Addiction in Psychology: Revision Notes for A-level Psychology

Addiction is characterized by key features:

• Dependence
• Tolerance
• Withdrawal symptoms

Addiction is included in the Statistical Manual of Mental Disorders (DSM 5) in the category “Substance-related and Addictive Disorders.”

The only behavior included is gambling, as not enough research on other behavior, such as internet use, has been carried out to justify their inclusion.

Dependence (AO1)

Physical dependence: occurs when a person has used a substance so often and in such amount that they experience withdrawal symptoms when they stop using the substance.

Psychological dependence: this is an emotional need to use a substance or perform a behavior that has no underlying physical need. e.g., when people stop smoking, they recover physically in a very short time, but their emotional need for nicotine takes a lot longer.

Tolerance (AO1)

Tolerance is shown when a person has a diminished response to a drug as a result of repeated use. The individual has to increase the dose of the substance to obtain the same effects as their initial response.

Tolerance is a physical effect of repeated use of a drug, not necessarily a sign of addiction. Tolerance can develop into many types of drugs: legal such as benzodiazepam (Valium), and illegal, such as cocaine.

The level of tolerance is different for different effects of the substance, e.g., to get the euphoric feelings produced by cocaine, an individual might have to increase the dose, but the effects on the respiratory system increase with the amount taken, which can lead to respiratory arrest and death.

Withdrawal Syndrome (AO1)

This occurs in drug and alcohol-addicted individuals who discontinue or reduce the use of the drug. This is due to the fact that the brain has adjusted its functioning to the presence of the drug. When the level is reduced, or the drug is absent, the brain seeks the substance to bring the level back up.

This can lead to very unpleasant psychological symptoms such as depression and anxiety and physical symptoms such as nausea, loss of sleep, and weight loss.

The type and severity of the symptoms depend on the type of drug, the amount used, and the length of time the substance has been used.

Fear of withdrawal syndrome often motivates people to carry on using the drug.

AO2 Scenario Question

Marie started smoking a few years ago and used to find smoking relaxing. However, she now finds that despite smoking a lot more than she used to, cigarettes don’t help her relax as much as they did when she first started.

Use your knowledge of the key features of addiction to explain what is happening to Marie.

(4 marks)

Marie smokes a lot more than when she started because she has developed nicotine physical dependence. She has used nicotine so often and in such amount that she experiences withdrawal symptoms when she does not smoke for a short period of time so she feels the urge to smoke a lot more often than when she started.

She has also developed tolerance for nicotine, she has a diminished response to nicotine as a result of repeated use this is why she does not find that cigarettes don’t help her relax as much as they used to. She has to increase the dose of the substance to obtain the same effects as her initial response of relaxation.

Risk factors in the development of addiction (AO1)

Genetic vulnerability AO1

Genetic factors play a role in addiction by predisposing individuals to become addicted to some substances. They do so by influencing the way various substances are metabolized, influencing the response to the substance by enhancing the positive or negative effects of the drug.

For example, generally, Europeans metabolize alcohol quickly, so they do not feel sick, but 50% of Asians metabolize alcohol slowly, so they feel very nauseous after drinking even a small amount of alcohol. As a result, they are unlikely to become addicted to alcohol.

There has to be a gene-environment interaction as, obviously, if the individual is not exposed to the drug, they are not going to become addicted.

Evaluation AO3

• There is support for the influence of genetic factors. For example, Kendler et al., 1997 carried out a twin study on a 2516 twin Swedish males sample and found a concordance rate of 33% for MZ twins and 15% for DZ twins. This suggests a significant influence of genetic factors.
• However, it also highlights the importance of environmental factors, as the concordance rate for MZ twins in all the studies was less than 100%. Additionally, the studies make the assumption that twins share exactly the same social environment, but MZ twins are treated more similarly by their social environment than DZ twins.
• Furthermore, the samples are not representative of the general population as their developmental environment is different from non-twins; e.g., before birth, they have to share the mother’s nutrients and oxygen, which is not the case for non-twins. This could have influenced their development.
• Furthermore, Kendler et al., 2012 found that individuals with one addicted parent who were adopted away from their biological parents had a greater risk of becoming addicted, 9%, compared to individuals also adopted away from their biological parents who had no addiction, 4%.
• These type of studies is now relatively rare. Still, they are important as they allow us to distinguish the contributions of genetic and environmental factors because biological relatives have only genes in common with the adopted individual. Adoptive relatives have only a shared environment in common with the adopted individual; the relative influence of genetic and shared environmental factors can be estimated by comparing the incidence of a disorder or the similarity of a trait in biological relatives to adoptive relatives.
• However, adopted individuals might still have contact with their biological family. Furthermore, the individual shared the social family environment until adoption and could have been influenced by it, so the influence of the shared environment is not completely eliminated.
• The vulnerability varies across substances, so it is specific rather than a general susceptibility to getting addicted to any substance.
  This explanation does not take into account social factors such as social norms, peer pressure, and moral values, e.g., some people choose not to take drugs or drink alcohol for moral or religious reasons.
• It is an example of biological reductionism as this explanation suggests that an individual is likely to become addicted to a substance due to their genetic makeup but does not take other factors into account, e.g., social factors such as peer pressure, social norms, and moral values. An interactionist approach combining genetic influence with social factors would be more appropriate and more likely to lead to more effective ways to deal with addiction.
• It is a determinist explanation as it does not recognize free will in whether an individual develops an addiction.
• It is a socially sensitive explanation as it implies that people are not responsible for their condition and the consequences, e.g., stealing to buy drugs.

Stress AO1

High levels of stress make people more vulnerable to addiction. They might turn to substances or behavior that give them temporary relief as a coping mechanism. However, addiction is less likely in stressful situations if there are mediating factors such as social support.

The stress could be due to the social environment, such as family but also where people live. There are more people addicted to drugs in cities than in the countryside; however, this could be due to the fact that drugs are more easily available in the urban environment.

Evaluation AO3

• Stress could also be due to childhood trauma, such as sexual abuse. This is supported by Epstein et al. 1998 found that women with a history of childhood rape had twice as many Post Traumatic Stress Disorder (PTSD) symptoms as women who had not been raped. They also had significantly more alcohol symptoms.
• Furthermore, childhood rape victims with PTSD symptoms had twice as many alcohol-related symptoms as victims without PTSD symptoms. This suggests that PTSD may be one of the contributing factors to alcohol use. It could be that people experiencing PTSD use alcohol to gain relief from the persistent memories of the abuse.
• Tovalacci et al., 2013 found that highly stressed university students (stress measured by a questionnaire) were more likely to smoke and abuse alcohol and were at higher risk of addiction to the internet. This suggests a link between stress and addiction; however, this was a correlational study, so it did not show a causal relationship between the two factors. Furthermore, the stress was measured using a questionnaire, so social desirability could have influenced the results.

