Psychosocial theories of addiction

1. Psychosocial Theories of
Addiction
Dr. Shehab H. M. Hassaan
Lecturer of psychiatry, Assiut University
Hubert H. Humphrey fellowship in substance abuse prevention
and treatment, Virginia Commonwealth University, USA
Dr. Shehab Hassaan 1

2. Why a theory of addiction?
Dr. Shehab Hassaan 2

3. Dr. Shehab Hassaan 3

4. Substance abuse from an Islamic prospective
All Intoxicants Are Prohibited:
Intoxicants in the Qur’an and Islamic Society
 It is for a definite reason that Islam resorted to a gradual
approach in prohibiting intoxicants. Islam did not speak out
against intoxicating drinks until the fifth year of the Prophet’s
settling in Medina. In other words, its gradual prohibition started
18 years after the beginning of Islamic revelations. The reason for
this is found in the nature of such addiction causing substances.
They require a gentle, gradual approach.
Dr. Shehab Hassaan 4

5.  The starting point in forbidding wines and intoxicants was
that Muslims were not allowed to offer their prayers when they
were under the influence of drink.
ََ ‫اا‬‫ن‬ ‫َِي‬َِْ‫َاا‬‫ص‬َ‫ا‬َْْ‫و‬َََََِْ‫اا‬َ‫ال‬َْ‫َا‬َ‫ين‬‫م‬‫آ‬‫اا‬‫ن‬‫ااأَِي‬َ‫ا‬َ‫ي‬َ‫ي‬َ‫ااأ‬َ‫ي‬َْ َ‫و‬َ ‫اا‬‫ن‬‫م‬َ‫ى‬َ‫ت‬َ‫َأح‬َ‫َاا‬‫ك‬َْ َ‫م‬‫اا‬ْ‫ن‬َ‫ي‬َ‫َو‬َ‫ة‬َ‫ااأ‬َََِْْ‫اا‬َ‫م‬َ‫ل‬
ََ‫َن‬َ‫ي‬َََْ‫و‬}َ‫ِيالسأء‬43
 In the second stage, Islam acknowledged that there were some
benefits in wine and drinks, but it stated clearly that its evil was
greater than its benefit. Therefore, some people abstained from
drinking at that stage, but the majority continued to drink.
َ‫م‬‫ف‬َْ‫ل‬َ‫َق‬ ‫م‬‫ا‬‫م‬‫س‬ْ‫ي‬َ‫م‬ْ‫ِي‬َ‫َو‬ ‫م‬‫ا‬ْ‫م‬َ‫خ‬ْ‫َِي‬‫م‬‫َن‬‫ع‬ََ‫ك‬َ‫ن‬ََ‫ي‬َ‫أ‬ْ‫س‬َ‫ي‬‫ل‬‫م‬‫ي‬ََ‫ع‬‫م‬‫ف‬‫أ‬َ‫ال‬ََْ‫َو‬ٌ‫يا‬‫م‬‫ب‬َ‫ك‬ٌَ ْ‫ث‬‫م‬‫إ‬َ‫أ‬َ‫م‬‫م‬‫يا‬َ‫أ‬َ‫م‬َ‫ا‬َ‫م‬ْ‫ث‬‫م‬‫إ‬َ‫َو‬ ‫م‬‫أس‬‫ن‬‫ال‬
َْ‫ال‬َ‫ي‬ََِ‫ذ‬‫أ‬َََْ‫ك‬َ‫ن‬ََ‫ي‬َ‫أ‬ْ‫س‬َ‫ي‬َ‫أَو‬َ‫م‬‫م‬‫ا‬‫م‬ ْ‫ف‬َ‫ن‬َْ‫ن‬‫م‬ََْ‫ا‬َ‫ب‬ْ‫ك‬َ‫ي‬ََ‫ب‬َ‫ي‬ََ‫ك‬‫م‬‫ي‬َ‫آ‬َ‫ك‬َََْ‫ف‬َ ْ‫َِي‬‫م‬‫ل‬َ‫َق‬َ‫َن‬َْ‫م‬‫ف‬َ‫م‬‫ت‬‫أ‬َ‫ي‬‫َِآل‬َ َََ‫ي‬ََ ‫ن‬‫ََِّلل‬َ‫ن‬‫م‬‫ي‬
ََ‫ون‬َ‫ا‬‫ن‬ََ‫ف‬َ‫م‬َ‫و‬َْ ََ‫ن‬‫ل‬َ َ‫ي‬))َ‫ِيبْاةَِآلية‬219
Dr. Shehab Hassaan 5

6.  Then the final stage; arrived when Muslims had shown their
true metal and that they were resolved to uphold Islamic teachings
at all costs. Hence, the final stage included a complete and full
prohibition:
ََ‫مااا‬‫س‬ْ‫ي‬َ‫م‬ْ‫ِي‬َ‫َو‬َ‫ااا‬ْ‫م‬َ‫خ‬ْ‫ااأَِي‬َ‫م‬‫ن‬‫ن‬‫م‬‫إ‬ََِ‫اا‬َ‫ال‬َْ‫َا‬َ‫مين‬‫آ‬‫اا‬‫ن‬‫ااأَِي‬َ‫ا‬َ‫ي‬َ‫ي‬َ‫ااأ‬َ‫ي‬ََ َْ‫ال‬َ‫ِأل‬َ‫َو‬َ ‫ااأ‬َ ْ‫ن‬َ‫ِأل‬َ‫و‬‫اا‬َ‫م‬َ‫ع‬َْ‫اان‬‫م‬َْ ٌ ‫اا‬ْ‫ج‬ ‫م‬‫ح‬َ‫م‬‫ل‬
َ‫م‬‫أن‬َ‫ط‬ْ‫ي‬‫ن‬‫ش‬‫ِي‬‫ََن‬‫ح‬‫م‬‫ل‬ْ‫ف‬َ‫و‬َْ ََ‫ن‬‫ل‬َ َ‫ي‬ََ‫ه‬ََ‫ب‬‫م‬‫ال‬َ‫م‬ْ‫أج‬َ‫ف‬,ََ‫م‬‫ن‬‫ن‬َِْ‫ن‬َ‫ي‬ََ‫أن‬َ‫ط‬ْ‫ي‬‫ن‬‫ش‬‫َِي‬َ‫د‬‫ي‬ ‫م‬‫َا‬‫ي‬َ‫أ‬ََََ‫ال‬‫ا‬ْ‫ي‬َ‫ص‬ََ‫ع‬‫م‬‫ق‬ََ‫ي‬ََ‫ء‬‫اأ‬َََْْ‫ب‬ْ‫ِي‬َ‫َو‬َ‫ة‬َ‫َِو‬‫د‬‫ا‬َ ْ‫َِي‬َ
َ‫م‬‫ما‬‫س‬ْ‫ي‬َ‫م‬ْ‫ِي‬َ‫َو‬ ‫م‬‫ا‬ْ‫م‬َ‫خ‬ْ‫يَِي‬‫م‬‫ف‬َ‫م‬ ‫ن‬‫ََِّلل‬ ‫م‬‫ا‬ْ‫ك‬‫م‬‫ذ‬َْ‫َن‬‫ع‬َْ َ‫ك‬‫ن‬‫د‬َ َ‫ي‬َ‫و‬ََ‫ا‬َ‫م‬ْ‫ال‬ََْْ َ‫م‬ْ‫ن‬َ‫ي‬َْ‫ل‬َ‫ا‬َ‫ف‬َ‫م‬‫ة‬ ‫ن‬ ‫َِي‬‫م‬‫َن‬‫ع‬َ‫َو‬ََ‫َن‬))َ‫ااااااااااادة‬‫ا‬‫ِيمأئ‬
‫ِآليأت‬90-91
Dr. Shehab Hassaan 6

