Pros and cons of exposure in addiction treatment

Some time ago I wrote about exposure as a possible treatment for addictions. Exposing the patient to addictive substances or to stimuli related to them at the right moment in the therapeutic process (careful, this is crucial) can have considerable advantages worth bearing in mind. Here’s a summary of the main ones:

• It helps reduce the craving triggered by the stimuli that cause it, through habituation to their presence. (Just as in other disorders anxiety decreases with proper exposure, the idea is that the craving produced by the addictive substance decreases with exposure through habituation and extinction, although, as you’ll see below, results aren’t always as expected.)
• It gives the patient the chance to practise coping responses in a real situation. Through exposure to situations considered high-risk, we can get to know the patient’s weak points and strengths better, correcting the former while reinforcing the latter. Practising in these situations helps improve the patient’s strategies and resources for when they find themselves in similar situations in the future.
• It increases the likelihood of successfully facing real situations in the future. The more times I face these situations, improving my skills with the therapist’s help, the more chance of success I have.
• It helps the patient accept that it’s impossible to avoid situations related to using and prepares them to face real life. Every case is different, but the truth is that it’s very hard to avoid every related stimulus, because this doesn’t only involve dealers or certain places, but also friends, bars, parks, films, conversations…

Exposure is a therapeutic technique whose aim is to prepare the patient to learn not to use, since from the perspective of behavioural psychology, substance use is considered a learned behaviour.

That said, it’s worth being cautious: the evidence for cue exposure in addiction is mixed. Some studies find benefits, especially when it’s combined with training in coping strategies, but others find it doesn’t improve outcomes compared with other treatments. What’s more, we now know the mechanism isn’t just habituation and extinction: extinction doesn’t erase what was learned, but creates new learning that competes with the old and depends heavily on context. That’s why what’s worked on in therapy doesn’t always carry over to real life, and why it’s best to vary the contexts of exposure and to use it as one component of a broader treatment rather than as a treatment on its own.

The usual approach in these cases is to start with imaginal exposure and/or photographs and videos until solid results are achieved, before starting to expose the patient to real situations.

However, we mustn’t forget the drawbacks that exposure treatment can involve in these cases. Some of the most important would be:

• Spontaneous recovery: this would be the most important disadvantage. It means the return or reappearance of the conditioned response to the stimulus after a period of time without it (in other words, the patient relapsing into using the addictive substance), with the danger that this reappearance isn’t a one-off and generalises to more situations.
• The danger posed by the influence of mood on craving, or the urge to use. This can be worked on, and the patient can be prepared by carrying out exposure to the feared stimulus while inducing different moods in the patient.
• The length and frequency of the exposure sessions needed to ensure habituation and extinction can also vary between patients. This has to be taken into account, because for some it may take much longer than for others.
• The possibility of sensitisation occurring instead of habituation. Although normally, if exposure is carried out correctly, this needn’t happen.
• The influence of cognitive variables: retention or memory, concentration, level of assertiveness or social skills… Assertiveness will be an important thing to train, as it will be a key variable when it comes to exposure.

Finally, I’d like to point out that although I’ve been talking about substance use, everything mentioned here could be applied to any kind of addiction.