Personality AO1

Eysenck (1997) proposed that some personality types were more prone to addiction. For example, those with high neuroticism (high levels of irritability and anxiety) and those with high psychoticism (aggressive and emotionally detached).

However, this theory is now rejected by most psychologists. The link between personality and addiction is still being investigated, and one factor seems key to addiction, impulsivity. This is characterized by a lack of planning, risk-taking, and the desire for immediate gratification of desire.

Evaluation AO3

• Ivanov et al. 2008, showed a strong link between impulsivity and drug use. Morein-Zamir et al. 2015 found inhibitory difficulties mediated by frontostriatal circuitry. This suggests that there is a neurological cause for impulsivity which in turn leads to addiction. However, more research is needed on this topic.
• One strength of this explanation is that it could help identify individuals at risk of developing addiction and provide them with help before they do. This would reduce the personal cost to the individual and to society.

Family influences AO1

Two key features of family influences: Social Learning Theory and perceived parental approval:

Social Learning Theory or social learning – AO1:

The individual (child or adolescent) observes their parents smoking or drinking and the results of the behavior, e.g., the parents feel more relaxed or seem to experience pleasure; the individual imitates the behavior to get the same result. Over time and repeated exposures, the individual becomes addicted.

Evaluation AO3

• However, cognitive factors mediate whether the child will smoke or not. He might be influenced by other sources, such as health messages and peers. Furthermore, the influence depends on the age of the individual younger children are more influenced by their families than older ones.
• It also depends on how much he/she identifies with the model of the behavior.

Perceived parental approval- AO1:

The adolescent perceives that their parents have a positive or at least a permissive attitude towards a particular drug or addictive behavior such as gambling. This perception might be based on the fact that their parents take the drug themselves or do not monitor their behavior, e.g., let the teenager drink to excess at home.

Evaluation AO3

• Quine and Stephenson 1990 carried out a study on a sample of 2336 10-12 years old Australian children and found that children were significantly more likely than other children to have the intention to drink or to have drunk a glass of alcohol if their parents drank at least weekly.
• Furthermore, Bonomo et al. (2001) found adolescents who had experienced an alcohol-related injury were 1.8 times more likely than other adolescents to have parents who drank alcohol daily.
• However, it is difficult to separate and measure the influence of the family from all other influences, such as peers and the media. Furthermore, these studies are correlational, so they do not show cause and effect.

Peers- AO1:

The influence of peers is greater than the influence of the family, according to Quine and Stephenson 1990.

O’Connell suggests that there are three features of peer influence that lead to addiction to alcohol or other drugs.

• An individual is influenced in his drinking or use of drugs by associating with peers who themselves drink or use drugs.
• These peers provide opportunities (and possibly access) to drink or use drugs.
• The individual overestimates how much their peers drink or use and increase their own consumption to keep up.

Evaluation AO3

• It is difficult to test the influence of peers. It could be the choice of peers to follow the addiction rather than the addiction being the result of the association with a particular group.
• The influence of peers varies in importance depending on the age of the individual. Peers are more important in the teenage years, after which their influence decreases.
• It is impossible to disentangle the influence of peers from other social influences, such as the influence of the family and media.
• This approach does not take into account other possible factors, such as social deprivation, unemployment, and stress.
• The research done is mostly correlational, so it does not show a causal relationship between the factor studied and addiction.
• No factor is by itself causal to addiction. These and other factors combine in various ways to lead to addiction but also to abstention from drugs, alcohol, and gambling. These factors can be social such as social norms and health messages, but also personal experience. For example, an individual who has seen his parents drinking to excess regularly might choose to avoid alcohol and become teetotal others might choose to abstain from drugs and alcohol for moral or religious reasons. So these are risk factors but not causes.
• However, research on this topic is important as it can be the base for preventing and treating addiction. For example, teenagers who don’t use alcohol, cigarettes, and other drugs are less likely to use them as adults. Therefore, targeting prevention health messages to teenagers is an effective way to prevent addiction in adult life.

AO2 Scenario Question

Julie comes from a family of drinkers. She began drinking vodka with her school friends at 12. Now in her early twenties, she has tried to stop drinking but finds it difficult, especially now that she has a very busy and demanding job.

Explain risk factors relevant to Julie’s addiction to drinking.

(4 marks)

Julie’s addiction could be explained by genetic factors. Her parents drink alcohol. They might have passed on to her genes that influence the way alcohol is metabolized therefore influencing the response to alcohol by enhancing its positive effects and decreasing the negative effects.

However, it could also be explained by social learning, and she has observed members of her family drinking and showing positive consequences such as feeling more relaxed (vicarious reinforcements), so she is imitating the behavior she has observed to get the same pleasant consequences.

Furthermore, Julie could have been influenced by her school friends, according to O’Connell, because she has associated with friends who drink vodka, they might have provided opportunities and access to alcohol, and she could have overestimated how much her peers drank and increased her own consumption to keep up.

Another possible reason is that she has a demanding job which increases her stress, so she might turn to drinking as a coping mechanism because it gives her temporary relief.

Explanations for nicotine addiction

Brain neurochemistry

Desensitization hypothesis – AO1:

Acetylcholine (ACh) is a neurotransmitter that, like all neurotransmitters, binds with receptors and activates post-synaptic neurons. One subtype of ACh receptors is called nicotinic receptors, and they bind with both nicotine and ACh.

When nicotine binds with nicotinic receptors, the neuron becomes become stimulated; however, almost immediately, the receptors shut down, and the neuron does not respond to any neurotransmitters (desensitization).

This also leads to the production of dopamine in the nucleus accumbens. This generates a pleasurable feeling, increased alertness, and a reduction of anxiety.

Evaluation AO3

• The Desensitisation hypothesis is supported by Domino, 2004 who used fMRI scans that showed a change in the blood flow in the nucleus accumbens, amygdala, and hippocampus immediately after smoking the first cigarette in the morning.
• After smoking the second cigarette, the effects were less than smoking the first. Low-nicotine cigarettes produced fewer changes in blood flow than those after the first average cigarette.
  D’Souza and Markou, 2013 found that by blocking the transmission of glutamates in rats, they reduced their addiction to nicotine.
• These results cannot be extrapolated without caution as animals are physiologically and psychologically different from humans, but it can give rise to research in humans and treatments aiming at blocking the transmission of glutamates to reduce addiction to nicotine.

Nicotine regulation model – AO1:

When the smoker does not take nicotine for a prolonged period of time, the nicotine is metabolized and excreted, and the nicotinic receptors become sensitized again, giving rise to feelings of agitation and anxiety (withdrawal symptoms) which motivate the individual to smoke.

Additionally, the ACh increased transmission is accompanied by a decrease in dopamine activity.

The repetition of this cycle creates chronic desensitization of the nicotinic receptors, so the intake of nicotine has to increase to produce the same effects (tolerance).

Furthermore, the prolonged use of nicotine results in an increase in the number of nicotinic receptors.