7. Models of Addiction in Islam
Jurm: Addiction as Crime
 Scholars have divided all actions into five categories, known as
legal norms: either something is necessary (wajib) to do, forbidden
(haram) to do or permissible (halal) to do. Those that are
permissible are either recommended (mandub) or disliked (makruh)
 Violating any legal norms entails a sin, but not necessarily a
crime. The punishment for sin is soteriological, and thus, God may
forgive it out of divine grace when one sincerely repents. All crimes
are deemed as sins, but are distinguished from sins in that they have
legal, as well as theological implications.
Dr. Shehab Hassaan 7

8.  With regards to drugs, most scholars with the exception of a few
viewed hashish and other drugs to be prohibited in the law.
‫إ‬‫تفق‬‫العلماء‬‫في‬‫مختلف‬‫المذاهـب‬‫اإلسالمية‬‫على‬‫حرمة‬‫تناول‬‫القدر‬‫المؤثر‬‫على‬‫العق‬‫ل‬‫من‬
‫المواد‬‫والعقاقـير‬‫المخدرة‬،‫فيحرم‬‫تعاطيها‬‫بأي‬‫وجه‬‫من‬‫الوجوه‬‫سواء‬‫كان‬‫بطريق‬‫األكل‬‫أو‬
‫الشراب‬‫أو‬‫التدخين‬‫أو‬‫الحقن‬‫بعد‬‫إذابتها‬،‫أو‬‫بأي‬‫طريق‬‫كان‬.‫واعتبر‬‫العلماء‬‫ذلك‬‫كبي‬‫رة‬‫من‬
‫كبائر‬‫الذنوب‬
‫وقال‬‫شيخ‬‫اإلسالم‬‫ابن‬‫تيمية‬‫رحمه‬‫هللا‬:"‫وكل‬‫ما‬‫يغيب‬‫العقل‬‫فإنه‬‫حرام‬‫وإن‬‫لم‬‫تحص‬‫ل‬‫به‬
‫نشوة‬‫وال‬‫طرب‬،‫فإن‬‫تغييب‬‫العقل‬‫حرام‬‫بإجماع‬‫العلماء‬.
‫قال‬‫شيخ‬‫اإلسالم‬‫ابن‬‫تيمية‬‫رحمه‬‫هللا‬‫مجيبا‬‫لمن‬‫سأله‬‫عن‬‫حكم‬‫تناول‬‫الحشيش‬)‫هذه‬‫الحشيشة‬
‫الصلبة‬‫حرام‬‫سواء‬‫سكر‬‫منها‬‫أو‬‫لم‬‫يسكر‬.‫والسكر‬‫منها‬‫حرام‬‫باتفاق‬‫المسلمين‬.‫ومن‬‫اس‬‫تحل‬‫ذلك‬
‫وزعم‬‫أنه‬‫حالل‬،‫فإنه‬‫يستتاب‬‫فإن‬‫تاب‬‫وإال‬‫قتل‬‫مرتدا‬‫ال‬‫يصلى‬‫عليه‬‫وال‬‫يدفن‬‫في‬‫م‬‫قابر‬
‫المسلمين‬.‫وقال‬‫في‬‫موضع‬‫آخر‬:)‫وهى‬‫بالتحريم‬‫أولى‬‫من‬‫الخمر‬،‫ألن‬‫ضرر‬‫آكل‬‫الحشيشة‬‫على‬
‫نفسه‬‫أشد‬‫من‬‫ضرر‬‫الخمر‬)
Dr. Shehab Hassaan 8

9. ‫الحافظ‬‫ابن‬‫حجر‬:"‫دل‬ُ‫ت‬‫واس‬‫بمطلق‬‫قول‬‫الرسول‬:(‫كل‬‫مسكر‬‫حرام‬)‫على‬‫تحريم‬‫ما‬
‫يسكر‬‫ولو‬‫لم‬‫يكن‬‫شرابا‬،‫فيدخل‬‫في‬‫ذلك‬‫الحشيشة‬‫وغيرها‬،‫وقد‬‫جزم‬‫النووي‬‫وغيره‬
‫بأنها‬‫مسكرة‬،‫وجزم‬‫آخرون‬‫بأنها‬‫مخدرة‬
‫وعلى‬‫تناول‬‫القليل‬‫منها‬‫والكثير‬‫حد‬‫الشرب‬:‫ثمانون‬‫سوطا‬،‫أو‬‫أربعون‬.‫إذا‬‫كان‬
‫مسلما‬‫يعتقد‬‫تحريم‬‫المسكر‬“.
‫لم‬‫يختلف‬‫العلماء‬‫في‬‫استحقاق‬‫متعاطي‬‫المخدرات‬،‫العقاب‬‫ولكنهم‬‫اختلفو‬‫ا‬‫في‬‫نوع‬
،‫العقوبة‬‫هل‬‫هي‬‫حد‬‫السكر‬‫أو‬‫التعزير‬.
‫فذهب‬‫جمهور‬‫الفقهاء‬‫إلى‬‫أن‬‫العقوبة‬‫تعزيرية‬‫وفق‬‫مايراه‬‫القاضي‬‫محققا‬‫لم‬‫صلحة‬
‫المجتمع‬‫وليست‬‫حد‬‫السكر‬‫و‬‫سندهم‬‫في‬‫وجوب‬‫التعزير‬‫فهو‬‫أن‬‫تناول‬‫المخدرات‬‫ذنب‬
،‫ومعصية‬‫لم‬‫يرد‬‫فيها‬‫حد‬‫مقرر‬‫أو‬‫كفارة‬‫وكل‬‫ما‬‫كذلك‬‫وجب‬‫فيه‬‫التعزير‬.
Dr. Shehab Hassaan 9

