Reducing Addiction

Drug therapies reduce addiction by acting directly on the brain's reward and withdrawal systems, the same neurochemical pathways (especially dopamine) that make a substance addictive in the first place. Rather than changing thoughts or behaviour, they alter the biological experience of taking the drug.

There are three distinct approaches, and the exam expects you to keep them apart.

Approach	How it works	Named examples
Agonists / substitutes	Provide a safer form of the drug to reduce withdrawal and craving	Nicotine replacement therapy (NRT) — patches, gum; methadone as a heroin substitute
Antagonists	Block the drug's rewarding effect at the receptor	Naltrexone blocks opioid reward
Aversives	Make taking the substance unpleasant	Disulfiram (Antabuse) causes nausea if alcohol is drunk

A substitute such as NRT gives a person the nicotine their body craves without the smoke, so withdrawal is manageable while the smoking habit is broken. An antagonist such as naltrexone occupies opioid receptors so that taking heroin no longer produces a high, removing the reinforcement. An aversive such as disulfiram interferes with alcohol metabolism, so drinking triggers unpleasant nausea and flushing.

Agonists reduce the need to take the drug, antagonists remove the reward from taking it, and aversives add a punishment for taking it. All three are drug therapies, but they work in opposite directions.

Behavioural interventions are based on classical conditioning. The idea is counter-conditioning: the addictive behaviour has become associated with pleasure, so therapy replaces that with an association with something unpleasant.

In aversion therapy the addictive behaviour is directly paired with a real, unpleasant (aversive) stimulus so that a new association forms. Because the pairing happens in reality, aversion therapy is described as being carried out in vivo (in real life).

Worked examples of the pairing:

• Alcohol — the person is given an emetic drug that induces nausea and vomiting, then drinks alcohol. Repeated pairings mean alcohol itself starts to trigger the feeling of nausea.
• Smoking — in rapid smoking, the person smokes continuously and far faster than normal until it becomes deeply unpleasant, so the act of smoking becomes associated with feeling sick and dizzy.

In classical-conditioning terms, the unpleasant stimulus (the emetic) is the unconditioned stimulus producing nausea (the unconditioned response). After repeated pairing, the alcohol becomes a conditioned stimulus that produces nausea and avoidance (the conditioned response).

Aversion therapy is done in vivo — the aversive stimulus is real and physical. The person genuinely feels sick; nothing is imagined.

Covert sensitisation uses the same classical-conditioning logic as aversion therapy, but the pairing happens entirely in the person's imagination. Nothing physically unpleasant is actually administered, so it is described as being carried out in vitro (in the imagination rather than in reality).

The person is asked to relax and then to vividly imagine performing the addictive behaviour and, at the same time, to imagine an intensely unpleasant consequence of it. For example, a smoker might picture lighting a cigarette and then imagine vomiting violently over themselves and everyone around them. The imagined behaviour becomes associated with the imagined disgust.

Feature	Aversion therapy	Covert sensitisation
Where the pairing happens	In reality (in vivo)	In the imagination (in vitro)
The aversive stimulus	Real (e.g. emetic, rapid smoking)	Imagined (e.g. imagined vomiting)
How unpleasant / traumatic	More unpleasant	Less unpleasant / traumatic
Underlying process	Classical conditioning	Classical conditioning

Because it is imagined rather than physically inflicted, covert sensitisation is generally considered less unpleasant and less traumatic than aversion therapy, which makes it more acceptable to many clients.

Both therapies rely on classical conditioning. The single distinguishing feature is in vivo (real) versus in vitro (imagined) — this is the most common thing to be tested on.

Drug and behavioural therapies target the biology or the association; cognitive behaviour therapy (CBT) targets the thinking that sustains an addiction. It combines cognitive restructuring (changing faulty thoughts) with behavioural skills training (learning new responses).

CBT works in two connected phases:

1. Identify and challenge cognitive distortions — the therapist helps the person recognise the irrational beliefs and biases that keep the addiction going. A gambler, for instance, may hold an illusion of control, believing skill or a "system" can influence a chance outcome. CBT tests these beliefs against reality until the person recognises them as distortions.
2. Teach coping skills and relapse prevention — the person learns practical strategies for high-risk situations. This means identifying the triggers and situations that tempt them (a particular pub, stress, payday) and rehearsing coping responses so they do not return to the behaviour.