Nicotine also stimulates the release of glutamates which also increase and speed up the release of dopamine, thus increasing the rewarding effects of nicotine.

Evaluation AO3

• The link between the use of nicotine and dopamine is also supported by the study of patients with Parkinson’s disease (this disorder is due to the loss of dopamine-producing cells). Research shows that smokers are less likely to develop Parkinson’s disease than non-smokers.
• This suggests that nicotine has a protective effect against the development of Parkinson’s disease and supports the existence of a link between nicotine and dopamine.
• Cosgrove et al. (2014) compared the brain of men and women while smoking using PET scans and found that the dopamine effect took place in different regions of the brain. This suggests that men and women might smoke for different reasons. This is not taken into account in this explanation.
• This explanation is limited as research shows that there are many more neurotransmitters involved in the addiction to nicotine, such as serotonin and GABA.
  This research is very important as addiction to smoking leads to very serious disorders such as cancer of the lungs, which can be fatal and is very expensive to treat, so the development of treatments based on this research can contribute to individuals’ well-being and to the economy.
• This explanation is reductionist; it focuses only on neurochemical processes and fails to take into account social and psychological factors, so it cannot explain why, as Choi et al. (2003) found the teenagers who were the most likely to get addicted to nicotine were individuals who felt that they were underachieving. It cannot explain either individual differences. For example, some people can be and remain occasional smokers, while others get addicted to nicotine very quickly.

AO2 Scenario Question

Josh has been a heavy smoker for many years. He has tried to give up, but the urge to smoke is so strong that he has failed every time. He always has a cigarette before he goes to bed, and smoking is the first thing he does when he wakes up. He always says that the first cigarette in the morning is the best cigarette of the day.

Use your knowledge of the brain neurochemistry explanation of nicotine addiction to explain Josh’s behavior. (4 marks)

(4 marks)

When Josh smokes a cigarette, the nicotine in the tobacco gets absorbed into the bloodstream and very quickly travels to his brain. There it binds with nicotinic receptors, and the neurons become stimulated; however, almost immediately, the receptors shut down, and the neurons do not respond to any neurotransmitters (desensitization).

This also leads to the production of dopamine in the nucleus accumbens. This generates a pleasurable feeling, increased alertness, and a reduction of anxiety. However, Josh does not smoke during the night, so the nicotine is metabolized and excreted, and the nicotinic receptors become sensitized again, giving rise to feelings of agitation and anxiety (withdrawal symptoms), and he wakes up with a craving for a cigarette.

The first cigarette of the day is the best because the receptors were sensitized, so he feels the effects of nicotine more than after the other cigarettes he smokes during the day, as he often smokes enough to avoid the unpleasant effects of abstinence when he is awake.

Learning Theory

The learning theory explanation of nicotine addiction aims to explain the initiation, maintenance, and relapse of nicotine addiction.

Initiation-> Social Learning Theory (SLT)

Maintenance -> Operant conditioning

Relapse -> Cue reactivity

Social Learning Theory (SLT) – AO1:

SLT suggests that people begin to smoke, particularly when they are young, due to learning from their social environment. They observe people, e.g., peers or parents smoking, and the consequences of the behavior, e.g., they enjoy it, they look “cool,” and are popular (vicarious reinforcements).

So they imitate the behavior- smoking- to get the same reinforcements.

Mayeux et al. (2008) carried out a longitudinal study and found significant positive correlations between smoking at 16 and popularity two years later in boys. However, they found a negative relationship in girls between smoking at 16 and popularity at 18.

This suggests that popularity might act as a vicarious reinforcement than a direct positive reinforcement for boys but not for girls.

Evaluation AO3

• DiBlasio & Benda (1993) found that adolescents who smoked associated themselves with other smokers and were more likely to conform to the social norm of a smoking group.
• This explanation accounts for the motivation to start smoking but does not explain why smoking continues despite the consequences -punishments-such as the cost, the health warnings, and the health difficulties resulting from smoking.
• This explanation has practical applications in the prevention of smoking. Individuals could be taught the skills necessary to resist social influence (Botvin, 2000).

Operant conditioning – AO1:

Operant conditioning explains why smoking continues after initiation. When an individual smokes, he/she gets positively reinforced by the action of nicotine on the dopamine reward system.

Nicotine leads to a release of dopamine in the nucleus accumbens, and this produces a mild feeling of euphoria, thus rewarding the behavior (smoking).

However, not smoking gives rise to feelings of agitation and anxiety, and this acts as a negative reinforcement. Therefore, the behavior – of smoking- is more likely to be repeated to avoid withdrawal symptoms.

Evaluation AO3

• Levin et al., 2010 trained rats to self-administer nicotine by licking one of two waterspouts. The number of licks increases with each training session which suggests that the effects of nicotine (higher dopamine leading to mild euphoria) reinforce the behavior of taking nicotine.
• However, this study was carried out on animals, so we cannot extrapolate to humans without caution as we are different both psychologically and physiologically, so the effects might be different in humans.
• Furthermore, the study used only nicotine, but real cigarettes and other tobacco products contain many other constituents, which might also affect the behavior, so the results might not represent the response to tobacco as a whole.

Cue reactivity- Classical conditioning – AO1:

Cue reactivity is the theory that people associate situations (e.g., meeting with friends)/ places (e.g., pub) with the rewarding effects of nicotine, and these cues can trigger a feeling of craving.

These factors become smoking-related cues. Prolonged use of nicotine creates an association between these factors and smoking.

This is based on classical conditioning. Nicotine is the unconditioned stimulus (UCS), and the pleasure caused by the sudden increase in dopamine levels is the unconditioned response (UCR).

Following this increase, the brain tries to lower the dopamine back to a normal level. The stimuli that have become associated with nicotine were neutral stimuli (NS) before “learning” took place, but they became conditioned stimuli (CS) with repeated pairings.

They can produce the conditioned response (CR). However, if the brain has not received nicotine, the levels of dopamine drop, and the individual experiences withdrawal symptoms; therefore, are more likely to feel the need to smoke in the presence of the cues that have become associated with the use of nicotine.

