individu- and conversely in its prevention, treatment and long-
al’s physical tolerance to a drug, it would be hard to term resolution. Relevant social contexts include the
convince ourselves or that person that they were family, provider–patient relationships, treatment envi-
addicted without the evidence of drug-seeking and ronment, peer groups and friendship networks, work
using, i.e. a particular behavior–environment interac- settings, self-help organizations, neighborhoods and cul-
tion. In addition to making psychology of central rel- tural groups, including religious/spiritual communities.
evance to understanding addiction, this distinction also As just a few examples, research in which psychologists
aids in the interpretation of research findings. It may have been involved has shown that association with
explain, for example, why an episode of sustained absti- substance-using peers is a major risk factor for initia-
nence in out-patient treatment predicts subsequent tion, escalation and relapse [23]; that the quality of
abstinence when detoxification alone does not. The provider–patient relationships contributes to patient
change in the persistent behavior, not the absence of the retention in substance use disorder treatment [24]; that
chemical alone, improves the likelihood of future absti- participation in a 12-Step community after treatment
nence [12]. facilitates ongoing recovery [25]; that improving paren-
Descriptions of addiction often use terms such as tal functioning and resources improves substance abuse
‘overwhelming desire’ or ‘out of control’ to describe the outcomes for adolescents [26]; and that participation in
persistence of substance use in the face of damaging con- organized religion and the family and social contexts
sequences [13]. Yet behavior that looks ‘out of control’ to that promote such participation are among the stron-
the observer is in fact an individual’s response to their gest predictors of not initiating substance use in chil-
environment and perceived options at the time. Models of dren and adolescents [27]. Clearly, the dynamic
motivation attempt to characterize the processes under- interface between the social group and the individual
lying these seemingly irrational choices. These models has a powerful influence on addiction.
posit a range of motivations. Stated generally, people use Several general psychological theories describe the
drugs because drugs feel good (positive reinforcement relationships between social context and individual
[14], because drugs reduce or remove the experience of addictive behavior. Among these, social control theory
feeling bad (negative reinforcement [15]), because brain emphasizes the motivational effects of the bonds between
processes enhance the reward value of substances over group members, social learning theory emphasizes the
time to the point that automatic addictive behaviors importance of role models in the development of

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
354 Elizabeth Gifford & Keith Humphreys

substance-related behaviors and attitudes, and stress and Learning principles characterize certain dynamic
coping theory emphasizes the impact of stressors result- interactions between individuals and their environments,
ing from social disorganization on the coping resources of and also offer a unique bridge for integrating basic and
the individual [28]. All these approaches describe influ- applied domains. The most successful psychosocial treat-
ence processes moving bidirectionally between individu- ments for addiction have applied basic functional models
als and their social setting [21]. Current psychological to clinical settings [35]. Contingency management, for
research is focused on characterizing these mutual example, an empirically supported treatment for stimu-
influence processes; for example, some of the dynamic lant abuse and for promoting retention in methadone
adaptational interactions between environments and maintenance programs, applies operant processes of
individuals described below. contingent reinforcement such as vouchers for clean
urine tests and take-home doses for attending clinic
counseling sessions [36]. Motivational interviewing, an
FUNCTIONAL empirically supported cognitive behavioral treatment for
BEHAVIORISM/BEHAVIORAL substance abuse, positively reinforces treatment relevant
ECONOMICS behaviors such as ‘change talk’ using interpersonal pro-
cesses within the therapy session (i.e. support, empathy
Addictive behavior interacts dynamically and
and contingent feedback; [37,38]).
lawfully with its environment.
Dynamic functional processes of problem resolution
The basic principles of learning and conditioning may also occur outside treatment settings [39]. The con-
observed by Thorndike [29] and other psychologists (i.e. tingency of reinforcement mediates contingency man-
operant and respondent paradigms) continue to provide a agement treatment, as specified in its functional model.
framework for understanding the interactions between Yet treatment is only one structured context where these
environment and addictive behavior. For example, Herrn- principles operate. Other social contexts such as 12-Step
stein’s Matching Law characterizes patterns of interac- fellowships or religious communities may also reduce the
tion between changes in reinforcement opportunities and likelihood of drinking or relapse by naturally reinforcing
individual choice [30]. The Matching Law showed that adaptive alternatives to substance use, e.g. sponsors in
the ratio of behavior distributed between two choices will 12-Step programs may provide social support contingent
‘match’ the ratio of reinforcement distributed across on abstinence and encourage socially normative activi-
them, expanding the notion of functional relationships to ties such as working, self-care, family life, recreational
include a broader environmental context rather than just activities, etc. [40]. Communities bring these functional
a unitary reinforcer. For example, environments with processes into play without the conceptual framework of
greater levels of available positive reinforcement in behavioral psychology, e.g. ‘reinforcement’, etc. [41].
general may make it less likely that a particular positively
reinforced behavior, such as substance use, will occur THE PSYCHOLOGICALLY INFORMED
[31]. The Matching Law has provided the basis for many NEUROSCIENCE OF ADDICTION
behavioral economic theories of choice which attempt to
Addiction involves learned responses to a drug and
quantify the relationships between benefit/cost ratios of
to the environments in which drug taking is
substance consumption and benefit/cost ratios of other
experienced. The brain encodes these learning
activities [32].
histories as neuroplastic adaptations including
We would note here that ‘reinforcement’ is a fre-
alterations in the mesolimbic dopamine
quently misunderstood term that refers to a fundamen-
reinforcement systems.
tally personal phenomenon. The form or topographic
features of an event do not define it as a reinforcer (e.g. Learning principles link not only basic and applied
giving a weeping client candy is unlikely to reinforce domains within psychology but also psychology and
continuing discussion of the costs of using); rather, other disciplines, thus offering one natural point of inter-
reinforcement refers to the functional impact of the disciplinary integration. Psychological data derived from
experienced event for that particular person (more the application of learning principles in animal models
technically, whether the event functions to increase have been essential to progress in the neurobiology of
the probability of the behavior it follows in a specific addiction. As stated recently in this journal, the agenda of
context [33,34]). Reinforcement is a function of a modern addiction brain science is to validate molecular
multi-dimensional person interacting with a complex and neurochemical candidate systems functionally by
environment. Attention, perception and motivation, for demonstrating their causal relationships with addictive
example, may be critical in establishing how a reinforcer processes [42]. Basic behavioral methods provide a
functions in any given setting. framework for evaluating the function of candidate

