Emotional exposure in the treatment of substance use disorders: Conceptual model, evidence, and future directions

doi:10.1016/j.cpr.2005.05.002

Clinical Psychology Review

Volume 25, Issue 6, September 2005, Pages 824-839

https://doi.org/10.1016/j.cpr.2005.05.002 Get rights and content

Abstract

In this article, we review research on the nature and treatment of panic disorder, and apply these findings to a discussion of the role of internal cue exposure in the treatment of substance use disorders (SUDs). Two features of panic treatment were used as a model for interventions for SUDs: exposure to internal (interoceptive) cues rather than reliance on external (environmental) exposure alone, and use of cue exposure to try to inoculate individuals against future maladaptive patterns. Specifically, we emphasized the role of exposure to internal, largely emotional cues, as a way to enhance resilience to cues for relapse in individuals with SUDs. Hypothesized moderators and mediators of this treatment approach were discussed, as were similarities between this research agenda and an increasing focus on the role of emotional acceptance/tolerance in cognitive-behavioral treatments.

Introduction

This special series (Zvolensky & Leen-Feldner, 2005), with its focus on the issues surrounding the co-occurrence of anxiety and substance use disorders (SUDs), underscores the impact that advances in the study of one disorder may have on a second disorder. In this article, we continue this focus and consider advances in the conceptualization and treatment of anxiety disorders that may offer benefit for the treatment of SUDs. In doing so, we consider the ways in which strategies for altering avoidant and other maladaptive responses to affect, developed for the treatment of anxiety disorders, have applications for altering drug use responses. Strategies for affect management are relevant to SUD populations because of high rates of affective comorbidity, and the link between comorbidity and substance use severity (Farrell et al., 2003, Kushner et al., 2000, Merikangas et al., 1998, Skinstad & Swain, 2001). However, we believe that a more central link is the role of emotional states in cueing substance use and relapse (Lowman et al., 1996, O'Connell & Martin, 1987, Wikler, 1965), particularly for the subgroup of patients with SUDs whose drug use is linked to attempts to avoid or otherwise control negative affective experiences (Chaney et al., 1982, Stewart & Kushner, 2001, Zvolensky et al., 2003).

In this article, we discuss advances in the conceptualization and treatment of panic disorder, with a focus on the role that emotion may play as a specific cue and internal context for substance use behaviors. Next, we describe a cognitive-behavioral approach to treatment that is directed toward interrupting substance use patterns linked to emotional cues and context. Preliminary efficacy evidence is presented, and potential moderators and mediators of treatment are discussed.

Section snippets

Progress in the treatment of anxiety disorders—focus on panic disorder

The treatment of anxiety disorders is an area of distinct achievement for cognitive-behavioral therapy (CBT). Individual treatment studies and meta-analytic reviews provide consistent evidence for the efficacy of CBT over control conditions, with evidence for effects that rival or exceed that provided by pharmacotherapy, particularly when longer-term outcomes are considered (for review see Otto, Smits, & Reese, 2004). Among the anxiety disorders, research on the application of

External cue exposure and drug craving

The power of external cues in influencing drug craving and use patterns is clear. Consistent with classical conditioning models, external cues such as the sights or smells of alcohol, drug paraphernalia, or the locations (context) where substances are used, develop the capacity to elicit or enhance alcohol or drug cravings (see Drummond et al., 1995, Siegel, 1983). For example, McCusker and Brown (1990) found that urges for and tolerance to alcohol were greater when alcohol was used in a

Treatment implications

One implication of these findings is that to help patients best build resilience to cues and contexts for drug or alcohol use, treatment should consider both external and internal cues for use. Similar to internal cue exposure in panic disorder, exposure to emotional and somatic cues for drug use could be applied in an attempt to: (1) “inoculate” patients against cravings and drug use in response to these cues, and (2) ensure that non-drug responses are rehearsed in a variety of internal (e.g.,

Conclusions and future directions

In this article, we discussed how advances in the conceptualization and treatment of panic disorder underscore treatment processes that may be of value for patients with SUDs. Specifically, we hypothesized that individuals who have substance use patterns characterized by attempts to avoid internal emotional or somatic cues may be particularly helped by emotional-exposure interventions designed to enhance emotional acceptance and the selection of more adaptive responses to internal cues for

Acknowledgement

Support for work on this manuscript was provided, in part, by a National Institute on Drug Abuse grant to Dr. Otto (R01 DA017904). Portions of this theoretical model were previously presented in Otto, Safren et al. (2004).

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