Evaluation AO3

• This can explain the maintenance of smoking and relapse in individuals who have given up smoking but cannot explain why people start smoking.
• Carter and Tiffany, 1999 support the cue reactivity theory, and they carried out a meta-analysis reviewing 41 cue-reactivity studies that compared responses of alcoholics, cigarette smokers, cocaine addicts, and heroin addicts to drug-related versus neutral stimuli. They found that dependent individuals reacted strongly to the cues presented and reported craving and physiological arousal.
• Calvert,2009 found that when smokers were shown packets of cigarettes, they experienced strong activation in the nucleus accumbens. This supports cue reactivity as the cigarette packets acted as a cue and elicited the same activation pattern as the intake of nicotine produces

Social Learning Theory (SLT) – AO3:

• There are practical applications: some treatments, such as aversion therapy and covert sensitization, are derived from this explanation (see reducing addiction).
• These treatments have been shown to be effective. It does not explain why men and women show some differences. For example, women find giving up smoking more difficult than men and are more likely to relapse than men.
• It does not explain why many people start smoking but do not become addicted. This suggests that other factors are involved which are not considered by this theory.
• Operant conditioning and classical conditioning are deterministic explanations; however, SLT does accept that the individual might decide not to imitate the behavior displayed by the models, so some free will is recognized in this instance.
• This theory does not take into account other negative environmental factors.
• Robin (1973) carried out research on American Vietnam veterans. About 20% of American soldiers were using heroin during the Vietnam war; however, when they returned home, she found that “only 5% of the men who became addicted in Vietnam relapsed within 10 months after return, and only 12% relapsed even briefly within three years”.
• These results are supported by Alexander et al. (1981). They placed rats in a cage in which they could drink from two dispensers. One dispenser contained a morphine solution, and the other plain tap water.
• When the rats were on their own, they drank 19 times more of the morphine solution than they did when they were with other rats.
  These studies suggest that negative environmental factors can lead to drug use and maintain addiction.

AO2 Scenario Question

William is 25 years old, he has been smoking since he was 14, and he has decided to give up because he wants to run a marathon next year. He is really struggling, especially on Friday and Saturday nights when he goes out with his friends to pubs and clubs. He also has an overwhelming urge to smoke when he has had a stressful day.

Using your knowledge of the learning theory explanation of nicotine addiction, explain why William is struggling to abstain from cigarettes. (4 marks)

(4 marks)

William has come to associate pubs and clubs with the rewarding effects of smoking over time, so they have become smoking-related cues.

They can produce an increase in dopamine with the related feelings of pleasure and reduced anxiety; however, following this increase, the brain tries to lower the dopamine back to a normal level.

But, as William’s brain has not received nicotine as he no longer smokes, the levels of dopamine drop, and William experiences withdrawal symptoms. This is why he is struggling more in the presence of these cues.

Furthermore, he is also struggling after a stressful day because he is craving the negative reinforcement (decreased anxiety) that nicotine used to provide when he smoked.

Explanations for gambling addiction

Social Learning Theory (SLT)

SLT suggests that people begin to gamble due to learning from their social environment. They observe people, e.g., peers or parents, gambling and the consequences of the behavior, e.g., they enjoy the excitement, and they win money (vicarious reinforcements). So they imitate the behavior- gambling- to get the same reinforcements.

Operant conditioning

The behavior of gambling is maintained by direct positive and negative reinforcements.

A reinforcement is anything that makes a behavior more likely to be repeated.

Positive reinforcement: anything that rewards the behavior, e.g., winning money, the excitement of betting, the social life associated with betting, e.g., in casinos and betting shops.

Negative reinforcement: anything unpleasant that is avoided by performing the behavior, e.g., gambling, can offer an escape from a stressful life and loneliness.

Schedule of reinforcement

Continuous reinforcement: Skinner’s research with rats and pigeons showed that when the behavior, e.g., pecking a disc, was reinforced by food every time it was performed (fixed ratio), the behavior was repeated, but when the rewards stopped, the behavior quickly ceased (extinction).

Variable ratio reinforcement: When the behavior was only rewarded unpredictably (only now and then, and it is impossible to say when the reward will occur), then the behavior took longer to learn, but once learned, it was very resistant to extinction.

Variable ratio reinforcement is a type of partial reinforcement. Applying the theory to gambling: A fruit machine might be set to give a payout on average every 30 games.

However, an individual might win at the 5th game and then not until the 47th game (variable ratio), but the individual will carry on playing despite the losses waiting for the reward.

Evaluation (AO3)

• It could be argued that operant conditioning does not explain why people continue gambling when they lose more often than they win, as the loss is punishment. Therefore, it should make gambling less likely.
• However, the magnitude of the losses is less obvious than the magnitude of the wins, e.g., in a fruit machine, the losses are a few pounds at a time, so they are not so obvious, but the win might be £50 at once, so it is more noticeable.
• Furthermore, the loss being relatively small each time does not give rise to a lot of anxiety, but the win gives rise to a feeling of euphoria, so the association between the behavior and the feeling of triumph is greater.
• Parke & Griffiths,2004 found support for the reinforcing role of winning but also of “near-win” (coming very close to winning, e.g., the horse comes second). This means that gambling is rewarded not only by winning but also by nearly winning, which makes it more addictive.
• Operant conditioning cannot explain how people start gambling (see SLT) but can explain how the behavior is maintained.
  Operant conditioning requires contiguity between the behavior and the consequences (short delay between the gambling and the win or loss).
• However, in some gambling activities such as poker or betting on the outcome of a sports game or a horse race, there is a fairly long delay between the two, so the association between the behavior and the consequences should be weaker than for fruit machines, but this does not seem to be the case as both types of gambling seem to be equally addictive.
• This theory cannot explain why many people gamble at some point during their lives and experience reinforcement. Only a relatively small number of people become addicted to gambling.
• This suggests that other factors are involved in the formation of gambling addiction.
• This theory is beta biased (it does not acknowledge the difference between men and women). According to a study of gambling in Victoria, Australia, by Hare, 2009 using a sample of 15 000 adults, 1.3% of men were addicted to gambling but only 0.6% of women.
• They also found that men were more likely than women to gamble for social reasons or for general entertainment, but women were more likely to gamble to relieve stress, loneliness, and boredom. This suggests that there are differences between the genders that the theory cannot explain.
• This theory is reductionist. It does not take into account the physiological rewards experienced by gamblers, such as the adrenaline and dopamine involved in the ‘buzz’ of winning.
• Operant conditioning is deterministic; it does not recognize free will, and the behavior is determined by the consequences, but SLT recognizes that the individual might not want to imitate the gambling behavior observed for moral or religious reasons.
• This explanation has practical applications: some treatments, such as aversion therapy and covert sensitization, are derived from the learning explanation (see reducing addiction). These treatments have been shown to be effective.

AO2 Scenario Question

Alice started going to the casino with her friends and, at the start, did not really enjoy it, but she had two big wins and a few near misses. Then she found that she started looking forward to going back every weekend. Now she places bets online when she cannot go to the casino and realized last month that she had spent over half her wages in that way.

Using your knowledge of the learning theory explanation of gambling addiction to explain Alice’s addiction. (4 marks)

(4 marks)

Operant conditioning could explain Alice’s addiction. According to this theory, the behavior of gambling is maintained by direct positive reinforcement, in Alice’s case, winning on two occasions.

However, the reinforcements are received only intermittently and unpredictably (variable reinforcement). For example, a fruit machine might be set to give a payout on average every 30 games. However, an individual might win at the 5th game and then not until the 47th game (variable ratio), but the individual will carry on playing despite the losses waiting for the reward.