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
Psychology of addiction 355

neurobiological systems (e.g. place preference paradigms, ‘automatic’ and favored. Understanding this process has
drug self-administration, reinstatement of drug seeking, obvious importance for modifying impulsive behavior in
etc.). Relevant systems include those involved in the neu- addiction. In particular, these studies have shown that
ropharmacological processes of behavioral response to the ability to inhibit automatic responding by the frontal
substances as well as the neuroadaptive mechanisms cortex is easily overwhelmed by loading of working
within specific neurocircuits that may mediate addictive memory, which occurs when experiencing stressors such
behavior, such as the circuits recruited in the transition as cravings. In other words, a person may not be able to
from occasional use to uncontrolled use, from positively stop a well-trained behavior such as drug taking using
reinforced to negatively reinforced addictive behavior, or frontal cortex inhibition when they are experiencing high
from compulsive use back to controlled use or abstinence. levels of cue-elicited craving.
Studies of mesolimbic dopamine circuits, for example, Psychology has thus expanded, and at times tran-
have identified neuroadaptive processes linked to rein- scended, its own discipline, applying learning principles
forcement in general (e.g. [43]) and have also identified and other contributions toward improving our under-
effects specific to drugs of abuse that may lead to the standing of the neuroanatomical substrates of affective
overvaluation of drug rewards as compared to natural and cognitive processes such as stress and executive func-
reinforcers [44,45]. tion. The field continues to play a pivotal role in identify-
Cue-elicited craving offers one example of psycholo- ing the dynamic neurobiological processes involved in
gy’s leadership role in transdisciplinary neuroscience col- vulnerability to addiction, consequences of substance use
laborations [46]. The presence of cues associated with the and important aspects of addiction including relapse, loss
availability of learned reinforcers such as alcohol or other of control, craving and drug choice.
drugs will increase behavioral responding for these Psychology can also serve as a useful guard against
rewards [47]. Cue conditioning is a key element in the concluding that because brain systems are involved in
development and maintenance of addiction, and cue- addiction, all solutions to addiction are found in the brain
elicited craving a key aspect of relapse [48]. The neu- (or in genes; see [59]). The environmental stressors that
ropeptide cortisol-releasing factor (CRF) offers one facilitate certain genetic expressions are not equal in their
possible pathway for the relationship between stress, cue effects across individuals. Psychological factors influence
conditioning and relapse in habitual users [49]. CRF how stressors are appraised and coping responses can
released in the nucleus accumbens shell in response to minimize or augment their impact; and changes in the
stress may increase the incentive salience of cues signal- environment can change individual behavior. The behav-
ing the availability of learned reinforcers, increasing ior economic literature, for example, suggests the impor-
behavioral responding for rewards when such cues are tance of restricting access to substances as a strategy for
present. Because drug withdrawal can be a significant reducing addiction, as it raises the behavioral costs of use
stressor, potently releasing CRF in limbic brain circuits, and thereby increases the attractiveness of other behav-
this process may become a negative reinforcement cycle iors. This has been well demonstrated in the effect of ciga-
driving ongoing drug use, described as ‘the downward rette cost on smoking [60].
spiral of addiction’ [50]. Notably, this explanation
describes neurobiological mechanisms conceptualized in
terms of behavioral principles of negative reinforcement. INTERVENTION
Cue-elicited craving has been associated with neu-
Many empirically based substance use disorder
ronal processing in the anterior cingulate cortex and
behavioral interventions facilitate recovery from
frontal cortex [51–53]. A related promising line of neu-
addiction, although not necessarily for the reasons
roscience research examines how the frontal cortex
specified in their theories.
inhibits automatic responding in immediate decision-
making tasks. Performance on executive function/task- Research indicates that well-specified psychosocial sub-
switching tests (which include inhibition) has been stance use disorder treatments have a positive impact on
associated with neural processing in the prefrontal cortex outcome, and there are many such treatments from
in both neuroimaging and electrophysiological studies which to choose. The US National Institute of Drug
[54–56]. For example, several studies have demonstrated Abuse, the British Association of Psychopharmacology
that activity in areas of the frontal cortex is associated [61] and the Swedish Council of Health Care Technology
with the ability to alter responding in a well-trained Assessment [62] are among notable organizations who
signaled response task [57,58]. These studies are provid- have compiled lists of empirically supported treatments
ing important information on individual decisions about for addiction and its prevalent comorbidities. Most of
behavior choice, and about how alternate behaviors can these treatments were developed by psychologists based
be produced even when a given response has become on psychological theories, including motivational