10.  This model is preventative and is based on a shame-culture.
 By emphasizing its legal implications over the theological,
scholars attempt to protect society from the harmful consequences
of drugs.
 The model may have functioned as a deterrent in Islamic
societies.
 the model fails to provide a solution in the modern era.
Currently, most Muslim countries do not carry out corporal
punishment for crimes committed, and the ones that do implement
it are discriminatory and selectively biased
Dr. Shehab Hassaan 10

11. Mard Ruhani: Addiction as Spiritual Disease
 People are an amalgamation of the sacred and the profane: a holy
union
 The profane aspect of the human being, known in Arabic as the
“nafs” (self), desires unrestricted pleasure, even at the risk of
committing sins, whereas the sacred spirit, the “ruh”, the location of
which is the physical heart, desires to go towards its pure origins.
 Committing a crime (which is also a sin) is first and foremost to
commit a crime against the heart, which then has an effect on the
whole person. The person enters a spiritual agitation, which is then
covered (kufr, the same word used to denote disbelief) by agents,
such as alcohol, drugs, and other illegal substances.
Dr. Shehab Hassaan 11

12.  According to this model, substance dependence will mean that
the addicted person’s “self” has succumbed to their satanic
impulses, thus severing it from the “spirit”. A dead, spiritless heart
does not remember God and does not yearn to return to God.
)ْ‫ن‬َ‫م‬ َ‫و‬َْ‫ان‬َ‫ك‬‫ا‬ً‫ت‬‫ي‬َ‫م‬ُْ‫ه‬‫َا‬‫ن‬‫ي‬َ‫ي‬‫ح‬َ‫أ‬َ‫ف‬‫َا‬‫ن‬‫ل‬َ‫ع‬َ‫ج‬ َ‫و‬ُْ‫ه‬َ‫ل‬ًْ‫ور‬ُ‫ن‬‫ا‬‫ِي‬‫ش‬‫م‬َ‫ي‬ِْ‫ه‬ِ‫ب‬‫ي‬ِ‫ف‬ْ ِ‫اس‬َّ‫ن‬‫ال‬ْ‫ن‬َ‫م‬َ‫ك‬ُْ‫ه‬ُ‫ل‬َ‫ث‬َ‫م‬‫ي‬ِ‫ف‬ِْ‫ت‬‫ا‬َ‫م‬ُ‫ل‬ُّ‫الظ‬
َْ‫س‬‫ي‬َ‫ل‬ْ‫ج‬ ِ‫َار‬‫خ‬ِ‫ب‬‫ا‬َ‫ه‬‫ن‬ِ‫م‬َْْۚ‫ك‬ِ‫ل‬ََٰ‫ذ‬َ‫ك‬َْ‫ن‬ِ‫ي‬ُ‫ز‬‫ي‬ ِ‫ر‬ِ‫ف‬‫ا‬َ‫ك‬‫ل‬ِ‫ل‬َْ‫ن‬‫ا‬َ‫م‬‫وا‬ُ‫ن‬‫ا‬َ‫ك‬َْ‫ون‬ُ‫ل‬َ‫م‬‫ع‬َ‫ي‬(‫االنعام‬﴿١٢٢﴾
 God says that intoxicants sever the relationship with God, as
well as family and community. It views intoxicants as the cause for
disruptive social behavior.
Dr. Shehab Hassaan 12

13. ‫ا‬َ‫ي‬‫ا‬َ‫ه‬ُّ‫ي‬َ‫أ‬َْ‫ِين‬‫ذ‬َّ‫ال‬‫وا‬ُ‫ن‬َ‫م‬‫آ‬‫ا‬َ‫م‬َّ‫ن‬ِ‫إ‬ُْ‫ر‬‫َم‬‫خ‬‫ال‬ُْ‫ِر‬‫س‬‫ي‬َ‫م‬‫ال‬ َ‫و‬ُْ‫اب‬َ‫ص‬‫ن‬َ‫أل‬‫ا‬ َ‫و‬ُْ‫م‬‫ال‬‫ز‬َ‫أل‬‫ا‬ َ‫و‬ْ‫س‬‫ج‬ ِ‫ر‬ْ‫ن‬ِ‫م‬َْ‫ع‬ِْ‫ل‬َ‫م‬
ِْ‫ان‬َ‫ط‬‫ي‬َّ‫ش‬‫ال‬ُْ‫ه‬‫و‬ُ‫ب‬ِ‫ن‬َ‫ت‬‫اج‬َ‫ف‬ْ‫م‬ُ‫ك‬َّ‫ل‬َ‫ع‬َ‫ل‬‫ون‬ُ‫ح‬ِ‫ل‬‫ف‬ُ‫ت‬,َّْ‫ن‬‫ا‬‫ا‬َ‫م‬ُْ‫د‬‫ي‬ ِ‫ر‬ُ‫ي‬ُْ‫ان‬َ‫ط‬‫ي‬َّ‫ش‬‫ال‬ْ‫ن‬َ‫أ‬َْ‫ع‬ِ‫ق‬‫و‬ُ‫ي‬َْ‫ن‬‫ي‬َ‫ب‬ُْ‫م‬ُ‫ك‬َْ‫ة‬ َ‫او‬َ‫د‬َ‫ع‬‫ال‬َْ‫ء‬‫ا‬َ‫ض‬‫غ‬َ‫ب‬‫ال‬ َ‫و‬
‫ي‬ِ‫ف‬ِْ‫ر‬‫َم‬‫خ‬‫ال‬ِْ‫ِر‬‫س‬‫ي‬َ‫م‬‫ال‬ َ‫و‬ْ‫م‬ُ‫ك‬َّ‫د‬ُ‫ص‬َ‫ي‬ َ‫و‬ْ‫ن‬َ‫ع‬ِْ‫ر‬‫ِك‬‫ذ‬ِْ َّ‫اّلل‬ِْ‫ن‬َ‫ع‬ َ‫و‬ِْ‫ة‬‫ال‬َّ‫ص‬‫ال‬ْ‫ل‬َ‫ه‬َ‫ف‬ْ‫م‬ُ‫ت‬‫ن‬َ‫أ‬ْ‫ن‬ُ‫م‬َْ‫ون‬ُ‫ه‬َ‫ت‬)
 The “spiritual disease model” explored above is more in line
with the “moral model” and like the “addiction as crime model”
in that it is mainly preventative and based on a cultural (Islamic)
understanding of shame. It explains what will happen to the
human soul and spirit and their relationship with God and family
in the case of substance addiction.
Dr. Shehab Hassaan 13