The behavior takes longer to learn, but once learned, it is very resistant to extinction. Furthermore, Parke & Griffiths (2004) found support for the reinforcing role of winning but also of “near-win” (coming very close to winning, e.g., the horse comes second).

This means that gambling is rewarded not only by winning but also by nearly winning, as Alice has done a few times, which makes gambling even more addictive.

Cognitive theory explanation for gambling addiction AO1

The cognitive theory explains gambling in terms of irrational/ maladaptive thought processes. It focuses on the reasons people give for gambling.

According to the cognitive theory, the behavior- of gambling- can be explained by cognitive biases.

A Cognitive Bias is a pattern of thinking and processing information about the world that produces distorted perceptions, attention, and memory of people and situations around us.

These biases operate at an automatic and pre-conscious level, but they influence attention and memory linked to the behavior.

Rickwood et al. (2010) identified four main categories of cognitive biases:

1. Skill and Judgement: Gamblers tend to overestimate the amount of control they have over their chances of winning, even with random forms of gambling such as the lottery. They may look back over recent draws and believe they can spot patterns in the winning numbers.
2. Personal characteristics and Rituals: Gamblers sometimes believe themselves to be naturally luckier than other people. They engage in ritualistic behaviors prior to or during gambling which they believe may influence the odds in their favor, e.g., they have a lucky number.
3. Selective Recall: The tendency to overestimate wins and underestimate losses and to see big losses as totally inexplicable.
4. Faulty perceptions: these include Gambler’s fallacy, the idea that random events equal themselves out over time, e.g., “I haven’t won for three weeks, so it should be my turn soon.”

Evaluation (AO3)

• Griffiths (1994) carried out a study to find out if regular fruit-machine players behaved and thought differently from non-regular gamblers (the control group).
• They gave each of the participants £3 to spend on the fruit machine, and the Ps were asked to “talk aloud” so that their cognitive activity could be assessed. Later they were interviewed to assess their perceived skill level.
• They found that the regular gamblers saw themselves as more skillful than non-gamblers- in fact, there was no difference. They made more irrational statements, such as statements suggesting that the machine had a personality or mood (this machine does not like me). They were also more likely to explain losses as near misses or even as near wins.
• The theory is also supported by Michealczuk et al. (2011). They compared 30 addicted gamblers to 30 non-gamblers while each group played fruit machines. The gamblers were far more likely to have cognitive distortions and a much greater sense of control.
• The results of these two studies support the cognitive explanation as it shows the presence of cognitive biases expected and irrational beliefs, e.g., attributing personality and moods to a fruit machine in the addicted gamblers.
• However, it could be argued that what the participants uttered whilst using the slot machines did not represent what they really thought, but as these biases operate at a pre-conscious level, it is very difficult to access these beliefs in any other way.
• It is impossible to know if cognitive biases are a cause or the symptoms of gambling addiction. If they come before the addiction, the theory does not explain how these biases occur or why they occur in some people and not others.
• This theory is beta biased. According to a study of gambling in Victoria, Australia, by Hare, 2009 using a sample of 15 000 adults, 1.3% of men were addicted to gambling but only 0.6% of women. They also found that men were more likely than women to gamble for social reasons or for general entertainment, but women were more likely to gamble to relieve stress, loneliness, and boredom. This suggests that there are differences between the genders that cannot be explained by the theory.
• This explanation is reductionist; it sees the gamblers in isolation from their social environment. For example, if people are struggling financially, it might make sense to buy lottery tickets regularly in the hope of a big win that would solve their problems. Furthermore, it does not take into account the physiological rewards experienced by gamblers, such as the adrenaline and dopamine involved in the ‘buzz’ of winning.
• A more holistic explanation combining cognitive, physiological, and social factors would be more complete.
• The knowledge of how gamblers think has practical applications. For example, cognitive behavioral therapy aims at addressing these biases and irrational beliefs to reduce gambling addiction.

AO2 Scenario Question

Ben plays the lottery every week; he could do it online but says he would not win this way. He always goes to the same shop at the same time, always uses his lucky pen, and chooses his numbers with care after examining the results of the 12 previous weeks, where he identifies patterns.

Using your knowledge of the cognitive approach, explain Ben’s behavior. (4 marks)

(4 marks)

Ben is showing evidence of the use of some of the cognitive biases identified by Rickwood et al. (2010). One of these biases is skill and judgment. He thinks he can identify patterns in the lottery-winning numbers. This gives him the illusion that he has a certain amount of control in a game where the results are completely random.

Another cognitive bias demonstrated by Ben is his use of rituals, such as using the same pen at the same shop at the same time every week. He believes that these rituals may influence the odds in his favor, whereas betting online would prevent him from winning.

Reducing addiction

Drug Treatments

There are three basic types of drug treatments:

1. Aversives:
   These drugs produce unpleasant consequences, e.g., vomiting and nausea, if taken with specific drugs. For example, if people consume alcohol while taking disulfiram, an antabuse drug, they experience nausea, vomiting, dizziness, blurred vision, and severe headache. They work on the principle of counterconditioning the behavior, replacing pleasant associations with unpleasant ones.
2. Agonists:
   These drugs are, in fact, drug substitutes. They act as a less harmful replacement for the drug on which people are dependent. They have fewer side effects. They bind to the same neuron receptors as the addictive drugs and produce similar effects. They allow a gradual and controlled withdrawal from the substance. One example is methadone for the treatment of heroin addiction.
3. Antagonists:
   These drugs block the neural receptors sites, thus preventing the drug addiction from having its usual effects, such as the feeling of euphoria, for example, naltrexone for the treatment of heroin addiction.

Drug therapy for nicotine addiction – AO1:

Nicotine replacement therapy (NRT) uses patches, gums, and inhalers to deliver nicotine, the psychoactive substance in tobacco, in a less harmful and more controlled way than smoking.

NRT uses “clean” means to release nicotine in the bloodstream. Although it still increases heart rate and blood pressure, it is not being taken with the cocktail of other harmful chemicals that are found in tobacco products such as cigarettes.

Nicotine acts in the same way as tobacco products. It stimulates the nicotinic receptors, releasing dopamine in the nucleus accumbens, thus producing sensations of pleasure and reducing anxiety.

Over time the amount of nicotine is reduced gradually. For example, the patches are reduced in size, so the withdrawal symptoms are managed over a period of two to three months.

Stead et al. (2012) reviewed 150 trials, including 50 000 people, and found that chances of stopping smoking were increased by 50 to 70% by the use of NRT compared to the placebo and no treatment groups.

They found no overall difference in effectiveness between different forms of NRT (patches, spray, or gums). This supports the effectiveness of the treatment but also supports the biological explanation of nicotine addiction.

Drug treatment for gambling addiction – AO1:

There is no specific drug to treat gambling addiction. However, naltrexone, usually used for the treatment of heroin addiction, is used in the U.S. because of the similarities between gambling addiction and substance abuse.