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
356 Elizabeth Gifford & Keith Humphreys

interviewing, social skills training, combined behavioral attributed entirely to intrapersonal variables. Disregard
and nicotine replacement therapy for nicotine addiction, for context has led to some psychologists making pro-
structured family and couples therapy and community nouncements on the ‘universal features of addiction’
reinforcement approach and family training [63]. (among many other features of human existence) on the
Psychologists have taken a leading role in proposing basis of how small samples of white, middle-class under-
new theories of treatment and in promoting rigorous graduates have filled out a questionnaire.
treatment evaluation, including the development of Psychologist have also at times over-psychologized
treatment integrity measures and other methodological ‘addiction’ by not taking drugs sufficiently seriously as
innovations (e.g. despite occasionally being portrayed as environmental features with unique, genuine and power-
a ‘touchy-feely’ irrationalist, the psychologist Carl Rogers ful properties not determined solely by the individual
helped begin the tradition of rigorous evaluation of psy- user’s expectancies, psychodynamic conflicts or cognitive
chotherapies; see [64]). The results of trials comparing biases. Psychologists who market services for alleged
well-specified behavioral therapies (and at times behav- ‘addictions’ to work, shopping and television should
ioral versus pharmacotherapies) show that different well- weigh carefully the public health implications of implic-
specified substance use disorder treatments usually have itly equating long days at the office, discounts at Sains-
similar levels of efficacy [65–67]. However, exceptions to bury’s and re-runs of Star Trek episodes with nicotine,
this rule exist. For example, a recent meta-analysis of heroin and alcohol. The latter three environmental fea-
cue–exposure therapy [68] yielded equivocal evidence for tures should be handled differently by programs and
its efficacy and also failed to support its specified mediat- policy makers because they are objectively different than
ing model, i.e. reductions in cue–reactivity are not pro- the former three, no matter how many people say that
duced by this treatment and/or do not effect the critical they feel addicted to them, ‘just like being addicted to
behaviors [69]. drugs’. The inner life of individuals is, of course, an
Large controlled trials including mediational analyses important part of psychology, but only in the context of
have rarely identified a treatment with reasonable evi- environmental features interacting with behavioral
dence for its purported mechanism of change. Among responses, and what the individual learns from those
the few exceptions appear to be contingent reinforcement interactions. Acontextual theories risk addressing only a
of abstinence in cocaine addiction [70] and Alcoholics small portion of an integrated system, and thus misdirect
Anonymous participation in 12-Step facilitation counsel- our attention to less relevant details at the expense of
ing [71,72]. Accurately identifying mediators is vitally factors related more directly to the phenomenon of
important, because clarifying the critical aspects of treat- addiction [13].
ment may allow us to improve its potency and determine
for whom a particular treatment might work [73]. It is
SETTING THE COURSE: TREATMENT
not as useful to know, for example, that men do better in
RESEARCH AS AN EXEMPLAR
certain smoking cessation treatments than women
unless we also know why and what to do about it (see [74] What can psychology do in the future to avoid repeating
for an excellent discussion). missteps and to break into new directions? Clarifying our
theoretical assumptions may help to guide future
research efforts. The field of treatment research offers one
WEAKNESSES
example.
Psychology has made major contributions to under- Decades of research on clinical treatment has led to a
standing addiction, but we would be the first to acknowl- substantial knowledge base. We know that treatment
edge that it has also occasionally ‘filled a much-needed benefits a significant proportion of addicted people, and
gap’ in the field’s approach and knowledge. Psychologists we have a variety of reasonably effective treatments to
have at times tried to explain individual behavior without offer. However, the results of large, well-funded and well-
sufficient appreciation of context. US psychology has designed treatment research studies such as Project
been the worst offender, in some ways reflecting the larger MATCH [76], the UK Alcohol Treatment Trial [77] or the
cultural narrative that individuals create their own lives VA Multisite Substance Abuse Treatment Study [78]
and triumph over all contexts (or if they do not, they have show that null findings are arguably the single most
only themselves to blame). For example, for every pub- common outcome in large-scale substance use disorder
lished article concerning ‘drug use and poverty’ in the treatment studies. Although one cannot prove the null
psychological literature, more than 50 articles focus on hypothesis that treatments do not differ, the consistency
‘drug use and personality’ [75]. Callous behavior by soci- of these non-results in well-powered studies suggests that
eties and governments are justified too easily when prob- our theories are failing to capture critical factors. It is
lems shaped by powerful environmental forces are time to consider additional strategies.