CBT is the only one of these interventions that tackles the underlying cognitions, not just the biology or the conditioned association. This is why it is often highlighted for behavioural addictions such as gambling, where distorted thinking is central.

Relapse prevention is a defining feature of CBT: rather than assuming the person is "cured", it plans for the moments most likely to cause a slip and equips the person to handle them.

Prochaska's transtheoretical model describes how people actually change an addictive behaviour. Its key insight is that change is not a single event but a cyclical process that moves through six stages, and a person can move back and forth between them.

Stage	What is happening
1. Precontemplation	The person is not yet considering change and may not see a problem
2. Contemplation	The person is weighing up the pros and cons of changing
3. Preparation	The person is getting ready and forming a concrete plan to change
4. Action	The person is actively changing the addictive behaviour
5. Maintenance	The person is sustaining the change and avoiding relapse
6. Termination	The change is permanent; the former addiction no longer tempts them

Two applications matter for the exam. First, relapse is treated as a normal part of the cycle rather than a failure — a person who relapses simply re-enters an earlier stage and continues the process. Second, interventions should be matched to the person's current stage: someone in precontemplation needs information to raise awareness, whereas someone in action needs practical support and relapse-prevention skills.

Learn the six stages in order and remember the model is cyclical, not linear. A student who lists them out of order, or who treats relapse as proof the model has failed, loses marks.

A strong exam answer weighs these interventions rather than just describing them. Aim for a few developed points, each stating the point, the evidence and the implication.

1. Drug therapy is effective and easy to use, but treats symptoms not causes

Drug therapies are effective and convenient: NRT improves quit rates and substitutes such as methadone reduce the harm associated with heroin use. However, they treat the symptoms rather than the underlying causes of the addiction, can produce side effects and their own dependence, and only work while the person keeps taking the drug. This limits how well the effects are maintained once treatment stops.

2. Behavioural interventions have mixed success and raise ethical issues

Aversion therapy often shows limited long-term success because the new association tends not to generalise beyond the clinic to real-world situations. It also has high dropout rates and clear ethical concerns, since it deliberately causes distress. Covert sensitisation is less traumatic because the aversion is imagined, but it rests on a weaker evidence base, so its effectiveness is harder to establish.

3. CBT tackles the underlying cognition, but is demanding

CBT has the strength of addressing the distorted thinking that maintains addiction, and it has good supporting evidence, especially for behavioural addictions such as gambling. The drawback is that it is effortful and time-consuming, requiring active engagement over many sessions, and relapse can still occur even after successful treatment.

4. Prochaska's model is realistic, but its stages may not be discrete

A genuine strength of Prochaska's model is that it is flexible and realistic: treating relapse as normal and tailoring interventions to a person's readiness reflects how recovery actually works. Critics argue, however, that the stages are not truly discrete — people move back and forth or skip stages — and that the boundaries, such as the "preparation" stage, are somewhat arbitrary, which weakens the model's precision.

1. Confusing aversion therapy with covert sensitisation

Aversion therapy pairs the behaviour with a real aversive stimulus in vivo; covert sensitisation pairs it with an imagined consequence in vitro. The therapies share a mechanism (classical conditioning) but differ on whether the aversion is real or imagined. Mixing these up is the single most common error on this topic.

2. Confusing agonists, antagonists and aversives

These are three different drug approaches. Agonists/substitutes (NRT, methadone) reduce withdrawal, antagonists (naltrexone) block the reward, and aversives (disulfiram) punish use. Do not describe naltrexone as a substitute or NRT as a blocker.

3. Getting Prochaska's six stages out of order

The order is precontemplation → contemplation → preparation → action → maintenance → termination. Swapping preparation and contemplation, or leaving out maintenance, is easy to do under pressure. Learn the sequence as a set.

4. Treating relapse as a failure of Prochaska's model

Relapse is a normal part of the cyclical model, not a flaw in it. A person who relapses re-enters an earlier stage and continues. Writing that relapse shows the model "does not work" misreads its central claim.

5. Only describing therapies in an evaluation question

An AO3 question asks you to evaluate, not restate the method. Marks come from effectiveness, evidence, side effects and ethical issues — not from re-describing how each therapy is carried out.