Like nicotine, heroin, and other drugs, gambling leads to the release of dopamine, thus activating the reward system.

Naltrexone, an opiate antagonist, reduces the release of dopamine in the nucleus accumbens therefore decreasing the feeling of pleasure and increasing the release of GABA in the mesolimbic system, which is a neurotransmitter that decreases cravings.

In the UK, naltrexone is used only for the treatment of heroin addiction. However, in the USA, it is becoming more widely used for other addictions.

A significant issue with naltrexone is that this drug can have serious side effects such as anxiety, drowsiness, fatigue, panic attack, and depression.

Furthermore, this drug could also stop patients from feeling pleasure in all other areas of their life, which leads to non-compliance (the patients stop taking the drug), which reduces the effectiveness of the treatment.

Kim, 2001 carried out a 12-week double-blind placebo-controlled trial of naltrexone and found that a dose of 188 mg/day reduced the frequency and intensity of gambling urges, as well as the behavior itself in 45 pathological gamblers compared to the placebo group.

Another group of drugs, the Selective Serotonin Reuptake Inhibitors (SSRIs), is also used. The serotonin system is associated with impulse control by inhibiting the reuptake of serotonin. These drugs make more of it available in the synapses. Therefore, they should increase impulse control and reduce gambling.

This is supported by Hollander et al. (2000), who found a significant improvement in the experimental group compared with the group given a placebo; however, Saiz-Ruiz et al. (2005) found no difference.

Evaluation (AO3)

• Drug treatment is cheaper than other forms of treatment, such as CBT, as it requires only prescription and medical supervision. However, the use of drugs raises ethical issues as there are serious side effects to some of the drugs used.
• This should be clearly discussed with the people treated. Though, some drug addicts might not have the mental capacity to give informed consent because of the damage caused by the drugs.
  This treatment requires people to take their tablets/injections regularly, and this might be difficult for drug addicts who lead a very disorganized life or whose memory has been damaged by the use of drugs such as cannabis, ecstasy, and cocaine.
• Drug treatment might not be effective on its own for example, McLellan et al. (1993) found that a group of drug addicts on methadone receiving also psychological intervention responded better to the treatment than a group treated with methadone but without psychological help.
• By focusing only on the biological problem rather than considering addiction as a choice, this approach removes the stigma of addiction and the blame culture that surrounds it.
• On the other hand, it does not address the difficulties that might have led to addiction in the first place, e.g., stress, loneliness, or other social problems such as unemployment.
• Furthermore, it does not address the issue of cognitive biases, which are involved in some addictions, such as gambling.

AO2 Scenario Question

Mia is addicted to cigarettes. She has smoked 20-30 cigarettes a day for over 10 years. She realizes that it is bad for her health and costs her a lot of money which she could use for other more enjoyable things like a holiday. She wants to stop smoking but has tried before and has failed. She has decided to use nicotine patches this time but is concerned about the withdrawal symptoms.

Explained to Mia how nicotine patches work and the benefits of using them.

(4 marks)

Nicotine patches are a form of Nicotine Replacement Therapy (NRT). They deliver nicotine, the psychoactive substance in tobacco, in a less harmful and more controlled way than smoking.

NRT uses “clean” means to release nicotine in the bloodstream, although it still increases heart rate and blood pressure, it is not being taken with the cocktail of other harmful chemicals that are found in tobacco products such as cigarettes, so her breathing should improve.

The nicotine acts in the same way as tobacco products. It stimulates the nicotinic receptors, releasing dopamine in the nucleus accumbens, thus producing sensations of pleasure and reducing anxiety.

So Mia does not need to worry about the withdrawal symptoms, she might miss holding a cigarette in her hand but she will not have any of the symptoms associated with stopping nicotine, such as anxiety and low mood, so she is more likely to succeed in her attempt.

Over time the amount of nicotine is reduced gradually. For example, the patches are reduced in size, so the withdrawal symptoms are managed over a period of two to three months.

Behavioral interventions

Aversion therapy – AO1:

This is based on classical conditioning. According to the learning theory, two stimuli become associated when they frequently occur together (pairing). In addiction the drug, alcohol, or behavior, in the case of gambling, becomes associated with pleasure and high arousal.

Aversion therapy uses the same principle but changes the association and replaces the pleasure with an unpleasant state (counterconditioning).

Aversion therapy and alcohol addiction

Patients are given an aversive drug which causes vomiting-emetic drug. They start experiencing nausea. At this point, they are given a drink smelling strongly of alcohol, and they start vomiting almost immediately.

The treatment is repeated with a higher dose of the drug.

Another treatment involves the use of disulfiram (e.g., Antabuse). This drug interferes with the metabolism of alcohol. Normally alcohol is broken down into acetaldehyde and then into acetic acid (vinegar).

Disulfiram prevents the second stage from occurring, leading to a very high level of acetaldehyde which is the main component of hangovers. This results in severe throbbing headaches, increased heart rate, palpitations, nausea, and vomiting.

Aversion therapy for gambling addiction

For behavioral addictions such as gambling, electric shocks are used, these are painful but do not cause damage.
The gambler creates cue cards with key phrases they associate with their gambling and then similar cards for neutral statements.

As they read through the statements, they administer a two-second electric shock for each gambling-related statement. The patient set the intensity of the shock themselves, aiming to make the shock painful but distressing.

Covert sensitization – AO1:

This is more likely to be used now than aversion therapy. It is also based on the principle of counterconditioning.

Rather than experiencing electric shocks or vomiting, the client is asked to imagine how it would feel to experience these. This is called in vitro conditioning.

The client is asked first to relax and then to imagine an aversive situation, for example, feeling sick, vomiting, or seeing a snake coiled around their drink if they are afraid of snakes. The therapist encourages the client to go into a lot of detail, mentally picturing the color, texture, smell, etc.

Then they imagine themselves smoking, drinking, or gambling whilst thinking about the unpleasant consequences. These might include smoking cigarettes smeared with faces.

The aim is to make the scene as vivid as possible to create a strong association. It is thought that the more negative the imagined situation, the greater the chance of success.

Evaluation of behavioral interventions as a way to reduce addiction (AO3)

• Meyer & Chesser (1970) found that with aversion therapy, 50% of alcoholics abstained for at least a year and that the treatment was more successful than no treatment. This supports the effectiveness of interventions based on classical conditioning.
• However, Hajek and Stead (2011) reviewed 25 studies on the effectiveness of aversion therapy and found that all but one had significant methodological flaws, which means that their results have to be treated with caution.
• Compliance with the treatment is low due to the unpleasant nature of the stimuli used, e.g., inducing violent vomiting.
• There are ethical issues associated with the use of aversion therapy, such as physical harm (vomiting can lead to electrolyte unbalance) and loss of dignity. For this reason, covert sensitization is now preferred to aversion therapy.
• Ashem et al. (1968) found that 40% of a group of alcohol addicts receiving covert sensitization were still abstaining after six months compared to a control group in which all carried on their normal drinking patterns.
• McConaghy et al. (1983) found that after one year, 90% of gamblers who received covert sensitization had reduced their gambling activities compared with 30% of the participants who had received aversion therapy.
• This suggests that the effect of covert sensitization has a longer-term effect than aversion therapy.
• However, relapse is a problem for both therapies. Away from the controlled environment where the associations between behavior/drug and unpleasant stimuli are formed, it is common for addictions to return.
• Behavioral therapies are mostly used in combination with other therapies [(CBT) or biological (drugs)]. It is, therefore, difficult to evaluate their effectiveness.
• Behavioral interventions focus on the behavior but do not address the underlying cause of addiction, such as biological factors, cognitive biases, or social environment (i.e., the thing that is leading them to addictive behavior in the first place). A more holistic approach might be more effective in achieving lasting improvement.