14. ‫الكامله‬
‫المرضية‬
‫الراضية‬
‫المطمئنة‬
‫اللوامه‬
‫التوابه‬
‫األماره‬
‫بالسوء‬
Dr. Shehab Hassaan 14

15. 1- Automatic processing theories
 Addicts acquire addictive behaviours through mechanisms
that shape human behaviours without the need for
conscious decisions or intentions and/or influence our
capacity for self-regulation.
1.1 Learning theories
 Addiction involves learning associations between cues,
responses and powerful positive or negative reinforcers
(pleasant or noxious stimuli).
Dr. Shehab Hassaan 15

16. a. Operant learning theory (operant conditioning):
 This is a general theory of behaviour change in which, in the
presence of particular cues, experience of positive and
negative ‘reinforcers’ increases or decreases the likelihood of
occurrence of a behaviour on which it is contingent (Mook,
1995).
 Positive reinforcers are events that increase the frequency of
prior behaviours, whereas negative reinforcers are events that
decrease that frequency or which will lead to behaviours that
achieve avoidance or escape from them.
Dr. Shehab Hassaan 16

17. Dr. Shehab Hassaan 17

18. b. Classic (Pavlovian) conditioning theory:
 Conditioned Stimulus (CS) does not produce a
physiological response, but once we have strongly
associated it with an Unconditioned Stimulus (UCS) (e.g.,
food) it ends up producing the same physiological response
(i.e., salivation).
Dr. Shehab Hassaan 18

19. Classical conditioning and Addiction
 Repeated pairings of particular events, emotional states, or
cues with substance use can produce craving for that
substance
 Over time, drug or alcohol use is paired with cues such as
money, paraphernalia, particular places, people, time of
day, emotions
 Eventually, exposure to cues alone produces drug or
alcohol cravings or urges that are often followed by
substance abuse
Dr. Shehab Hassaan 19

20. Classical conditioning: Application to CBT
techniques
 Understand and identify “triggers” (conditioned cues)
 Understand how and why “drug craving” occurs
 Learn strategies to avoid exposure to triggers
 Cope with craving to reduce / eliminate conditioned
craving over time
Dr. Shehab Hassaan 20

21. Implications for prevention and
promoting recovery
 The main implications of learning theory approaches are
that prevention of addictive behaviours must focus on
removing the opportunities for potential addicts to become
exposed to the behaviours, and treatment should involve
attempting to loosen the associations between cues and
rewards or cues and behaviour. For example, one might use
‘cue exposure’ to loosen the association between reward
and the behaviour or medications that block the reinforcing
actions of the addictive drug (antagonists) (Ferguson and
Shiffman, 2009).
Dr. Shehab Hassaan 21

22. 1.2 Imitation theories
 Addiction involves, or at least begins with, imitation of behaviour
patterns and assimilation of ideas and identities. There are strong
associations between exposure to models (whether parental, sibling
or peer group) and uptake of addictive behaviours (Kandel and
Andrews, 1987).
 Exposure to models in the media is associated with greater
motivation to engage in addictive behaviours (Lovato et al., 2011).
Limitations
 Addictive behaviours can clearly develop without direct exposure
to models, and many of those who are exposed to models do not take
on that behaviour pattern.
Dr. Shehab Hassaan 22

23. Examples
 Social learning theory: This theory proposes that people can
learn by observing others’ behaviour and the outcomes of these,
that it can occur even though there may be no change in
behaviour (through observation alone) and that cognition plays a
role in learning with attention playing a critical role (Bandura,
1977).
 The theory proposes that individuals need to be motivated to
imitate models and that the process involves reward and
punishment or observation of reward and punishment being
applied to others. The status of the model can have a powerful
effect.
Dr. Shehab Hassaan 23

24. 1.3 disease model
 The ‘disease model’ of addiction: at its heart is the idea that
addiction involves pathological changes in the brain that result in
overpowering urges to engage in the addictive behaviour.
 This model has been very influential in ‘medicalising’ addiction
because it construes it as a medical disorder, an abnormality of
structure or function that results in impairment (Gelkopf et al.,
2002).
 Loss of control
 Craving
 Self cure
Dr. Shehab Hassaan 24

25. 2- Reflective choice theories (Addiction As
Choice)
 Addicts choose to engage in the addictive behaviour, and
recovery involves choosing not to engage in it. The
choice may be rational or biased, but always involves a
comparison of the costs and benefits.
 Prevention and promotion of recovery involves altering
the actual or perceived costs and benefits and/or
improving the decision-making process.
Dr. Shehab Hassaan 25

26. 2.1 ‘Rational’ choice theories
 The term ‘rational’ in these theories does not mean ‘reasonable’
or ‘sensible’; it merely refers to a process whereby individuals
weigh alternative courses of action against each other and seek to
apply reason and analysis to choose between them.
 According to these theories, for at least some ‘addicts’ engaging
in the addictive behaviour may be preferable to the same
existence without doing so. They may not accept, or to some
degree may be unaware of, the adverse consequences of the
behaviour or they may consider that the benefits outweigh the
possible or actual costs.
Dr. Shehab Hassaan 26

27.  Addiction involves making a rational (in the sense that preferences)
choice that favors the benefits of the addictive behaviour over the
costs.
Evidence
 Many addicts perceive life as better with their addictive
behaviour than without it (Davies, 1997).
 Incentives and disincentives can be effective in modifying
addictive behaviours, at least in the short term (Lussier et al.,
2006).
Limitations
 Educational interventions aimed at informing addicts or
potential addicts of the consequences of their actions often
have little or no effect (Flay, 2009).
Dr. Shehab Hassaan 27

28. Implications for prevention and promoting recovery
 These theories all predict that combating addiction involves altering
the actual or perceived costs and benefits of engaging in the
behaviour.
 Education in schools should tell young people about the harms of
drugs, and if they are not adequately deterred by this the criminal
justice system or fiscal policy should be used in addition to coerce
addicts or potential addicts to ‘see sense’.
 Interestingly, in western capitalist countries, these latter policies tend
not to be used, or be used in only a modest way, in the case of
products such as alcohol, tobacco and gambling, in which the
industries involved are deeply embedded in the economic structure.
Dr. Shehab Hassaan 28

