ADC 515 Module 8 Prevention and Treatment Targeting Implicit Cognition Example

Training the Automatic Mind: What Works, What Is Uncertain and What a Program Should Keep

Student Name

Psychology and Addiction Studies Program, Aspen University

ADC 515: Psychology of Addiction

Instructor Name

Month Day, Year

Training the Automatic Mind: What Works, What Is Uncertain and What a Program Should Keep

Six months after beginning its pilot of approach-avoidance training, the residential program near Grand Rapids asked Marcus, the graduate intern, to evaluate the evidence and the pilot's results and recommend what to keep. The program, its pilot numbers and its clients, Denise among them, are fictional; the studies are real.

Cognitive Bias Modification: The Wider Evidence

Approach-avoidance training is one form of cognitive bias modification, a family of computer-based trainings designed to change automatic biases. Others train attention away from drug cues or retrain associations. Cristea et al. (2016) pooled the randomized trials of cognitive bias modification for addictive substances that had been published. They found that the training produced small to moderate changes in the targeted biases immediately after training. Effects on substance use outcomes, however, were small and not reliably different from control conditions, particularly at follow-up, and many trials had a high or unclear risk of bias. They concluded that the evidence did not yet support cognitive bias modification as an effective treatment for addiction and that better-designed trials were needed.

Approach Bias Training Revisited

The meta-analysis pooled many kinds of training, substances and settings. The strongest evidence remains for approach bias training added to inpatient treatment for alcohol dependence. Eberl et al. (2013) replicated the original finding in a larger sample, with lower relapse a year after training, and found the training helped older patients and those with the strongest initial pull toward alcohol the most. The two sets of findings are not contradictory: a broad class of trainings may have weak average effects while one form in one setting shows replicated benefit.

Mindfulness-Based Relapse Prevention

Mindfulness offers a different way of working with automatic processes. Instead of retraining biases through repetition, it teaches people to notice cravings, urges and the thoughts accompanying them without automatically acting, creating space between impulse and action. Bowen et al. (2014) randomized adults who had just finished an intensive phase of treatment for substance use disorders to one of three conditions: the mindfulness version, the conventional skills-based version or the program's ordinary aftercare. Both relapse prevention approaches reduced drug use and heavy drinking compared with usual care in the following months. At twelve months, participants in mindfulness-based relapse prevention used drugs on fewer days, and drank heavily less often, than people in either of the other two groups, which hints that its gains last longer.

Comparing the Options

Why Mindfulness Might Work Differently

Bias training tries to change automatic tendencies directly. Mindfulness takes a different route: it leaves the urge in place but changes the person's relationship to it. Participants practice noticing cravings as passing sensations and thoughts, observing them with curiosity rather than reacting. In dual-process terms, mindfulness may strengthen the reflective system's ability to notice impulses early and to hold them without acting. Because it is a skill people can use anywhere, it may travel better from treatment into daily life than a computer task can.

The Pilot Results

Of forty-one clients with alcohol use disorder offered approach-avoidance training, thirty-three completed all six sessions. Approach bias toward alcohol, measured before and after, shifted toward avoidance in most completers. At three months after discharge, 21 of 33 completers reported no drinking, compared with 52 percent of alcohol clients discharged in the previous year. The difference was in the expected direction but small and drawn from a small group without random assignment, so it cannot be attributed to the training with confidence. Clients described the task as dull but most completed it after the rationale was explained.

What Denise Said

Asked at her outpatient follow-up which parts of treatment had helped most, Denise named three: the plans written for specific situations, the explanation that noticing alcohol everywhere was expected and her sponsor. She remembered the joystick training as "strange but harmless." Her account is one person's view, but it echoes the evidence: the elements she valued work with automatic processes through understanding, planning and support rather than through repetition alone.

Recommendations

The program should keep approach bias training for clients with alcohol use disorder, given the replicated trial evidence and acceptable pilot results, and continue tracking outcomes. It should not adopt attentional bias training. It should add mindfulness-based relapse prevention groups, which address automatic urges in a way clients can carry after discharge and which can continue in outpatient aftercare. And it should keep the planning work that helped Denise contain her lapse, since implicit processes are best managed with several tools at once.

Costs and Staffing

The choices also have practical costs. Approach bias training needs a computer and fifteen minutes of a client's time per session but little staff time once set up. Mindfulness-based relapse prevention requires facilitators trained in the approach and their own regular mindfulness practice, an investment the program would make by sending two counselors to training. Dropping attentional bias training frees computer time and staff attention for the approaches with stronger evidence.

Reflections on the Course

The course began with a paradox: people who sincerely want to stop drinking or using often do not. It explained the paradox through implicit cognition, dual-process models, attentional bias, approach tendencies, executive function and stress. The treatments that followed from these ideas have had mixed success, a reminder that a good explanation of a problem does not guarantee an effective intervention. What the course offers practice most reliably is a different way of understanding clients like Denise: not as people who lack will, but as people whose automatic processes and circumstances need as much attention as their intentions.

Conclusion

Cristea, Kok and Cuijpers's meta-analysis shows that cognitive bias modification changes biases more reliably than it changes substance use, while Eberl and colleagues' replication supports approach bias training for alcohol inpatients. Bowen and colleagues' trial shows mindfulness-based relapse prevention producing durable benefits. The program will keep one training, drop another and add mindfulness groups, measuring as it goes.

References

Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., Carroll, H. A., Harrop, E., Collins, S. E., Lustyk, M. K., & Larimer, M. E. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: A randomized clinical trial. JAMA Psychiatry, 71(5), 547-556. https://doi.org/10.1001/jamapsychiatry.2013.4546

Cristea, I. A., Kok, R. N., & Cuijpers, P. (2016). The effectiveness of cognitive bias modification interventions for substance addictions: A meta-analysis. PLOS ONE, 11(9), Article e0162226. https://doi.org/10.1371/journal.pone.0162226

Eberl, C., Wiers, R. W., Pawelczack, S., Rinck, M., Becker, E. S., & Lindenmeyer, J. (2013). Approach bias modification in alcohol dependence: Do clinical effects replicate and for whom does it work best? Developmental Cognitive Neuroscience, 4, 38-51. https://doi.org/10.1016/j.dcn.2012.11.002