AO2 Scenario Question

Melanie has been smoking for many years. She had tried to give up smoking many times but failed even when she used the nicotine patches.

She is getting very concerned about her cough in the morning, which she thinks is due to her smoking. Her doctor advised her to consider aversion therapy. She is not sure what it consists of and asks for your advice.

Using your knowledge of behavioral interventions to reduce addiction, explain how aversion therapy might help Melanie to stop smoking and whether you would recommend this treatment.

(6 marks)

Aversion therapy is based on classical conditioning. According to the learning theory, two stimuli become associated when they frequently occur together (pairing).

In Melanie’s case, cigarettes have become associated with pleasure and relaxation. Aversion therapy uses the same principle but changes the association and replaces the pleasure with an unpleasant state (counterconditioning).

In Melanie’s case, she might be given an electric shock every time she sees a picture of a cigarette or reaches for a lighter. After repeated pairings, she should come to associate cigarettes with electric shocks and stop smoking.

Aversion therapy can be effective for alcohol addiction. For example, Meyer & Chesser (1970) found that with aversion therapy, 50% of alcoholics abstained for at least a year and that the treatment was more successful than no treatment.

However, it is an unpleasant treatment, and she might find it difficult to comply and give up the treatment before the association between cigarettes and the pain of the electric shocks is strong enough to stop her from smoking.

Furthermore, aversion focuses on the behavior but does not address the underlying cause of addiction, such as biological factors, cognitive biases, or social environment (i.e., the thing that is leading them to addictive behavior in the first place). A more holistic treatment, such as a combination of nicotine replacement therapy and cognitive behavioral therapy, might be more effective to achieve a lasting improvement.

Cognitive behavioral therapy (CBT)

CBT assumes that behavior and addiction are determined by our ways of thinking. Therefore, the aim of the therapy is to identify and change the way people think about their addiction in a more adaptive way (functional analysis).

The second aim is to help the client to develop strategies to avoid situations that trigger addiction behavior (skills training).

Functional analysis – AO1:

The client and the therapist identify the situations in which he/she is likely to gamble/take drugs or drink alcohol. They explore the thoughts and motivations before, during, and after the event in an attempt to help the patient to identify “faulty thinking,” cognitive distortions, or cognitive biases.

These are challenged by the therapist. Functional analysis is ongoing throughout the treatment to assess the success of the therapy and guide its future direction.

Skills training – AO1:

People who are addicted usually respond to the challenges of everyday life by turning to their addiction. CBT helps by suggesting other strategies.

Cognitive restructuring: the treatment helps the client in modifying their irrational beliefs and cognitive biases.

Specific skills: The aim is to enable the client to cope with situations that lead to drinking/gambling or drug use. The skills taught vary depending on the client’s needs. They may include assertiveness training to help an alcoholic firmly but politely refuse a drink offered at a party.

Social skills: These skills help people avoid situations likely to result in a lapse in managing social situations more effectively. The therapist explains and models the behavior then the client imitates the behavior in a role play.

Evaluation of cognitive interventions as a way to reduce addiction (AO3)

• Ladouceur et al. (2001) randomly allocated 66 gamblers to either a CBT group, where their irrational thoughts about gambling were challenged, and they were given training in relapse prevention, and a control group, where the participants were placed on a waiting list for treatment.
• The results show that 86% of those in the CBT group reduced their gambling to the point where they were no longer defined as addicts. This improvement was maintained at a one-year follow-up.
• This supports the effectiveness of CBT.
• This is also supported by Petri (2006), who compared pathological gamblers attending Gambler’s Anonymous (GA). They either had GA and CBT or just GA. A year later, those from the CBT group were gambling significantly less than the GA group.
• However, Cowlishaw et al.(2012) reviewed 11 studies on the effectiveness of CBT and found that there are medium to large positive short-term effects (3 months), but there was no difference after 12 months.
• CBT is carried out over 10-15 one-hour weekly sessions. Furthermore, one important aspect of this therapy is the “homework,” as, after each session, the client will be asked to practice new skills in real-life situations. This makes CBT time-consuming, and it also requires commitment from the client. This might be a problem for certain types of addicts, such as drug addicts who lead very disorganized life.
• This leads to a high rate of dropout. Cuijpers (2008) found that the drop-out rate is five times greater for CBT than for other types of therapies. So only very motivated clients are likely to benefit from the therapy.
• CBT does not take into account the influence of biological factors. However, it can be used with other treatments, such as drugs, to help with withdrawal symptoms.
• A strength of CBT is that, unlike other therapies, it provides skills to resist social pressure and deal with everyday situations without engaging in drugs or alcohol.
• A further limitation of CBT is that it does not deal with the stressors in the social environment which might have led to the addiction or maintain the addiction, such as demanding jobs, difficult home life, or housing problems. A more effective solution to addiction needs to take a wider approach to address the social environment.
• Furthermore, individuals with a long history of abuse face other difficulties, such as unemployment and homelessness, and drugs/ alcohol are part of their culture and environment. They might not have the skills and resources to change to a new life and require more than CBT to adjust.

Applying theories of behavior change to addictive behavior

Theory of planned behavior (TPB)

This is a cognitive theory by Azjen and Fishbein (1975) that proposes that an individual’s decision to engage in a specific behavior, such as gambling or stopping gambling, can be predicated by their intention to engage in that behavior.

According to the theory of planned behavior, intentions are determined by three variables:

Personal attitudes – This is our personal attitude towards a particular behavior. It is the sum of all our knowledge, attitudes, and prejudices, positive and negative, that we think of when we consider behavior. For example, our individual attitude to smoking might include tobacco is relaxing and makes me feel good, but it makes me cough in the morning, costs a lot of money, and smells bad.

Subjective norms – This considers how we view the ideas of other people about a specific behavior, e.g., smoking. This could be the attitude of family and friends, and colleagues toward smoking. It is not what other people think but our perception of others’ attitudes.

Perceived behavioral control – This is the extent to which we believe we can control our behavior (self-efficacy).
This depends on our perception of internal factors, such as our own ability and determination, and external factors, such as the resources and support available to us.