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
Psychology of addiction 357

Psychologists have long discussed factors common to and respond differently to internal states previously asso-
different treatment approaches that may be responsible ciated with using [90]. In a recent study, patients from
for treatment effects. The therapeutic relationship is the treatment programs with supportive, involved relation-
most frequently researched of these so-called ‘common ships were more likely to respond adaptively to internal
factors’ [79]. Although researchers described originally states associated previously with substance use, develop
the therapeutic relationship as ‘non-specific’ in an constructive social relationships and achieve long-term
analogy to the pharmacologically inert component of treatment benefits. This functional model accounted for
medication, it has become clear that the therapeutic rela- 41% of the variance in outcomes 2 years after treatment
tionship is an active interaction [80,81] that may [41]. Researchers continue to examine the processes
increase treatment engagement and other recovery- involved in socially reinforcing interactions via social
relevant behaviors [24,82]. Currently, the critical ques- neuroscience, basic and clinical process and outcome
tion is how the therapeutic relationship functions, i.e. research.
how does the provider interact with the patient in specific Emphasis on function provides a common empirical
processes which change the patient’s behavior and are ground for examining the behavior change process
responsible for treatments’ effects [83]? across treatment modalities. The pre-existing practices of
Miller [84] recently distinguished ‘name brand’ treat- a variety of treatments and treatment settings include
ments from the mediating processes by which treatments factors related to positive outcomes [41]. Identifying
exert their effects. Summarizing the current knowledge these practices might bring parsimony to the multiplicity
base on addiction in the biological, psychological, social of available treatments and aid in dissemination by build-
and intervention research domains, Miller and colleagues ing on aspects of treatment that providers already deliver.
drew a number of evidence-based conclusions: addictive The dissemination gap between empirically supported
behavior is reinforcing, chosen behavior; emerges gradu- treatments and substance use disorder treatment pro-
ally and occurs along a continuum; does not occur in vider practice is arguably a result of the failure of
isolation but as part of behavior clusters; occurs within a researchers and administrators to address the functional
family context; responds to changes in reinforcement; is aspects of clinicians’ behavior. Rather than simply
affected by a larger social context; has identifiable risk and attempting to impose top-down change, viewed from a
protective factors, tends to become self-perpetuating once functional perspective the dissemination question
established; is motivated behavior; and is influenced by becomes: ‘How do we facilitate behavior change in the
the therapeutic relationship [84]. Notably, all these con- treatment provider?’. To answer this question one first
clusions reflect a functional perspective. needs to understand what providers are doing and then
Psychology has an opportunity to lead the addiction use this information to shape changes in behavior, i.e.
field by identifying functional concepts that characterize build upon constructive evidence-based practices and
the multi-dimensional processes responsible for treat- weaken competing alternatives. Data regarding the func-
ments’ effects. Clarity about these processes will permit tional dimensions of clinician behavior include studies
systematic treatment improvement [35,83]. Conducting showing that meaningful changes in treatment provision
transdisciplinary research requires a shared conceptual are less likely with a single workshop (e.g. [91]) than with
or theoretical framework that integrates knowledge fully ongoing supervisory feedback [92]. Functional principles
across disciplines [85–87]. Among the many contribu- offer specific environmentally based ways of facilitating
tions discussed previously, psychology has also developed behavior change in both patients and providers, includ-
the most precise scientific methodology for validating ing building on current repertoires, shaping new ways of
conceptual constructs (e.g. multi-trait–multi-method interacting and providing systematic methods for gener-
matrices); such methods might be used to identify theo- alizing behavioral changes [93].
retically based functional processes that synthesize In short, using a functional approach to modeling
research across disciplines [88]. behavior change directly targets the patient behaviors
Functional models, by definition, characterize that lead to better long-term outcomes; serves as a point
individual–environment interactions, and therefore of integration for interdisciplinary research efforts aimed
provide a pragmatic means of changing behavior via at characterizing the process of behavior change; pro-
environmental factors. For one example, behavior vides pragmatic methods for influencing these changes in
change is more likely with abstinent supportive social behavior; and builds upon what programs and providers
reinforcement [28]. In applied settings, treatment per- are already doing in order to improve treatment delivery.
sonnel who behave in a supportive rather than a confron- A final compelling reason for focusing scientific efforts
tational manner appear to improve the likelihood of on processes of change is that these adaptational or func-
positive outcomes [82], perhaps by increasing patient tional principles apply beyond the treatment context. The
involvement [89] and helping patients learn to accept processes that contribute to improvement in treatment