29. 2.2 ‘Biased’ or Irrational choice theories
 Biased choice theories are clearly more realistic than the rational
choice models in reflecting the facts that preferences are unstable
over time, and that the very process of making decisions is subject
to well-demonstrated emotional and cognitive biases.
 Addiction arises at least in part from the influence of emotional
and cognitive biases on the process by which options to engage or
not engage in addictive behaviours are compared.
Evidence
 Addicts exhibit cognitive and motivational biases that could
promote the addiction (Field and Cox, 2008).
 Emotional states as well as utilities influence decision-making
processes (Pfister and Bohm, 2008).
Dr. Shehab Hassaan 29

30. Cognitive model
 Beck et al (1993) developed a cognitive model specifically to address
the problem of substance abuse.
 People who present drug and alcohol problems tend to have core and
intermediate beliefs regarding lack of love, helplessness,
hopelessness and a low threshold for frustration and boredom.
 When someone starts using a substance, anticipatory beliefs appear:
• At first, these beliefs take the form of statements such as “drinking
will make me feel better” or “it’s ok to use every now and then”.
• As the person starts obtaining gratification from the drug, beliefs
start changing into statements such as “smoking relaxes me” or
“drinking makes me more cheerful”.
Dr. Shehab Hassaan 30

31.  Beliefs that are contrary to use develop concomitantly, especially with
regard to illegal drugs. These are called control beliefs.
 Permissive beliefs and control beliefs manifest simultaneously in the
subject, and using or refraining from using drugs is a result of the
conflict between permissive and control beliefs (Beck et al., 1993).
 Activation of permissive beliefs occurs in the presence of certain
activating stimuli, those that can activate the person’s cravings and
beliefs regarding use.
 The cognitive model for substance abuse was organized in the
following manner:
Dr. Shehab Hassaan 31

32. Cognitive Bias
Addiction is maintained by biases in the cognitive system, including
beliefs, expectancies, self-efficacy, attributions and attention.
‘Attentional bias’
addicts show a tendency to pay closer attention to stimuli related to the target of their
addiction than would be the case for non-addicts. Thus, in the case of individuals
dependent on alcohol, for example, stimuli in their environment that are linked to
alcohol achieve greater prominence and can trigger cravings in a way that would not be
the case for other individuals.
‘recall biases’
in which addicts differentially forget the negative effects of their addictive behaviour
and remember the positive effects. Thus, a person who suffers from alcohol
dependence may have forgotten, the day after a binge, the adverse effects experienced
at the time.
Dr. Shehab Hassaan 32

33. Implications for prevention and promoting recovery
 This class of theory has been taken to imply a set of interventions
that aim to mitigate the effect of the irrational biases. It also seeks
to deploy training interventions that mitigate emotional
distortions of the decision process.
 Individuals with vulnerabilities that result in maladaptive
emotional influences on their decision-making could be taught
skills for dealing with such emotions.
 Finally, if an addictive behaviour arises out of a failure of a clear
self-protective intention, prevention could be bolstered through
education and persuasion.
Dr. Shehab Hassaan 33

34. 3- Goal-focused theories
Addiction arises out of pleasure seeking or avoidance of distress
or discomfort.
3.1- Positive reward theories
Theory
Addiction arises out of the pleasure and satisfaction caused by the
activity. The greater the pleasure and satisfaction, the greater the
risk of addiction.
Dr. Shehab Hassaan 34

35.  The positive experiences may involve feelings of well-being or
simple enjoyment arising directly out of the behaviour (e.g. as
in the pharmacological effect of drugs) or they may arise from
other factors such as the sense of belonging or sharing that
may arise from the activity.
 The positive reward may also arise from functions that the
activity performs, such as maintaining a low body weight (e.g.
in the case of stimulants) or achieving a particular type of body
image (e.g. in the case of steroids).
Dr. Shehab Hassaan 35

36. Implications for prevention and promoting recovery
 If addiction involves an element of pleasure-seeking, then
prevention should involve:
 limiting access to the source of pleasures, at least for vulnerable
individuals;
 strengthening motivation or capacity to resist the temptations;
 providing alternative sources of pleasure or the functions being
sought.
 Promoting recovery would involve blocking the pleasurable
effects (e.g. with medication), restricting access, providing
substitute sources of pleasure or the functions provided by the
addictive behaviour and/or boosting capacity and skills for self-
control. Dr. Shehab Hassaan 36

37. 3.2 Opponent Process Theory
 The drug reward process from repetitive drug use is upset by
opponent processes that have a homeostatic function following
drug euphoria to restore baseline levels. This leads to a reduction in
the effect of the drug and withdrawal symptoms during abstinence.
 At the beginning of drug or any substance use, there are high levels
of pleasure and low levels of withdrawal. Over time, however, as
the levels of pleasure from using the drug decrease, the levels of
withdrawal symptoms increase, thus providing motivation to keep
using the drug despite a lack of pleasure from it.
Dr. Shehab Hassaan 37

38. Tolerance
Protracted
withdrawal
Dr. Shehab Hassaan 38

39. Implications for prevention and promoting recovery
 One strategy is to treat the withdrawal symptoms with medication.
Thus, nicotine replacement therapies, bupropion and varenicline are
effective in reducing the mood disturbance and craving for cigarettes
that occur during attempts to stop smoking (Cahill et al., 2011).
 Benzodiazepines are used to reduce potentially dangerous alcohol
withdrawal symptoms during ‘detox’ (Amato et al., 2010). Methadone
and buprenorphine reduce the symptoms of heroin withdrawal (Mattick
et al., 2009).
 Another strategy is to provide counseling to help addicts cope with the
withdrawal symptoms without relapsing (Lancaster and Stead, 2005).
Dr. Shehab Hassaan 39

40. 3.3 Pre-existing need theories
Theory:
 Addiction involves engaging in behaviours that meet important pre-
existing needs.
 A striking observation in those people who are addicted to illicit drugs
is the proportion who suffered abuse as children (Simpson and Miller,
2002).
 There is also good evidence of a strong association between depression
and anxiety in children and subsequent development of addiction to a
range of drugs including alcohol and nicotine (Douglas et al., 2010).
 This, together with self-reports of addicts, has led to the view that an
important motive for taking up and continuing with an addictive
behaviour pattern is to meet pre-existing psychological needs.
Dr. Shehab Hassaan 40