The theory argues that our perception of behavioral control has two effects:

• It affects our intentions to behave in a certain way, i.e., the more control we think we have over our behavior, the stronger our intention to perform the behavior.
• It also affects our behavior directly; if we perceive that we have a high level of control, we will try harder and longer to succeed.

Evaluation AO3

• TPB is the model most used in health psychology. It has been useful in predicting intentions relating to smoking and drinking, as supported by Hagger et al. (2011). He found that the three components of the model (personal attitudes, subjective norms, and perceived behavioral control) correlated with alcohol addicts’ intentions to limit or stop their drinking. He also found that those intentions were reflected in their behavior and could predict the approximate number of units consumed after 1 and 3 months. However, it did not predict binge drinking.
• Penny (1996) found that smokers were less likely to believe they would quit smoking and therefore were less likely to try the more times they have failed to quit previously. This shows the importance of perceived behavioral control in shaping our intentions, as predicted by TPB.
• However, Webb et al. (2006) carried out a meta-analysis of 47 studies and found that although there is a link between intention and actual behavior, that link is small. This suggests that there is a significant gap between intentions and behavior.
• There are methodological problems associated with research on this theory. All the components of the model are assessed using questionnaires or interviews, so the answers are influenced by social desirability. Furthermore, these interviews or questionnaires are done when the participants are not under the influence of drugs/ alcohol but when they are in situations that trigger their addiction behavior (pub, party, etc.), their intentions might soon be forgotten, and the behavior resume.
• A strength of TPB is that it takes into account the influence of peers (subjective norms), which is significant in both the beginning of the behavior and its maintenance (SLT and operant conditioning).
• TPB assumes that all behaviors are conscious, reasoned, and planned; however, it does not consider the role of emotions such as sadness and frustration, which can play an important role in influencing behavior.
• TPB has been used in health education campaigns. Anti-drug campaigns often give data about the percentage of people engaging in risky behavior such as smoking or drug use to change the subjective norm. For example, teenagers who smoke are usually part of a peer group who smoke. Therefore, they might think smoking is the norm; however, most teenagers don’t smoke, so exposure to statistics showing them the true extent of smoking should change their subjective norm.

AO2 Scenario Question

Miguel smokes about 40 cigarettes a day and is concerned that it is affecting his health negatively. He is also concerned about the cost. His family and his colleagues want him to quit. However, he does not feel he has the willpower to do so.

Using your knowledge of the theory of planned behavior, explain whether Miguel is likely to quit smoking successfully. (4 marks)

Miguel has a positive personal attitude toward quitting as he realizes that smoking is affecting his health, and he is concerned about the cost of smoking.

He also has a subjective norm which should help him in his attempt, as his family and colleagues make it clear that they want him to quit. However, he does not have the perceived behavioral control (self-efficacy) as he does not believe that he can quit smoking.

According to the theory of planned behavior, this is the most important factor in determining whether he would succeed. This makes him unlikely to succeed if he attempts to stop smoking.

Prochaska’s six-stage model of behavior change

Prochaska and DiClemente (1983) noticed that the change from unhealthy behavior (smoking) to healthy behavior (not smoking) is complex and involves a series of stages.

These stages do not happen in a linear order. The process is often cyclical. Some stages may be missed, or the addicts might go back to an earlier stage before progressing again.

The model considers how ready people are to quit the addiction and adapts intervention to the stage the client is at.

Stages of Prochaska’s model of behavior change

1. Precontemplation

At this stage, people are not considering changing their behavior in the near future. They might be in denial or feel demotivated by their failure in previous attempts. Intervention at this stage should focus on helping them realize that they have a problem

2. Contemplation

People have become increasingly aware that they need to change. They consider the advantages and the cost of changing. This stage can last for a long time. At this stage, intervention should help the client see that the pros outweigh the cons.

3. Preparation

At this stage, the individual has decided to change but has not got a plan on how to do it yet. Any intervention should focus on helping the client to decide which support will be needed to achieve the change successfully, e.g., contact GP, specialized clinics, or helpline.

4. Action

At this stage, people change their behavior, e.g., they get rid of all tobacco products and lighters …. Relapse can happen. Intervention should focus on supporting the individual with practical help, praise, and rewards, to maintain the change.

5. Maintenance

The individual has maintained the change for at least six months and is growing in confidence that the change can be permanent. Intervention at this stage focuses on strategies learned to prevent relapse, e.g., emphasizing the benefits of stopping the addiction…

6. Termination

The change is permanent and stable. Abstinence is now automatic; there is no relapse. Some people do not achieve this stage and remain in the maintenance stage for many years. Relapse for them is still possible.

Evaluation AO3

• The model is flexible and dynamic. It reflects the changing emotions and attitudes that addicts have toward their condition. Sometimes they appear to be in denial, and at other times, they recognize that their addiction is a problem.
• It also offers a different focus of intervention at every stage. This should lead to more individually tailored interventions which are more likely to be successful than a “one size fit all” approach.
• However, the research carried out on the effectiveness of this model is inconclusive. Velicer et al. (2007) reviewed five studies and found a 22-26 success rate, which compared well with other interventions. Furthermore, Aveyard et al. (2009) found that tailoring the intervention to the stages of change did not increase its effectiveness in individuals who were trying to stop smoking. Similarly, Baumann et al. (2015) carried out a study on randomly allocated alcohol addicts to an experimental group and to a control group. They found no beneficial effect of a staged intervention.
• The model encourages a more realistic view of relapse, which is seen as an inevitable part of the process rather than a failure on the part of the client. This is a strength as it avoids the low self-confidence and demotivation likely to arise if the client sees relapse as a failure.
• One weakness of the model is that the difference between stages is often “blurry,” e.g., the difference between contemplation and preparedness is vague. So it is questionable whether they are, in fact, two distinct stages.
• A further weakness is that the model neglects the influence of social factors, for example, living conditions and unemployment within this environment. It also fails to recognize the influence of wider social norms as in some societies, and it is expected that when people socialize, they will drink alcohol, so abstaining would be very difficult.

AO2 Scenario Question

Layla has been smoking for a few months now, but she realizes that it is affecting her health and costing her a lot of money. On the other hand, she feels that she enjoys her first cigarette in the morning and that cigarettes help her relax when she is stressed at work.

With reference to Prochaska’s model of behavior change, explain which stage Layla is at. Justify your answer. (4 marks)

Layla is at the contemplation stage of the model, which is the second stage. She has become aware that she needs to change her smoking habit as this is affecting her health and costing her a lot of money.

She is considering the advantages, in her case, better health and some savings, and the disadvantages, such as the lack of enjoyment of her first cigarette of the day and having to find another way to deal with the stress at work.

This stage can last for a long time. At this stage, intervention should help Layla to see that the pros outweigh the cons.

Further information

• Approaches Revision PowerPoint(1)
• Approaches Revision PowerPoint(2)