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
358 Elizabeth Gifford & Keith Humphreys

may also be implicated in recovery in mutual help The psychologically derived principles or descriptions
organizations, processes involved in ‘natural’ recovery of the ‘functioning of natural phenomena’ presented
(which, indeed, is how most individuals overcome addic- here share an assumption, namely that addiction
tion), prevention and recovery in religious/spiritual cul- research is concerned fundamentally with interactions
tural communities, etc. From a functional perspective, between individuals and their environments, and that
treatment essentially provides a structured environment maintaining clarity about our subject matter will help
within which to influence (i.e. boost variability in) rel- promote a focused, flexible and progressive addiction
evant processes. Thus treatment is particularly important science. Future questions include application of these
for those who do not have access to these types of context principles to broader social contexts. For example, how
in their natural environment or who are in need of more might we apply these principles to addiction in the public
intense exposure to curative environments. Broadening health and public policy domains [99]?
the lens to include context also entails recognizing that Addiction involves dynamic adaptations occurring at
treatment may be simply one chain in a larger causal multiple levels that are influenced by a variety of contexts
model [94]. Clients describe their own change process in including but not limited to treatment environments. If
both intrapersonal and interpersonal terms, embedded in we want to improve our understanding of addiction and
the contexts within and outside the treatment setting recovery, we should examine these processes directly. Psy-
[95]. Indeed, causal mediators of treatment may be diffi- chological science is well suited for this endeavor.
cult to find because the critical processes occur outside
treatment. For example, Longabaugh and colleagues [96]
Acknowledgements
found that improvement in social skills did lead to
improved alcohol treatment outcomes, as described by This work was supported by the US Department of Veter-
their theoretical model, but causal chain analyses ans Affairs Office of Mental Health Services and Health
revealed that these changes in social functioning did not Services Research and Development Service. We thank
occur within treatment. Stephen Maisto, Rudolf Moos and Robert West for
Most members of the field concede that addiction extremely helpful comments and discussions.
research is more informative when it is theoretically
based. Less commonly discussed is the fact that our
References
assumptions specify what sort of theoretical explanations
are considered adequate and thereby guide the direction 1. Dictionary A. H. The American Heritage® Dictionary of the
English Language. In: Answers.com, editor, 4th edn. Boston,
of inquiry. In general, the field of psychology has suffered
MA: Houghton Mifflin Company; 2004.
from a proliferation of theories with relatively little 2. Moos R. Coping Response Inventory: Adult Form Manual.
pruning [35] (see [13] for an excellent discussion; also Odessa, FL: Psychological Assessment Resources; 1993.
[97]). However, the propagation of labels should not be 3. Moos R. Evaluating Treatment Environments. New York: John
mistaken for scientific progress [98]. Psychology’s com- Wiley; 1974.
4. Reitan R., Wolfson D. The Halstead–Reitan Neuropsychological
mitment to rigorous evaluation offers both great progress
Test Batter, 2nd edn. Tucson, AZ: Neuropsychology Press;
and humility. We may need to surrender some of our 1986.
cherished ways of speaking in order to further our 5. McLellan A., Luborsky L., Woody G., O’Brien C. An
ongoing goal of improving interventions that treat and improved diagnostic evaluation instrument for substance
prevent addiction. abuse patients: the Addiction Severity Index. J Nerv Ment Dis
1980; 168: 26–33.
6. Campbell D., Kenny D. A Primer on Regression Artifacts. New
CONCLUSION York: Guilford Press; 1999.
7. Cronbach L., Meehl P. Construct validity in psychological
We have adumbrated psychology’s contributions to tests. Psychol Bull 1955; 52: 281–302.
addiction in the social, behavioral, neurobiological and 8. Campbell D., Fiske D. Convergent and discriminant valida-
intervention domains. This survey fails to describe innu- tion by the multitrait–multimethod matrix. Psychol Bull
1959; 56: 81–105.
merable contributions, including much of cognitive
9. Baron R., Kenny D. The moderator–mediator variable dis-
psychology, developmental psychology, physiological psy- tinction in social psychological research: conceptual, stra-
chology and neuropsychological assessment. Further, tegic and statistical considerations. J Person Soc Psychol
our assumptions and the principles we derive from these 1986; 51: 1173–82.
domains are our own, and both other assumptions and 10. Smith M., Glass G. Meta-analysis of psychotherapy outcome
studies. Am Psychol 1977; 32: 752–60.
other interpretations are possible. We simply hope to
11. O’Brien C., Volkow N., Li T. What’s in a word: addiction
show the relationship between definitional assumptions, versus dependence in DSM-V. Am J Psychiatry 2006; 163:
explanations and progress in what we view as a particu- 764–5.
larly important and vital knowledge base. 12. Lussier J., Higgins S., Badger G. Influence of the duration of

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
Psychology of addiction 359