41. Examples:
 Psychodynamic models
 Attachment model
 Self medication
Dr. Shehab Hassaan 41

42. Psychodynamic Theories
1- Regression to oral stage of development.
2- Pleasure seeking behavior.
3- Aggression towards self (self-destruction)
4- Ego deficit in structure and function, and it represents a
maladaptive attempt to compensate for these deficits, the major
areas of deficits are:
Dr. Shehab Hassaan 42

43. 1)-Impairment of affect regulation and impulse control
functions:
Defective regulation of painful and powerful affects such
as rage, shame, depression as well as any states of distress.
Defective ability to control impulsive acts.
2)-deficits in self care and self protective functions:
Inadequate internalization of caring parental figures, they
suffer impaired judgment and diminished capacity for self
protection (e.g., unable to evaluate and anticipate the
dangers of drug abuse).
Dr. Shehab Hassaan 43

44. 3)- impaired object relation functions:
Diminished capacity to tolerate and regulate interpersonal
closeness and maintain stable relations with others.
4)- self esteem problems:
1)-low self-esteem i.e. feeling of lack of worth, incompetence,
powerlessness and helplessness.
2)-Drug abuse help them to:
reestablish a sense of power and control.
Relief of distress and painful affects.
Increase capacity to cope and function.
Better ability to manage interpersonal relations..
Dr. Shehab Hassaan 44

45. Addiction as a repetition compulsion
 Addiction as substitution for regressive infantile
autoeroticism, which was first experienced as
pleasurable, then unpleasurable, the vicious cycle of most
addictions.
 In this cycle, the wish for pleasure becomes gratified, but
with accompanying guilt and loss of self-esteem.
 These feelings produce unbearable anxiety, which, in
turn leads to repetition of the act in order to find relief.
 Attempts are made to master the painful feelings and to
regain self-esteem.
Dr. Shehab Hassaan 45

46. Abraham
Stressed the role of alcohol in reducing sexual inhibitions in men.
He theorized that male alcoholics have intense conflicts about
homosexuality, and that alcohol allows them to express these
unconscious feelings in a way that society deems acceptable.
Rado
Emphasized the “eletant” effects of drugs to alter depressed
moods.
Addicts take drugs in order to find relief from a specific type of
depression.
Dr. Shehab Hassaan 46

47. Winnicott
 Sees addictions to drugs, alcohol and food, and to sexual
promiscuity as attempts to re-find the lost object through
direct physical gratification. In that sense, addictions are
similar to transitional phenomena because they represent the
mother and yet are recognized as not being the mother.
 withdrawal is accompanied by physical symptoms of
psychomotor agitation and strong mental dependence, absence
of the mother brings restlessness among infants
Dr. Shehab Hassaan 47

48.  Various medications (most sedative-hypnotics, some
antidepressants and even some antipsychotics) can serve as
transitional objects since they are readily available, reduce
anxiety, provide relaxation and can be used before sleep, like
children’s usage of transitional objects.
McDougall
 Suggested that some mothers were “addictive”.
 “They encourage the babies to become dependent on them as
an addict needs drugs, with total dependence on an external
object-to deal with situations which should be handled by self-
regulatory psychological means”.
Dr. Shehab Hassaan 48

49. Attachment Theory
 A pattern of sensitive and responsive care leads to a secure
pattern of attachment
 With a secure attachment relationship, infants can use the
caregiver as a secure base to explore the world
 Attachment patterns shape the child’s view of the world and
their view of themselves
Dr. Shehab Hassaan 49

50.  From early caregiving relationships, infants form an
understanding of themselves and their relationships with others
because they learn what to expect
 These views are referred to as representational models of
relationships, or internal working models
 Children’s views of their parents/caregivers and their views of
themselves are linked (models of self and others are linked)
Dr. Shehab Hassaan 50

51. Attachment and Expectations
 A secure child has developed a view of self as lovable and
others as caring and trustworthy
 Without this security the child may develop a view of self as
unlovable and of others as not dependable
 If parents/caregivers are inconsistent, fail to meet the child’s
needs, or are hurtful, the child is likely to develop an insecure
attachment relationship (e.g., maltreated child)
Dr. Shehab Hassaan 51

52. c. Self medication
 It proposes that individuals intentionally use drugs to treat
psychological symptoms from which they suffer (e.g. Gelkopf
et al. 2002).
 Addicts have pre-existing psychological problems arising out
of early life experiences, genetic endowment or an interaction
between the two, and the addictive activity provides relief
from the aversive experiences arising from these.
 This may be by a way of numbing of affect, reduction in
negative affect, distraction or countervailing positive affect
(Khantzian, 1997).
Dr. Shehab Hassaan 52

53. Implications for prevention and promoting recovery
 The main implication of pre-existing need theories is that it will
not be sufficient to treat withdrawal symptoms or other
consequences of the behaviour; the underlying need has to be
addressed.
 This may be done through individual or group therapy,
therapeutic communities and/or in some cases with medication
with effects that are less damaging than those of what they are
currently using (Caspers et al., 2006).
Dr. Shehab Hassaan 53

54. Type 1 Type 2
start abusing alcohol later in life (>25
years).
exhibit alcohol-seeking behavior early
in life (<25 years),
They can be male or female They tend to be males
require environmental provocation in
order to manifest a susceptibility to
alcohol
have strong inheritable influences
independent of the environment
These patients experience withdrawal
symptoms and loss of control and
often feel guilty about their drinking
behavior.
tend to be impulsive and risk-taking,
manifest antisocial behavior
Alcohol dependence typology
1- Cloninger´s Typology
Cloninger identified two types of alcohol abuse that have different
genetic and environmental causes.
Dr. Shehab Hassaan 54

55. With the application of this typology, it became evident
that:
 patients of Type 1 have personality characteristics that include:
 high harm avoidance
 low novelty seeking
 high reward dependence
 whereas personality characteristics of Type 2 patients include:
 low harm avoidance
 high novelty seeking
 low reward dependence.
Dr. Shehab Hassaan 55

56. 4 Integrative theories
Addiction involves a wide range of processes for different
behaviours, populations, contexts and individuals.
Social and environmental factors interact with different pre-
existing dispositions to trigger initiation of this behaviour.
This leads, through an interactive process, to changes in the
personal environment and personal dispositions to increase the
strength of motivation to engage in the behaviour relative to
competing behaviours.
Dr. Shehab Hassaan 56

57. Transtheoretical Model
 The Transtheoretical Model offers an integrative framework for
understanding and intervening with human intentional
behaviour change.
 Beginning and quitting addictive behaviors involve the individual
and his or her unique decisional considerations.
 A person’s choices influence and are influenced by both character
and social forces
 There is an interaction between the individual and the risk and
protective factors that influence whether the individual becomes
addicted and whether he or she leaves the addiction.
Dr. Shehab Hassaan 57