abstinence on the relative reinforcing effects of cigarette 34. Keller F., Schoelfeld W. Principles of Psychology: a Systematic
smoking. Psychopharmacology 2005; 181: 486–95. Text in the Science of Behavior. New York: Appleton-Century-
13. West R. Theory of Addiction. Oxford, UK: Blackwell Publish- Crofts; 1950.
ing; 2006. 35. Shiffman S. Smoking cessation treatment: any progress?
14. Glautier S. Measures and models of nicotine dependence: J Consult Clin Psychol 1993; 61: 712–22.
positive reinforcement. Addiction 2004; 99: 30–50. 36. Higgins S., Petry N. Contingency management: incentives
15. Eissenberg T. Measuring the emergence of tobacco depen- for sobriety. Alcohol Res Health 1999; 23: 122–7.
dence: the contribution of negative reinforcement models. 37. Miller W., Rollnick S. Motivational Interviewing: Preparing
Addiction 2004; 99: 5–29. People for Change, 2nd edn. New York: Guilford Press; 2002.
16. Baker T., Brandon T., Chassin L. Motivational influences on 38. Moyers T., Martin T. Therapist influence on client language
cigarette smoking. Annu Rev Psychol 2004; 55: 463–91. during motivational interviewing sessions. J Subst Abuse
17. Tiffany S., Conklin C., Shiffman S., Clayton R. What can Treat 2006; 30: 245–51.
dependence theories tell us about assessing the emergence 39. Tucker J. Natural resolution of alcohol-related problems. In:
of tobacco dependence? Addiction 2004; 99: 78–86. Galanter M., editor. Recent Developments in Alcoholism. New
18. Volkow N., Fowler J., Wang G., Swanson J. Dopamine in drug York: Kluwer; 2003, p. 77–90.
abuse and addiction: results from imaging studies and treat- 40. Van Etten M., Higgins S., Budney A., Badger G. Comparison
ment implications. Mol Psychiatry 2004; 9: 557–9. of the frequency and enjoyability of pleasant events in
19. Brandon T., Herzog T., Irvin J., Gwaltney C. Cognitive and cocaine abusers versus non-abusers using a standardized
social learning models of drug dependence: implications for behavioral inventory. Addiction 1998; 93: 1669–80.
the assessment of tobacco dependence in adolescents. 41. Gifford E., Ritsher J., McKellar J., Moos R. Acceptance and
Addiction 2004; 99: 51–77. relationship context: a model of substance use disorder
20. Orford J. Addiction as excessive appetite. Addiction 2001; treatment outcome. Addiction 2006; 101: 1167–77.
96: 15–31. 42. Spanagel R., Heilig M. Addiction and its brain science.
21. Moos R. Social contexts: transcending their power and their Addiction 2005; 100: 1813–22.
fragility. Am J Commun Psychol 2003; 31: 1–13. 43. Waelti P., Dickinson A., Schultz W. Dopamine responses
22. Longabaugh R., Beattie M., Noel N., Stout R., Malloy P. The comply with basic assumptions of formal learning theory.
effect of social investment on treatment outcome. J Stud Nature 2001; 5: 43–8.
Alcohol 1993; 54: 465–78. 44. Schultz W., Dickinson A. Neuronal coding of prediction
23. Bauman K., Ennet S. On the importance of peer influence errors. Annu Rev Neurosci 2000; 23: 473–500 [Review].
for adolescent drug use: commonly neglected consider- 45. Schultz W. Predictive reward signal of dopamine neurons.
ations. Addiction 1996; 91: 185–98. J Neurophysiol 1998; 80: 1–27.
24. Meier P., Donmall M., Barrowclough C., McElduff P., Heller 46. Blakely R., Baker R. An exposure approach to alcohol abuse.
R. Predicting the early therapeutic alliance in the treatment Behav Res Ther 1980; 18: 319–25.
of drug misuse. Addiction 2005; 100: 500–11. 47. Pecina S., Schulkin J., Berridge K. Nucleus accumbens CRF
25. Humphreys K., Wing S., McCarty D., Chappel J., Gallant L., increases cue-triggered motivation for sucrose reward:
Haberle B. et al. Self-help organizations for alcohol and paradoxical positive incentive effects in stress? BMC Biol
drug problems: toward evidence-based practice and policy. 2006; 4: 8.
J Subst Abuse Treat 2004; 26: 151–8;discussion 159–96 48. Carter B., Tiffany S. The cue-availability paradigm: the
[Review]. effects of cigarette availability on cue reactivity in smokers.
26. Henggeler S., Pickrel S., Brondino M. Multisystemic treat- Exp Clin Psychopharmacol 2001; 9: 183–90.
ment of substance-abusing and dependent delinquents: 49. Koob G. Stress, corticotropin-releasing factor, and drug
outcomes, treatment fidelity, and transportability. Ment addiction. Ann NY Acad Sci 1999; 897: 27–45 [Review].
Health Serv Res 1999; 1: 171–84. 50. Koob G. The neurobiology of addiction: a hedonic Calvinist
27. Humphreys K., Gifford E. Religion, spirituality and the view. In: Miller W., Carroll K., editors. Rethinking, Substance
troublesome use of substances. In: Miller W., Carroll K., Abuse: What the Science Shows and What We Should Do About
editors. Rethinking Substance Abuse: What the Science Shows It. New York: Guilford Press; 2006, p. 25–45.
and What We Should Do About It. New York: Guilford Press; 51. Brody A. L., Mandelkern M. A., Lee G., Smith E., Sadeghi M.,
2006, p. 257–74. Saxena S. et al. Attenuation of cue-induced cigarette
28. Moos R. Social contexts and substance use. In: Miller W., craving and anterior cingulate cortex activation in
Carroll K., editors. Rethinking, Substance Abuse: What the bupropion-treated smokers: a preliminary study. Psychiatry
Science Shows and What We Should Do About It. New York: Res 2004; 130: 269–81.
Guilford Press; 2006, p. 182–200. 52. Lee J. H., Lim Y., Wiederhold B. K., Graham S. J. A func-
29. Thorndike E. Animal intelligence: Experimental studies. tional magnetic resonance imaging (FMRI) study of cue-
New York: MacMillan; 1911. induced smoking craving in virtual environments. Appl
30. Herrnstein R. On the law of effect. J Exp Anal Behav 1970; Psychophysiol Biofeedback 2005; 30: 195–204.
13: 243–66. 53. McClernon F. J., Hiott F. B., Huettel S. A., Rose J. E.
31. Carroll M. The economic context of drug and non-drug Abstinence-induced changes in self-report craving correlate
affects acquisition and maintenance of drug-reinforced with event-related FMRI responses to smoking cues. Neuro-
behavior and withdrawal effects. Drug Alcohol Depend 1993; psychopharmacology 2005; 30: 1940–7.
33: 201–10. 54. Garavan H., Ross T. J., Murphy K., Roche R. A., Stein E. A.
32. Vuchinich R., Heather N. Choice, Behavioural Economics and Dissociable executive functions in the dynamic control of
Addiction. London: Pergamon; 2003. behavior. inhibition, error detection, and correction.
33. Skinner B. The Behavior of Organisms: an Experimental Analy- Neuroimage 2002; 17: 1820–9.
sis. Oxford: Appleton-Century; 1938. 55. Menon V., Adleman N. E., White C. D., Glover G. H., Reiss A.

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
360 Elizabeth Gifford & Keith Humphreys

L. Error-related brain activation during a Go/NoGo response research recommendations. J Child Psychol Psychiatry
inhibition task. Hum Brain Mapp 2001; 12: 131–43. 2003; 44: 1116–29.
56. Vendrell P., Junque C., Pujol J., Jurado M. A., Molet J., 75. Humphreys K., Rappaport J. From community mental
Grafman J. The role of prefrontal regions in the Stroop task. health to the war on drugs: a study in the definition of social
Neuropsychologia 1995; 33: 341–52. problems. Am Psychol 1993; 48: 892–901.
57. Garavan H., Ross T., Stein E. Right hemispheric dominance 76. Miller W., Longabaugh R. Summary and conclusions. In:
of inhibitory control: an event-related functional MRI Babor T., editor. Treatment Matching in Alcoholism. Interna-
study. Proc Natl Acad Sci USA 1999; 96: 8301–6. tional Research Monographs in the Addictions. New York:
58. Hester R., Garavan H. Working memory and executive func- Cambridge University Press; 2003, p. 207–21.
tion: the influence of content and load on the control of 77. Team U. R. Effectiveness of treatment for alcohol problems:
attention. Mem Cogn 2005; 33: 221–33. findings of the randomized UK alcohol treatment trial
59. Humphreys K., Satel S. Some gene research isn’t worth the (UKATT). BMJ 2005; 331: 541–5.
money. New York Times, 18 January 2005. 78. Moos R., Finney J., Ouimette P., Suchinsky R. A compara-
60. Zhang B., Cohen J., Ferrence R., Rehm J. The impact of tive evaluation of substance abuse treatment. I. Treatment
tobacco tax cuts on smoking initiation among Canadian orientation, amount of care, and 1-year outcomes. Alcohol
young adults. Am J Prev Med 2006; 30: 474–9. Clin Exp Res 1999; 23: 529–36.
61. Lingford-Hughes A., Welch S., Nutt D. Evidence-based 79. Horvath A., Bedi R. The Alliance. In: Norcross J., ed. Psy-
guidelines for the pharmacological management of sub- chotherapy Relationships That Work: Therapist Contributions
stance misuse, addiction and comorbidity: recommenda- and Responsiveness to Patients. Oxford: Oxford University
tions from the British Association for Psychopharmacology. Press; 2002, p. 37–69.
J Psychopharmacol 2004; 18: 293–335. 80. O’Leary D., Borkovec T. Conceptual, methodological, and
62. Berglund M., Thelander S., Jonsson E. Treating Alcohol and ethical problems of placebo groups in psychotherapy
Drug Abuse: An Evidence Based Review. Wernheum, research. Am Psychol 1978; 33: 821–230.
Germany: Wiley-VCH; 2003. 81. Castonguay L., Holtforth M. Change in psychotherapy: a
63. Power E., Nishimi R., Kizer K. Evidence based practices for plea for no more ‘nonspecific’ and false dichotomies. Clin
substance use disorders. In: National Quality Forum Work- Psychol Sci Pract 2005; 12: 198–200.
shop. Washington, DC: National Quality Forum; 2005. 82. Lebow J., Kelly J., Knobloch-Fedders L., Moos R. Substance
64. Gendlin E. Forward to. In: Rogers C., Russell D., editors. Carl use disorders: the influence of therapist, family, and peer
Rogers: the Quiet Revolutionary. An Oral History. Roseville, relationships on treatment process and outcome. In: Beutler
CA: Penmarin Books; 2002. L., Castonguay L., editors. Principles of Therapeutic Change
65. Moyers A., Finney J., Swearingen C., Vergun P. Brief inter- That Work. New York: Oxford University Press; 2006.
ventions for alcohol problems: a meta-analytic review of 83. Kazdin A. Treatment outcomes, common factors, and con-
controlled investigations in treatment-seeking and non- tinued neglect of mechanisms of change. Clin Psychol Sci
treatment-seeking populations. Addiction 2002; 97: 279– Pract 2005; 12: 184–8.
92. 84. Miller W. Common and specific factors in substance abuse
66. Prendergast M., Podus D., Chang E., Urada D. The effective- treatment. In: 11th International Conference on the Treatment
ness of drug abuse treatment: a meta-analysis of compari- of Addictive Behaviors. Santa Fe, New Mexico; 2006.