58. The TTM posits that individuals move through six stages of
change:
Dr. Shehab Hassaan 58

59.  Precontemplation: In this stage, people do not intend to take action in
the foreseeable future. People are often unaware that their behavior is
problematic or produces negative consequences. People in this stage often
underestimate the pros of changing behavior and place too much
emphasis on the cons of changing behavior.
 Contemplation: In this stage, people are intending to start the healthy
behavior in the foreseeable future. People recognize that their behavior
may be problematic, with equal emphasis placed on the pros and cons
of changing the behavior. people may still feel ambivalent toward
changing their behavior.
 Preparation (Determination): In this stage, people are ready to take
action. People start to take small steps toward the behavior change, and
they believe changing their behavior can lead to a healthier life.
Dr. Shehab Hassaan 59

60.  Action: In this stage, people have recently changed their
behavior and intend to keep moving forward with that
behavior change.
 Maintenance: In this stage, people have sustained their behavior
change for a while and intend to maintain the behavior change
going forward. People in this stage work to prevent relapse to
earlier stages.
 Termination: In this stage, people have no desire to return to
their unhealthy behaviors and are sure they will not relapse.
Since this is rarely reached, people tend to stay in the
maintenance stage.
Dr. Shehab Hassaan 60

61. How Do People Change?
 People change voluntarily only when they:
◦ Become concerned about the need for change
◦ Become convinced that the change is in their best interests
◦ Organize a plan of action that they are committed to implement it
To progress through the stages of change, people apply cognitive,
affective, and evaluative processes. Ten processes of change have
been identified with some processes being more relevant to a specific
stage of change than other processes.
Dr. Shehab Hassaan 61

62. Processes of Change
 Cognitive/Experiential Factors.
 Behavioral Factors.
Dr. Shehab Hassaan 62

63. Processes of Change
Cognitive/Experiential processes:
 Consciousness raising: Gaining information that increases awareness about the
current behavior pattern or the potential new behavior.
 Emotional arousal: Experiencing emotional reactions about the existing state
and/or the new behavior.
 Self re-evaluation: Seeing and evaluating how the existing state or the new behavior
fits in with or conflicts with personal values.
 Environmental re-evaluation: Recognizing the positive and negative effects the
existing state or new behavior have upon others and the environment.
 Social liberation: Noticing and increasing social alternatives and norms that help
support the existing state and/or change and initiation of the new behavior.
Dr. Shehab Hassaan 63

64. Behavioral processes
 Self-liberation: Making choices, taking responsibility for, and making
commitments to engaging in a new behavior or behavior change.
 Stimulus generalization or control: Creating, altering, or avoiding
cues/stimuli that trigger or encourage a particular behavior.
 Conditioning or counter-conditioning: Making new connections
between cues and a behavior or substituting new, competing behaviors
and activities in response to cues for the “old” behaviors.
 Reinforcement management: Identifying and manipulating the
positive and negative reinforcers for current or new behaviors. Creating
rewards for new behaviors while extinguishing (eliminating
reinforcements) for current behavior.
 Helping relationships: Seeking and receiving support from others
(family, friends, peers) for current or new behaviors.
Dr. Shehab Hassaan 64

65. The Well-Maintained Addiction
 Addiction represents the final stage of the process of change,
and this explains why it can be so difficult to dislodge.
 Once individuals complete the maintenance tasks and
incorporate the addiction into their lives, they leave the
process of becoming addicted and enter the
precontemplation stage of the change process that ends in
recovery.
Dr. Shehab Hassaan 65

66. THE STAGES OF CHANGE FOR ADDICTION AND
RECOVERY
ADDICTION
RECOVERY
Sustained
Cessation
Dependence
PROCESSES, CONTEXT AND MARKERS
OF CHANGE
Dependence
PC C PA A M
PC C PA A M
Dr. Shehab Hassaan 66

67. Precontemplation Stage of Becoming Addicted
I do not intend to take action or change in the foreseeable future.
 This is based on:
Available information about drugs
Feelings about drugs
Social evaluation of drug abuse
Current behavior Pros and cons
Risk factors (Temptation, availability etc..)
Protective factors (academic and interpersonal success, religiosity,
religious involvement, good family relationships and interactions, good
self-control or self-regulation skills, peers, parental monitoring, etc.)
Dr. Shehab Hassaan 67

68.  One strategy is to keep individuals ignorant of the behavior’s
existence.
 The precontemplators, by virtue of ignorance or lack of
opportunity, may actually be more vulnerable to moving quickly
to considering use and experimenting and to abuse and dependence.
 When the environment is filled with the availability and
opportunity to use, knowing about the addictive behavior and
making choice not to engage is a more protective stance than
remain ignorant about it.
How do individuals remain in Precontemplation for an
addictive behavior?
Dr. Shehab Hassaan 68

69. Contemplation Stage for Addiction
I’m seriously considering change my behavior
 The tasks of the contemplation stage of addiction are to gather information
in order to weigh the pros and cons of engaging in the addictive behavior
either to move forward to preparation or to return to precontemplation.
 The contemplation stage can include some initial experimentation with the
addictive behavior.
 Initial experimentation seems to fit into this stage better than in the
preparation stage, since a large number of individuals who engage in
limited experimentation find information about the addictive behavior
that shifts the decisional balance away from considering any additional
use.
Dr. Shehab Hassaan 69

70. Contemplation Stage for Addiction
There are three outcomes for contemplators who are processing all
these consideration:
1) To have the decisional consideration shift toward engagement
and transition forward to the preparation stage.
2) To have all these considerations, experiences, and evaluation
create a decisional balance that is firmly against engagement and
supports a transition back into precontemplation stage.
3) To remain in contemplation and to continue information
gathering with a decisional balance that is rather ambivalent
and insufficient to support movement forward or backward in the
stages of change.
Dr. Shehab Hassaan 70

71. Preparing Stage for Addiction
I’m intending to change my behavior and I have made some
behavioral changes
 The preparation stage for initiation is marked by continued
experimentation and an often gradual but deliberate setting of the
stage for regular use.
 Decisional consideration supporting engagement are strong enough
to create a commitment to engage in the behavior as opportunity arises.
 Temptation to use increases and there is a growing sense of
confidence that the individual can engage without serious
consequences.
 Self-efficacy to abstain from the behavior decreases.
Dr. Shehab Hassaan 71