son group studies. Drug Alcohol Depend 2002; 67: 53– 85. Abrams D. Transdisciplinary paradigms for tobacco preven-
73. tion research. Nicotine Tob Res 1999; 1: S15–23.
67. Prendergast M., Podus D., Finney J., Greenwell L. Contin- 86. Abrams D., Leslie F., Mermelstein R., Kobus K., Clayton R.
gency management for treatment of substance use disor- Transdisciplinary tobacco use research. Nicotine Tob Res
ders: a meta-analysis. Addiction 2006; 101: 1546–60. 2003; 5: S5–10.
68. Niaura R., Rohsenow D., Binkoff J., Monti P., Pedraza M., 87. Colby S., Lee C., Lewis-Esquerre J., Esposito-Smythers C.,
Abrams D. Relevance of cue reactivity to understanding Monti P. Adolescent alcohol misuse: methodological issues
alcohol and smoking relapse. J Abnorm Psychol 1988; 97: for enhancing treatment research. Addiction 2004; 99:
133–52. 47–62.
69. Conklin C. A., Tiffany S. T. Applying extinction research and 88. Silva F. Psychometric Foundations and Behavioral Assessment.
theory to cue–exposure addiction treatments. Addiction London: Sage Publications, Inc.; 1993.
2002; 97: 155–67. 89. Moyers T., Miller W., Hendrickson S. How does Motivational
70. Higgins S., Wong C., Badger G., Ogden D., Dantona R. Con- Interviewing work? Therapist interpersonal skill predicts
tingent reinforcement increases cocaine abstinence during client involvement within Motivational Interviewing
outpatient treatment and 1 year of follow-up. J Consult Clin sessions. J Consult Clin Psychol 2005; 73: 590–8.
Psychol 2000; 68: 64–72. 90. Gifford E., Kohlenberg B., Hayes S., Antonuccio D., Piasecki
71. Humphreys K., Huebsch P., Finney J., Moos R. A compara- M. Acceptance based treatment for smoking cessation.
tive evaluation of substance abuse treatment. V. Substance Behav Ther 2004; 35: 689–704.
abuse treatment can enhance the effectiveness of self-help 91. Miller W., Mount K. A small study of training in motivational
groups. Alcohol Clin Exp Res 1999; 23: 558–63. interviewing: does one workshop change clinician and client
72. Wirtz P., Zweben A., Stout R. Network support for drinking, behavior? Behav Cogn Psychother 2001; 29: 457–71.
Alcoholics Anonymous and long-term matching effects. 92. Miller W., Yahne C., Moyers T., Martinez J., Pirritano M. A
Addiction 1998; 93: 1313–33. randomized trial of methods to help clinicians learn moti-
73. Paul G. Strategy of outcome research in psychotherapy. vational interviewing. J Consult Clin Psychol 2004; 72:
J Consult Psychol 1967; 31: 109–18. 1050–62.
74. Kazdin A., Nock M. Delineating mechanisms of change in 93. Goldstein A., Myers C. Relationship-enhancement methods.
child and adolescent therapy: methodological issues and In: Kanfer F., Goldstein A., editors. Helping People Change. A

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361
Psychology of addiction 361

Textbook of Methods, 3rd edn. New York: Pergamon; 1986, 97. Lykken D. What’s wrong with psychology anyway? In:
p. 19–65. Cicchetti D., Grove W., editors. Thinking Clearly About
94. Tucker J., Roth D. Extending the evidence hierarchy to Psychology. Minneapolis: University of Minnesota Press;
enhance evidence-based practice for substance use disor- 1991, p. 3–39.
ders. Addiction 2006; 101: 918–32. 98. Follette W., Houts A. Models of scientific progress and the
95. Orford J., Hodgson R., Copello A., John B., Smith M., Black role of theory in taxonomy development: a case study
R. et al. The clients’ perspective on change during treatment of the DSM. J Consult Clin Psychol 1996; 64: 1120–
for an alcohol problem: qualitative analysis of follow-up 32.
interviews in the UK Alcohol Treatment Trial. Addiction 99. Humphreys K., Tucker J. Toward more responsive and effec-
2006; 101: 60–8. tive intervention systems for alcohol-related problems.
96. Longabaugh R., Wirtz P., Zweben A., Stout R. Network Addiction 2002; 97: 126–32.
Support for Drinking. Bethesda, MD: National Institute of
Alcohol Abuse and Alcoholism; 2001.

© 2007 Society for the Study of Addiction. No claim to original US government works Addiction, 102, 352–361