72. Preparing Stage for Addiction
 Negative experiences or consequences reconsideration of
the decision to engage. return to the contemplation or
precontemplation stages.
 commitment and reinforcement continue the individual
includes this addictive behavior in his or her life.
 the addictive behavior becomes patterned and habitual
the transition into the action stage of addiction.
Dr. Shehab Hassaan 72

73. from Preparation to Action on the Road to
Addiction
I have recently changed my behavior and intend to keep moving
forward with that behavior change.
 Decisional balance is skewed toward a positive view of
the new behavior and support repeated engagement in
the behavior.
 conditioning and reinforcement are involved in establishing
patterns of use and reinforcing engagement over a wide
range of situations.
 Stimulus generalization rather than stimulus control is
operative, so that more and more situations become
attached to engagement in the addictive behavior.
 Cognitive processes are used to normalize engagement
and minimize problems associated with the
engagement.
 Self-efficacy to control and avoid the behavior is
weakened. Dr. Shehab Hassaan 73

74. Processes Influencing Movement
Through The Stages of Change
Precontemplation Contemplation Preparation Action Maintenance
Becoming aware
Emotional Response
Environmental Analysis
Thinking through the issues
Seeing other options
Self-efficacy
Social support
Helping relationships
Reinforcement
Seeing other
options
Being in control
Social support
Dr. Shehab Hassaan 74

75. PRIME Theory
Humans are more or less instinctive, habit-driven, emotional
decision-makers with a propensity to make and break plans,
powerfully influenced by our social world, with a sense of
identity which can act as a source of self-control
 An attempt at a theory of motivation that puts into a single
model diverse features
 plans and self-control
 analytical decision making
 emotional decision making and drives
 habits and instinctive responses
Dr. Shehab Hassaan 75

76.  A motivational system with 5 levels working together:
 Impulses vs. inhibition
 Activation of CNS pathways underpinning actions, and
competing pathways inhibiting them (urges)
 Motives
 Mental representations of future world states with feelings
of anticipated pleasure or satisfaction (wants) or relief
(needs)
 Evaluations
 Beliefs involving sense of what is useful/harmful
(functional), right/wrong (moral), pleasing/displeasing
(aesthetic)
 Plans
 Mental representations of future actions associated with
feeling of varying degrees of commitment (intentions and
rules)
 Responses
 starting, stopping or modifying actions
A possible structure for the motivational system
Dr. Shehab Hassaan 76

77. A starting point for understanding behaviour
• At any specific moment we:
 act on impulse
 we do it without thinking about the consequences
 want or need something
 we seek a source of pleasure or satisfaction, or of relief
 think it is right or will serve a purpose
 we do what we consider best
 are following a plan
 we act on a prior intention
Dr. Shehab Hassaan 77

78. PRIME and addiction
 Addiction involves a chronic disposition
 to experience powerful motivation to engage in particular
volitional behaviours
 to fail to exert self-regulatory control over such volitional
behaviours
 It arises when the combination of
 individual vulnerability
 environmental promoters
 effects of a drug
 lead the individual
 to experience powerful wants or needs to engage in the
activity
 and to fail to exert self-regulatory control to inhibit it
Dr. Shehab Hassaan 78

79. Dr. Shehab Hassaan 79

80. Dispositions
 The way that we react is determined by our ‘dispositions’
 These are more or less stable features of the functioning of our
nervous system deriving mainly from the features of, and
interconnections between, neurones.
 At a psychological level, long term dispositions are thought of
in terms of ‘personality’, ‘attitudes’, ‘mind sets’ etc.
 Short-term dispositions include things such as ‘mood’ and
‘frame of mind’
Factors affecting Motivational System
Dr. Shehab Hassaan 80

81. How dispositions come about?
DispositionsGenetic endowment
Experience
1. Habituation/sensitisation -
becoming less or more
sensitive to repeated or
ongoing stimuli
2. Associative learning - habit
formation, classical
conditioning
3. Explicit memory - images and
thoughts recreated in response
to cues
Time
Dr. Shehab Hassaan 81

82. Identity
 People differ in the propensity to think about themselves, the nature of
the thoughts and feelings that they have, and how consistent and
coherent these are
 Identity is a very important source of motives; it is the foundation of
personal norms that shape and set boundaries on our behaviour
 Major elements are:
– Labels (e.g. non-smoker)
– Attributes (e.g. health-conscious)
– Rules (e.g. I do not smoke)
Identity refers to a disposition to generate particular thoughts
and feelings about ourselves
Dr. Shehab Hassaan 82

83. Self-control
 Self-control is a cornerstone of behaviour change. The
moment-to-moment wants and needs arising from that must be
strong enough to overcome impulses, wants and needs coming
from other sources.
 The exercise of self-control is effortful; it requires and uses up
mental resources.
Self-control refers to wants and needs that arise from
evaluations associated with our identity
Dr. Shehab Hassaan 83

84. Understanding why people smoke and Why smoking
cessation is difficult
 They light up and puff on impulse
 much smoking is ‘habitual’, done without thinking
 Many smokers experience powerful cue-driven impulses in
situations in which they would normally smoke
 The want to smoke
 Many smokers enjoy and get satisfaction from smoking
 The need to smoke
 ‘Nicotine hunger’, adverse effects of abstinence
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85.  Positive beliefs about smoking
 they expect it to help with stress, weight control and
concentration
 The routine of smoking
 Strong over-learned plans to smoke at certain times
 They form plans to smoke
 they plan to go for a cigarette during coffee breaks
 These motivations are stronger than any competing motivations
including a plan not to smoke
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86. How to reduce motivation to smoke
 Reduce the impulse
medication during smoking to break the smoking-reward link
reduce exposure to smoking cues
 Reduce the want and need
medication during smoking and abstinence to make smoking
less satisfying and reduce nicotine hunger and adverse
symptoms
control exposure to events that provoke wanting and needing
 Change beliefs
convince smokers that smoking does not confer benefits
 Change plans
 change routines that involve smoking
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87. increasing motivation not to smoke
 Generate competing impulses
set up competing habitual responses to smoking cues
 Increase the want and need not smoke
use extrinsic rewards and punishments (e.g. social approval,
disapproval, vouchers)
maintain salience of negative feelings about smoking (e.g,
disgust, anxiety)
foster intrinsic rewards for not smoking (e.g. achievement)
 Change beliefs
foster negative beliefs about smoking and positive non-smoker
identity
 Establish firm, coherent plans
Establish clear ‘not a puff’ rule as part of new identity
Establish clear if-then rules to minimise wants, needs and urges
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88. Dr. Shehab Hassaan 88